Nurses as police

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Anybody else hear of this..?

The main hospital of my program is about to undergo JACHO inspection. We were recently told that we have to carry copies of our credentials (for procedures) to produce on demand to any nurse who wants to see them.

The nurses are undergoing assertiveness training in order to better enable them to question our ability to perform procedures.

Apparently, they can demand to for us to prove we are credentialed to perform a procedure. If we don't show them the appropriate document, they can prevent us from performing a procedure. (Mind you, "procedures" include things like d/cing central lines)

When we protested how ridiculous this is, we were told that this is a nationwide requirement for the hospital to pass inspection.

None of my friends at other programs have heard of this. Has anybody in SDN land?

 

[Seaglass]

Never heard of it. Unlike at my previous hospital we don't undergo formal credentialing (sp?) here. At the other place it was like do 5, then credentialed. Here it's like "You feel OK with this?" and then go for it.

Anyway the gist of it is, I wouldn't have anything to show them.

 

[Winged Scapula]

What kind of "credentials" do they require? As residents, I wasn't aware that we were "credentialed" in anything, although we do keep track of procedures/surgeries done.

I sure haven't heard of this as a JCAHO requirement, although I wouldn't be suprised that there is more attention to unqualified people doing invasive procedures.

BTW, do you really have to remove central lines? Don't the nurses do it for you?

 

[soon2bdoc2003]

dont sweat it.. jcaho crap is for nurses and administrators to deal with. When the hospital I was in underwent inspections last year they repainted, cleaned, and stocked every cabinet and closet the way it should be stocked. During the week of inspection all of my IV's were in and working, I was never called because an idiot nurse couldnt read my handwriting, and all of my order were processed in a timely manner. The inspectors never interacted with us at all.

 

[docB]

I've never heard of the exact brand of pain your hospital is sticking to you but it is my experience that with every JACHO cycle something gets blown out of proportion and taken to extremes. On my last JACHO it was abbreviations. We could'nt use any abbreviations or the pharmacy could have us shot. JACHO is just another hurdle/ roadblock to deal with and it will never die. Take comfort in the fact that their lives are futile as they really just make people change the way they do things for a week at a time.

 

[njbmd]

Anybody else hear of this..?

The main hospital of my program is about to undergo JACHO inspection. We were recently told that we have to carry copies of our credentials (for procedures) to produce on demand to any nurse who wants to see them.

The nurses are undergoing assertiveness training in order to better enable them to question our ability to perform procedures.

Apparently, they can demand to for us to prove we are credentialed to perform a procedure. If we don't show them the appropriate document, they can prevent us from performing a procedure. (Mind you, "procedures" include things like d/cing central lines)

When we protested how ridiculous this is, we were told that this is a nationwide requirement for the hospital to pass inspection.

None of my friends at other programs have heard of this. Has anybody in SDN land?

Hi there,
I have never heard of this and I suspect that it will quickly fade into the sunset. As Kimberly said, "Don't the nurses d/c the central lines?"

njbmd 🙂

 

[Winged Scapula]

I've never heard of the exact brand of pain your hospital is sticking to you but it is my experience that with every JACHO cycle something gets blown out of proportion and taken to extremes. On my last JACHO it was abbreviations. We could'nt use any abbreviations or the pharmacy could have us shot. JACHO is just another hurdle/ roadblock to deal with and it will never die. Take comfort in the fact that their lives are futile as they really just make people change the way they do things for a week at a time.

Good point - every hospital DOES seem to act or overreact when its JCAHO time. I can always tell when an inspection is coming up - the halls between the ORs and PACU are suspiciously bereft of clutter.

Last time we were inspected the "big deal" was a) abbreviations (for awhile the nurses were requesting that residents rewrite their orders when using a banned abbreviation. I found however, that if they liked you, they would simply rewrite it for you and not bother you.) and b) food/drinks at the nurses stations, counters. For this particular soda drinker that was much harder to change than writing out "Morphine Sulfate". Now that inspectors are gone, the nurses have relaxed their "rules" about leaving drinks around.

 

[docB]

For this particular soda drinker that was much harder to change than writing out "Morphine Sulfate".

I don't think writing out morphine sulfate is good enough. I think everyone should write "injectable refined opium poppy derivative" and then have to draw the chemical structure. The problem is that just writing morphine sulfate I'm still able to deliver some health care and the apparent goal of JACHO was to stop that. They could also mandate that I write all orders on parchment in caligraphy in my own blood. That would slow me down even more.

