CHAPTER 6. Practice Settings, Policies, and Procedures
Sara N. Waldron
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define the scope of practice for perianesthesia nursing.
2. Describe the preanesthesia phase of care.
3. Explain the three phases of postanesthesia care.
4. List three inpatient and three outpatient settings where perianesthesia nursing care is delivered.
5. Differentiate between a policy and a procedure.
6. Describe how a procedure is used to implement a policy.
7. Name three agencies or organizations that influence perianesthesia policies and procedures.
8. Identify policies and procedures that define practice in perianesthesia nursing settings.
I. SCOPE OF PRACTICE
A. Perianesthesia scope of nursing practice involves:
1. Assessment and intervention for, and diagnosis and evaluation of physical or psychosocial problems or risks for problems that may result from the administration of sedation/analgesia or anesthetic agents and techniques
2. Care of the patient and family/significant other along the perianesthesia continuum
a. Physical
b. Psychological
c. Educational
d. Cultural
e. Spiritual
B. Perianesthesia nursing practice is based on knowledge of:
1. Physiological and psychological responses
2. Vulnerability of patients subjected to:
a. Sedation/analgesia
b. Anesthetic agents and techniques
c. Specific surgical or procedural interventions
3. Principles of age-specific medical-surgical nursing and critical care nursing
4. Evidence-based practice
C. Perianesthesia nursing roles encompass:
1. Clinical practice
2. Education
3. Research
4. Management
5. Administration
6. Consultation
7. Advocacy
D. Perianesthesia nursing practice occurs in, but may not be limited to:
1. Hospital settings (inpatients and outpatients)
a. Preadmission assessment/testing unit
b. Preoperative/preprocedural holding area
c. Post anesthesia care unit
d. Same-day surgery units
e. Extended observation
f. Labor and delivery
g. Emergency department
h. Special procedure areas
(1) Interventional radiology
(2) Endoscopy
(3) Cardiac catheterization lab
(4) Electroconvulsive therapy (ECT)
(5) Pain management clinic
2. Outpatient settings
a. Ambulatory surgery unit
(1) Hospital based
(2) Free-standing center
b. Special procedure clinics
(1) Interventional radiology
(2) Endoscopy
(3) Cardiac catheterization
(4) ECT
(5) Pain management clinic
c. Office-based practice
(1) Dental
(2) Dermatology
(3) Ophthalmology
(4) Plastic surgery
E. Perianesthesia nursing during all levels of care includes the patient’s family/significant other and other supports whenever possible.
1. Preanesthesia phase
a. Preadmission: preparation for surgery/procedure
(1) Identify potential and/or actual problems
(a) Interview
(b) Physical assessment
(c) Diagnostic testing
(2) Develop plan of care
(3) Education/teaching
b. Day of surgery/procedure: final preparation for surgery/procedure
(1) Review/confirm collected data
(2) Physical assessment
(3) Implement plan of care
(4) Education/teaching
c. Preanesthesia patients separated from patients undergoing procedure and/or recovering from sedation/anesthesia
2. Postanesthesia
a. Phase I: acute care in the immediate postanesthesia period
(1) Focus on safety and comfort during recovery from:
(a) Sedation/analgesia
(b) Anesthetic agents and techniques
(c) Specific surgical or procedural interventions
(2) Utilize and amend plan of care.
(3) Prepare patient for transition to:
(a) Critical care inpatient unit
(b) General inpatient unit
(c) Phase II
(d) Extended observation
(4) Phase I care provided in close proximity to where sedation/anesthesia is administered
b. Phase II: care after the acute phase of recovery from sedation, analgesia, and anesthetic agents
(1) Patient and/family/significant other readied for discharge to self or assisted care
(a) Resolve elements in plan of care.
(b) Conclude education/teaching.
(c) Facilitate discharge arrangements.
(2) Patient is discharged to:
(a) Home
(b) Presurgical/preprocedural care setting/facility
(c) Extended observation
(3) Phase II care is provided in:
(a) Phase I unit
(b) Proximity to phase I unit
(c) Another area of the facility
c. Extended observation—ongoing patient observation after discharge from:
(1) Phase I level of care
(a) Patient meets discharge criteria but is waiting for transfer to inpatient unit.
(b) Patient meets discharge criteria but is waiting for transition to phase II level of care.
(2) Phase II level of care
(a) Patient requires prolonged observation until final outpatient discharge.
(b) Patient is waiting discharge to family/caregiver or facility.
(3) Extended observation is provided in:
(a) Phase I unit
(b) Phase II unit
(c) Another area of the facility
(4) Extended observation may include overnight stay.
II. POLICIES AND PROCEDURES
A. Policy
1. Definition
a. Set of principles used as a guide for action
b. Organizational rules to define desired outcomes
(1) Define the means to achieve organizational goals.
(2) Reflect and support organization’s vision and mission.
