1. ASPAN Standards and Practice Recommendations Update
3:45 – 5:00 PM 1

2. Objectives Identify 4 elements needed to prove malpractice.
Identify the role ASPAN Standards have in your every day practice in caring for patients in the perianesthesia arena.

3. Standards of Care All professions have standards of care
Minimal level of expertise that must be delivered to the patient
Starting point for acceptable nursing care
Wacker-Guido 4th edition 2006

4. Standards of Care Set internally or externally
Internal pertain to individual practitioner or institution
External pertain to nurses in all states and territories
Helps define scope of practice

5. Standards of Care Found in State nurse practice act
Published standards of professional organizations and specialty practice groups (ASPAN, AORN, ANA, ENA, AACN)
Federal agency guidelines and regulations
Hospital policy and procedure manuals
Individual nurse’s job description
Manufacturer’s published materials
Inservice films/materials
Wacker-Guido 4th edition 2006

6. Standards of Care
Nurses are accountable for all standards of care as they pertain to their profession
To maintain competence and skill
Read professional journals
Attend pertinent continuing nursing education programs
Wacker-Guido 4th edition 2006
Update journal pic?

7. Standards of Care
Determined for the judicial system by expert witnesses
‘Court sees deviations from nursing standards’
Experts testify to the prevailing standards in the community
These are standards that all nurses are accountable for matching or exceeding
Adherence to such standards ensures that patients receive quality, competent nursing care
Wacker-Guido 4th edition 2006

8. Standards of Care In specialty practice areas Reasons
Courts are almost universally holding health care providers to a national standard of care
Reasons
All have access to same information/educational opportunities
Most important: all patients have the right to quality health care regardless of where that care is delivered - small or large, rural or urban
Wacker-Guido 4th edition 2006

9. LAW Rule or standard of human conduct
Established and enforced by authority, society or custom
Tells us what we can and cannot do
Statutory: Passed by federal or state legislature
Public: constitutional, administrative and criminal law; private or civil; relationship with one another

10. Tort Law Concerns wrongful act, damage or injury done
Civil suit can be brought
Malpractice falls in this category

11. LEGAL ISSUE DEFINITIONS
TORT - “CIVIL WRONGDOING”
INTENTIONAL
Assault: Threat to do bodily harm
Battery: Committing bodily harm
Invasion of Privacy
False Imprisonment
Defamation
Inflicting Emotional Stress

12. LEGAL ISSUE DEFINITIONS
TORT - “CIVIL WRONGDOING”
NONINTENTIONAL
PROFESSIONAL NEGLIGENCE- Failure to do what reasonably prudent person under similar circumstances would do.
MALPRACTICE - Improper or negligent treatment resulting in damages/injury.

13. LEGAL ISSUE DEFINITIONS
RESPONDEAT SUPERIOR
“Let the Master speak” Hospital held liable for any damages that result from negligence of one of it’s employees.
RES IPSA LOQUITUR
“The thing speaks for itself” Negligence has been done

14. Legal Issue considerations
Time Out
Verification just before procedure starts
Right Patient
Right site
Right procedure
Correct positioning
Availability of implants or special equipment
Documentation “Time-out” taken
Risk Management

15. LIABILITY 4 elements of negligence for liability suit
DUTY: Need to be professional relationship between health care provider and health care consumer.
BREACH of DUTY: Damages must be due to negligence
DAMAGE: There must be an injury (damages- physical, mental, financial)
CAUSES: Damages must be direct and proximate result of negligence

16. PACU LIABILITY Failure to monitor Failure to communicate
Errors in use of equipment
Errors in medication and treatment
Patient falls
Failure to follow orders/exercise independent judgment
Patient Safety

17. Current ASPAN Standards
Perianesthesia Nursing Standards and Practice Recommendations
Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements

18. 2012-2014 Standards This updated text contains
standards of perianesthesia nursing practice,
evidence-based clinical practice guidelines,
practice recommendations, position statements,
resources from partnering organizations
interpretive statements.

19. ASPAN Standards Include
Standards: generic statements which best describe the desirable and achievable level of performance
Guidelines: developed from systematic review of literature and research, a prime tool for evidence based practices, and require frequent updating as new information becomes available
Practice Recommendations: which best describe the desirable and achievable level of performance expected of perianesthesia registered nurses. 19

20. ASPAN Standards Include
Position Statements: represent an organization’s viewpoint on a particular issue
Resources: recommendations for practice based primarily on expert consensus, expertise and opinion from partnering organizations
NEW: INTERPRETIVE STATEMENTS provided in sidebar format offer clarification, definitions and examples 20

21. YOU! What are your needs? What would make your practice easier?
Clinical Practice
Education
Research
Standards
YOU!
What are your needs?
What would make your practice easier?
What would make patient care safer?
Standards are derived from practice… 21