 

[supercut]

I'm not worried about the inspectors. I know they won't bother us. The most annoying thing right now is that housekeeping is busily waxing floors all over the hospital, and attending to things like cleaning our call rooms even less than they usually do.

I am a bit concerned about the fact that it seems that nurses might be allowed to stop us from doing a procedure. Up until now, we got credentialed at our six month reviews by the PD asking if we felt comfortable doing things. He reads a list of things that are approprate for each level. There is no way interns would ever be credentialed for putting in lines or chest tubes. But the list does include foleys, d/c central lines (nurses do put in foleys but aren't allowed to d/c central lines), inserting subclav, IJ, femoral lines, inserting and d/cing chest tube, intubation....all the way up to emergency laparotomy and thoracotomy. Now we acutually have to get an attending to sign off a certain number of times for each procedure. (they haven't decided if they will let the chief resident sign off). We still won't be offically credentaled til our next 6 month meeting with the PD

OUr nurses are pretty aggressive. If they decide they want something in particular, they will stop at nothing to get it. One example...last year as an intern a nurse paged me in the wee hours to demand that I restart a pt (who I am cross covering) home lantus insulin dose. I say, no leave that to the primary team in the morning, because they know the pt. She says but they are planning to discharge the pt in the am. I say it's not up to the cross cover to make changes in the med regimine, and the pt is adequately covered by sliding scale. About 1.5 hrs later, same nurse pages me and says I just talked to the chief resident for that pt's service and he told me to tell you to order the lantus. I say, if he wants me to do it he can call me himself. Needless to say, he never called me. Nurses here do that kind of stuff all the time. They do this WITHOUT the assertivness training.

So eventually, some poor resident will want to put in a line (after having done a bunch) but doesn't have it on the offical credeitaling sheet, and some nurse will demand to see the sheet and then tries to stop him from putting in a line. In this environment, I'm sure it will happen at some time.

Glad to know that no one else has to put up with this.

 

[edmadison]

I've never heard of the exact brand of pain your hospital is sticking to you but it is my experience that with every JACHO cycle something gets blown out of proportion and taken to extremes. On my last JACHO it was abbreviations. We could'nt use any abbreviations or the pharmacy could have us shot. JACHO is just another hurdle/ roadblock to deal with and it will never die. Take comfort in the fact that their lives are futile as they really just make people change the way they do things for a week at a time.

Except that starting next year (I think) all JHACO inspections will be unannounced.

Having standards to aim for is a good idea. It's unfortunate that most institutions don't care about them except when there is an inspection. Hopefully the new rule of unannounced inspections will improve quality overall.

Ed

 

[notstudying]

We are in the same boat as the OP. As a peds resident I haven't exactly been raking in the procedures, but we are required to be able to prove that we are signed off on a procedure to a JCAHO rep or nurse who questions it, if we are doing it unsupervised. Of course, we can be signed off on a procedure if we have done it once successfully, so for us it's not particularly onerous. We have a JCAHA visit coming up as well, and this is clearly in response. We are also getting hourly (ok, I might be exaggerating) reminders about abbreviations (was that a trailing 0 or a leading 0 we can't use) and HIPAA (you mean we aren't supposed to talk about patients in a crowded elevator?), among other scintillating topics.

 

[Apollyon]

I don't think writing out morphine sulfate is good enough. I think everyone should write "injectable refined opium poppy derivative" and then have to draw the chemical structure.

You realize that this order would mean you could also be ordering heroin? Even so, I said last year that, if I ever came back to the VA, I would be ordering heroin for a patient (since I'd done the Marinol and beer), but I finished my SICU month with minimal opiate abuse (but two patients over-narced to needing Narcan - bummer!).

 

[southerndoc]

Anybody else hear of this..?

The main hospital of my program is about to undergo JACHO inspection. We were recently told that we have to carry copies of our credentials (for procedures) to produce on demand to any nurse who wants to see them.

The nurses are undergoing assertiveness training in order to better enable them to question our ability to perform procedures.

Apparently, they can demand to for us to prove we are credentialed to perform a procedure. If we don't show them the appropriate document, they can prevent us from performing a procedure. (Mind you, "procedures" include things like d/cing central lines)

When we protested how ridiculous this is, we were told that this is a nationwide requirement for the hospital to pass inspection.

None of my friends at other programs have heard of this. Has anybody in SDN land?