(3) Consistent with all applicable legal and regulatory requirements
2. The purpose of a policy is to:
a. Give direction: the action to take in a particular situation
b. Define responsibility and accountability: who is expected to take action
c. Define boundaries: specific actions included or excluded
d. Provide consistency: same action in each circumstance
e. Support objective decision-making: reference for deciding course of action and clarifying misunderstandings
f. Promote compliance: how to meet professional standards or external regulatory requirements
g. Assign authority: who oversees defined actions
h. Establish benchmarks: assess performance related to expectations of policy
B. Procedure
1. Definition
a. Instructions with detailed steps how to accomplish a task
b. Specific directions how to implement a policy
2. The purpose of a procedure is to:
a. Provide all information necessary to complete the task/action
b. Explain concisely how to do a task
c. Establish organization’s approved method of achieving the goal(s) of a policy
d. Serve as a:
(1) Guide for learning new tasks
(2) Resource for teaching new personnel
(3) Standard to assess performance related to compliance with accepted procedure
C. Policy and procedure format
1. Defined by organization and consistently applied. Includes:
a. Authorizing signatures
b. Approving body
c. Dates of implementation, review, and revision
d. Item, page and section numbering
2. Policy commonly followed by procedure in same document
a. Policy includes:
(1) Reason the policy exists
(2) Definition of terms
(3) Assignment of responsibilities
b. Procedure includes:
(1) Necessary resources/equipment
(2) Sequential steps
(3) Time frame requirements
(4) Documentation guidelines
(5) References
3. Policies and procedures require a process for review and revision.
4. Policies and procedures are readily accessible to staff.
a. Written
b. Electronic format
D. Perianesthesia policies and procedures
1. Guide and define the delivery of care in the perianesthesia setting
a. Congruent with:
(1) American Nurses Association Code of Ethics for Nurses With Interpretive Statements
(2) American Hospital Association Patient Care Partnership
(3) American Society of PeriAnesthesia Nurses Perianesthesia Standards for Ethical Practice
b. Comply with standards of accrediting bodies
(1) Joint Commission
(2) Centers for Medicare and Medicaid Services
(3) Accreditation Association for Ambulatory Health Care
(4) American Association for the Accreditation of Ambulatory Surgical Facilities
c. Consistent with state regulatory and licensing agencies
(1) Board of Nursing
(2) Health department/services
2. Benefit from collaboration among administrators, managers, and direct care perianesthesia nursing providers.
3. Incorporate research findings and evidence-based practices.
4. Require systematic review and timely revision in response to changes in:
a. Standards of practice
b. Regulatory requirements
c. Technology
E. The number and scope of policies and procedures in any practice setting is determined by the:
1. Nature of the perianesthesia unit or care area
2. Type of health care facility
3. Procedures performed
4. Services provided
5. Characteristics of the patient population
F. Examples of perianesthesia policies and procedures.
1. Administrative
a. Unit description, hours of operation
b. Job descriptions, hiring prerequisites, required certifications
c. Staffing patterns, availability, call back
d. Attire, professional conduct, personal communication devices
e. Employee health, annual testing or screening
2. Patient rights
a. Health Insurance Portability and Accountability Act (HIPAA)
b. Consents
(1) Surgical, procedural, anesthesia, blood products
(2) Emergency, minors, incompetency
c. Advance directives
d. Power of attorney
e. Ethical treatment
3. Environment of care
a. Supplies: inventory, procurement, storage
b. Equipment operation and maintenance
c. Fire and safety plans
d. Emergency preparedness and disaster response
e. Infection control, personal protective equipment
f. Hazardous material management: medical waste, anesthetic gases
g. Security: patients, staff, visitors, volunteers
h. Access to unit, restricted areas, visitation
4. Patient care (specific to each level of perianesthesia care)
a. Patient care management
(1) Anesthesia provider responsibilities and availability
(2) Physician orders: procurement and implementation
(3) Chain of command: nursing, medical, surgical, administrative
b. Admission and discharge criteria
c. Standards of care: diagnosis and age-specific patient care plans, or treatment protocols
d. Nurse-patient ratios
e. Assessment and monitoring guidelines
f. Medications: storage, access, administration, controlled substances, wastage, documentation
g. Patient education, discharge planning
h. Patient transportation, transfers
i. Translation services
5. Quality management/performance improvement
a. Staff orientation
b. Continuing education
c. Individual performance evaluation, competency assessment
d. Unit-specific and organizational performance improvement program
6. Information management
a. Medical record access, storage
b. Confidentiality and security
c. Release of information
BIBLIOGRAPHY
1. American Society of Anesthesiologists, Standards for post anesthesia care, Available at:www.asahq.org/publicationsandservices/standards/36.pdf ( 2004); Accessed June 20, 2008.
2. American Society of PeriAnesthesia Nurses, Standards of perianesthesia nursing practice 2008–2010. ( 2009)American Society of PeriAnesthesia Nurses, Cherry Hill, NJ.
3. In: (Editors: Drain, C.F.; Odom-Forren, J.) Perianesthesia nursing: A critical care approached 5 ( 2009)Saunders, St Louis.
4. Page, S.B., Establishing a system of policies and procedures. ed 6 ( 2002)Process Improvement, Westerville, OH.
5. The Joint Commission, Comprehensive accreditation manual for hospitals. ( 2008)The Joint Commission, Oakbrook Terrace, IL.