22. 2012-2014 Standards Effective December 2012 Revised and expanded
Includes:
Scope of Practice
Principles of Perianesthesia Practice
Ethical Practice
Safety
6 Standards
3 Clinical Practice Guidelines (posted on web site)
10 Practice Recommendations
10 Position Statements
3 Resources

23. 2012-2014 Changes Introduction expanded New***
Introduced the sidebar concept for Interpretive Statements
New***
Interpretive Statements: this format allows for the opportunity to provide clarification and add detail to the context of the standards
Why do the ASPAN standards change every 2 years?
Practice keeps changing, questions demand interpretation, clarity is needed to help practitioners define their practice 23

24. Scope of Perianesthesia Nursing Practice
Preanesthesia level of care
Preadmission
Day of surgery/procedure
Postanesthesia levels of care
Phase I
Phase II
Extended Care
Settings

25. Perianesthesia Standards for Ethical Practice
Competency, responsibility to patients, professional responsibility, collegiality, research, advocacy
Application to practice
Nurse refuses to attend unit inservices - always staffs so others can attend
Witness break in sterile technique while procedure performed, remains quiet
For item nurse: Under competency, “maintains personal accountability for professional competency,” “participates in professional continuing educational activities,” “remains current on new products and procedures affecting practice”

26. Principles of Safe Perianesthesia Practice
ASPAN’s core values for a culture of safety include
Communication
Advocacy
Competency
Efficiency
Timeliness
Teamwork

27. 2012 - 2014 Standards I. Patient Rights Autonomy Confidentiality
Practice is based on concepts that recognize & maintain individual
Autonomy
Confidentiality
Privacy
Dignity
Worth

28. Standard I: Patient Rights Case
Nurse loses position for breach of confidentiality through computer entry into patient files including diagnostics & other privileged information.
Hospital/facility has policy regarding patient confidentiality

29. 2012 - 2014 Standards II. Environment of Care
Perianesthesia nursing practice promotes and maintains a safe, comfortable and therapeutic environment.

30. Standard II Environment of Care Case
QI shows increased PONV when preoperative and postoperative patients are mixed in same room.
Mother transports infant home without second person in auto. Child has obstructed airway.

31. 2012 - 2014 Standards III. Staffing and Personnel Management
Appropriate number of RNs with demonstrated competence in each level of care based on
Patient acuity
Census
Patient flow process
Physical facility

32. Staffing and Personnel Management Application to Practice
Usual daily patient population over age 18; 1 to 3 pediatric patients per week (under age 7)
All nurses ACLS provider status
Do the nurses need PALS provider status?
How would you handle this?
Some might say, no not worth the expense; only some nurses certified; then how do you staff that? What is best for the patients?

33. Standard III Staffing & Personnel Management Case
Child has orthopedic surgery. Arrives in PACU where only one nurse is available to care for patient.
2nd nurse is changing clothes in the dressing room. Anesthesiologist leaves patient with PACU nurse to set up for next case.
Patient is non-responsive and ultimately has respiratory arrest after anesthesiologist leaves the PACU.

34. 2012 - 2014 Standards IV. Quality Improvement
RN monitors and evaluates care
Areas for improvement are resolved through a collaborative multidisciplinary approach

35. Standard IV QI Case
Monitored pain levels in patients in ambulatory setting.
Same anesthesiologist for patients with increased pain. Had no narcotics in the O.R. It was his practice in anesthesia delivery.
Department of Anesthesia reviewed cases and looked at pain management within the department.

36. 2012 - 2014 Standards V. Research and Clinical Inquiry Research
Includes:
Research
Evidence-based practice
QI initiatives
Small tests of change that test innovation

37. Standard V Research & Clinical Inquiry Case
When ASPAN did one of the initial Delphi studies, it was discovered that the Aldrete scoring system had not been validated.
Since that time the scoring system has been changed.

38. 2012 - 2014 Standards VI. Nursing Process Assessment Planning
Applied to each patient
Assessment
Planning
Implementation
Evaluation

39. Standard VI Nursing Process Case
9 month M&T brought to Phase I for recovery. Given appropriate dose of Fentanyl but immediately discharged to Phase II.
In mother’s arms in Phase II the nurse could not get adequate reading on pulse oximeter. Stated “This equipment has not been working right.” 39

40. Standard VI Nursing Process Case
While child held by mother, became obtunded. When the mother told the nurse the child was having trouble breathing, it was too late.

41. Standard VI Nursing Process Case
Pt develops compartment syndrome after orthopedic procedure on leg.
Upon review of charting, there is no evidence of any capillary refill or pulse checks of lower extremities.
Assessment data not documented - so juries concur: if not documented, not done.

