Accreditation

Preanesthesia assessment tool impresses surveyors

Briefings on The Joint Commission, May 1, 2005

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One hospital's preanesthesia assessment tool impressed JCAHO surveyors so much that they didn't even look at patient history and physicals (H&P).

The tool belongs to Peninsula Regional Medical Center in Salisbury, MD, a 332-bed acute care hospital surveyed in November. It meets PC.13.20 EP 10, which requires performance of a presedation or preanesthesia assessment, and it doubles as the facility's universal form for conscious sedation.

"Surveyors were so impressed with the form we used," says Donna Thompson, RN, BSN, performance improvement director. "They saw consistency in its use throughout the organization. They had nothing bad to say about it."

Of course it doesn't take the place of an H&P, it's simply a preanesthesia presedation form, and because it meets all the requirements of an H&P, the surveyor did not scrutinize the H&P when he saw it, says Linda Townsend, RN, director of the hospital's post-anesthesia care unit, same-day surgery (SDS), and preanesthesia.

"They thought it was perfect," says Townsend. "The [physician] surveyor saw it on every chart, wherever he went. Once he saw it, he was looking for it. And he saw it everywhere."

Building the tool

The idea for the tool originated from a mock survey conducted early in 2004, during which Townsend realized staff were relying on written progress notes to comply with the standard and everyone had different ways of doing them. Some were thorough, but others had random or incomplete information.

The notes could read simply, "no previous problems with anesthesia," or could be a page and a half long, depending on the anesthesiologist.

"Now they have no choice; they have to fill it all in," Townsend says. "It makes it better for patient care all around."

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