We are required to carry a punch card at all times. When we are certified in a procedure, we get that procedure punched with a weird looking punch (so we can't use just any regular punch and do it ourselves).

The procedures listed are:
- Dobbhoff
- Central Lines (separate IJ, femoral, subclavian)
- Art Line
- Chest Tube
- Paracentesis
- Thoracentesis
- LP
- Pelvic Exam
- Conscious Sedation
- Airway Management (Intubation)

I think I left out one or two.

 

[southerndoc]

There is no way interns would ever be credentialed for putting in lines or chest tubes.

Interesting. Are most hospitals reluctant to let interns start central lines? I have done quite a few as an intern with only 4 months experience, and I've done even more as a fourth-year medical student.

 

[supercut]

Interesting. Are most hospitals reluctant to let interns start central lines? I have done quite a few as an intern with only 4 months experience, and I've done even more as a fourth-year medical student.

Dont know about most. Like you I did lines as a M4, probably about 25. Got 10 chest tubes. (Med school in the south) Now a resident in the northeast, I did one line as an intern and 2 chest tubes. My chest tube total as R2 is much better (did trauma early), but not many lines yet. At my current program, there is a great deal of reluctance to do any central line on the floor. Any floor pt who needs central access gets a PICC, which is put in by the PICC nurses. Only floor pts who get a line are those that crump and are ICU bound. Lines are really only put in in the ICU and the ED. This is one of many things I hate about my current program.

 

[southerndoc]

Dont know about most. Like you I did lines as a M4, probably about 25. Got 10 chest tubes. (Med school in the south) Now a resident in the northeast, I did one line as an intern and 2 chest tubes. My chest tube total as R2 is much better (did trauma early), but not many lines yet. At my current program, there is a great deal of reluctance to do any central line on the floor. Any floor pt who needs central access gets a PICC, which is put in by the PICC nurses. Only floor pts who get a line are those that crump and are ICU bound. Lines are really only put in in the ICU and the ED. This is one of many things I hate about my current program.

Like you, I also attended medical school in the South and currently completing a residency in the Northeast.

Maybe it's just a southern thing to let medical students do more procedures. Like you, I also did quite a few central lines (subclavians, IJ's, femorals), chest tubes, percutaneous trachs, PEG placements, needle chest decompression, and even an emergent thoracotomy. I had an awesome surgical/critical care rotation where the resident played the role of teacher/supervisor alongside the attending, and the fourth-year medical student was expected to perform the procedures. It was awesome!

 

[thegasman]

This nurse police thing has been discussed at my institution as well. They've planned for each resident to have approved procedures listing on the computer, and when you are about to perform one the nurses are supposed to check and make sure you have privilges. This seems a little ridiculous to me. I think it is sort of an internal medicine driven thing at my hospital. The im interns do very few procedures. Doing a line for the medicine service or in the MICU seems to always involve a full complement of residents, interns, fellows, attendings, everyone. THis is different for surgery. I was doing lines by myself on July 1 of intern year in sicu, with supervision available only if I needed it.

 

[axm397]

I have rotated at two institutions where they utilize an online program called new innovations to credential residents to do certain procedures - residents either need to be supervised or can do independently - nurses have access to new innovations credentialing program and they can go online and check to see if a certain resident is allowed to perform a procedure by himself.

I know at my institution there was a problem during codes because the medicine resident wanted to administer conscious sedation before cardioverting and intubating but the nurse insisted that he did not have the proper credential to administer versed. This was confirmed by the head of nursing/risk management dept at the institution.

I know residents were upset about this - since it interferes with good patient care. We're going to see if we can take a few hour course to get credentialed - otherwise, we have to get anesthesia to come every time

Ironically, when we rotate at another affiliated institution in their ICU, we are allowed to administer conscious sedation. hmmmmm

 

[The White Coat Investor]

We are required to carry a punch card at all times. When we are certified in a procedure, we get that procedure punched with a weird looking punch (so we can't use just any regular punch and do it ourselves).

The procedures listed are:
- Dobbhoff
- Central Lines (separate IJ, femoral, subclavian)
- Art Line
- Chest Tube
- Paracentesis
- Thoracentesis
- LP
- Pelvic Exam
- Conscious Sedation
- Airway Management (Intubation)

I think I left out one or two.

If we're going to start credentialing pelvics I wanna start charging "procedure" prices for them.

 

[caroladybelle]

Like we have the freakin' time to police you guys, they must be kidding.


(Psst. I promise never to ask as long as you are polite and wearing your hospital ID)