42. Clinical Practice Guidelines
Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia
Clinical Guideline for Pain and Comfort
Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV
All guidelines available on ASPAN Web Site. (
Talk about using the guidelines in your daily practice?
Available online or in the Journal - discuss key points, reinforce these are evidence based guidelines! 42

43. Practice Recommendations
Patient Classification/Staffing Recommendations
1A. Staffing Recommendation and Management of the Patient on Precautions

44. PR 1 - Patient Classification/ Staffing Recommendations
SIDEBAR:
It is difficult to prescribe staffing ratios for the day of surgery/procedure units based on wide variations across the country in the role and function of the nursing staff in these units.
When considering staffing patterns, patient safety is of highest priority with plans to accommodate patients with high acuity needs. 44

45. PR 1 - Patient Classification/ Staffing Recommendations
SIDEBAR:
The intent of this standard is that a nurse providing care to a Phase I patient is not left alone with the patient.
The second nurse should be able to directly hear a call for assistance and be immediately available to assist. 45

46. PR 1 - Patient Classification/ Staffing Recommendations
SIDEBAR:
Appropriate staffing requirements should be met to prioritize the safe, competent nursing care for the immediate postanesthesia patient, or the patient with the highest level of care needs, in addition to the care of the blended patient population.
Patient safety is of highest priority. 46

47. Practice Recommendations
Components of Initial, Ongoing, and Discharge Assessment and Management changed to Components of Assessment for the Perianesthesia Patient
Equipment for Preanesthesia/Day of Surgery Phase, PACU Phase I, Phase II, and Extended Care
Recommended Competencies for the Perianesthesia Nurse

48. Practice Recommendations
Competencies of Perianesthesia Support Staff
Safe Transfer of Care: Handoff and Transportation
The Role of the RN in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures

49. Practice Recommendations
Fast Tracking the Ambulatory Surgery Patient
Visitation in the Perianesthesia Care Unit
NEW***Obstructive Sleep Apnea in the Adult Patient 49

50. 2012-2014 Retirements Position Statements
Minimum Staffing in Phase I PACU
Has a PR
The Nursing Shortage
Visitation in Phase I
Perianesthesia Safety
Elevated to Perianesthesia Principles
These were deleted and the content incorporated into the Standards and Practice Recommendations. 50

51. Position Statements
Perianesthesia Patient with a Do-Not-Resuscitate Advance Directive
Registered Nurse Utilization of Unlicensed Assistive Personnel
“On Call/Work Schedule”
ICU Overflow
These are current.

52. Position Statements Med-Surg Overflow Safe Medication Administration
Older Adult
Pediatric Patient
Workplace Violence in the Perianesthesia Settings

53. Position Statements NEW** Substance Abuse in Perianesthesia Practice
Specialty practice areas have higher levels of substance
These areas involve physical, emotional and/or mental stress that may cause nurses to turn to substances
Also have a rather wide range of access to and availability of controlled substances.

54. Resources
Nine Provisions of the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements
American Society of Anesthesiologists (ASA) Standards:
Statement on Routine Preoperative Laboratory and Diagnostic Screening
ASA Basic Standards for Preanesthesia Care
ASA Standards for Postanesthesia Care
NEW***ASA Standards for Basic Anesthetic Monitoring

55. Resources
Association for Radiologic & Imaging Nursing (ARIN) Clinical Practice Guideline: Handoff Communication Concerning Patients Undergoing a Radiological Procedure with General Anesthesia

56. To Purchase Standards ASPAN 90 Frontage Road
Cherry Hill, NJ
Toll free
Fax

57. Bibliography
Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses, 2012

58. References
Atlee, John. Complications in Anesthesia. 2nd Edition. Philadelphia: Saunders Elsevier
Cole, Daniel and Michelle Schlunt. Adult Perioperative Anesthesia: The Requisites in Anesthesiology. Philadelphia: Mosby Elsevier. 2004
Drain, Cecil and Jan Odom-Forren. Perianesthesia Nursing: A Critical Care Approach. 5th edition. St. Louis, MO: Saunders Elsevier. 2009

59. References
Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care. Philadelphia: F.A. Davis Company. 2009
Reed, Alan. Clinical Cases in Anesthesia. 2nd Edition. New York: Churchill Livingstone.1995
Schick, Lois and Pamela Windle (Editors) PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd Edition. St. Louis, MO: Saunders Elsevier, 2010.

60. ONLINE References
His and hers heart disease accessed at
Obstructive Sleep Apnea. Accessed at
Pulmonary Disorders accessed at
Sutherland, Sara. “Pulmonary Embolism: Treatment and Medication” at
What is Obstructive Sleep Apnea (OSA)? Accessed at

61. THANK YOU Lois Schick MN, MBA, RN, CPAN, CAPA 12823 W. 3rd Place
Lakewood, CO 80228
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