HospitalInspections.org

Based on review of the Tennessee Code Annotated, review of the American College of Surgeons job description for a Surgical Assistant, review of the Commission on Accreditation of Allied Health Education Programs for Surgical Assisting, review of facility job descriptions, review of competency checkoff lists, and interviews, the facility failed to ensure Certified Surgical Technologists (CST) functioned within their scope of practice for 1 CST (#3) of 4 CST's reviewed.

The findings included:

Review of Tennessee Code Annotated 68-57-105, Scope of Practice for Surgical Technologists dated 2010, showed "...'surgical technologist' means one who works under supervision to facilitate the safe and effective conduct of invasive surgical procedures. This individual is...supervised during the surgical procedure according to institutional policy and procedure to assist in providing a safe operating room environment that maximizes patient safety by performing certain tasks, including...Preparation of the operating room and the sterile field for surgical procedures by preparing sterile supplies, instruments, and equipment using sterile technique...preparation of the operating room for surgical procedures by ensuring that surgical equipment is functioning properly and safely; and passing instruments, equipment or supplies to a surgeon, sponging or suctioning an operative site, preparing and cutting suture material, holding retractors, transferring...assisting in counting sponges, needles, supplies, and instruments, and performing other similar tasks as directed during a surgical procedure..."

Review of Tennessee Code Annotated 68-57-101, Qualifications for employment of surgical technologists dated 2020, showed "...(a) Individuals employed as surgical technologists shall:
(1) Hold current national certification established by the National Board of Surgical Technology and Surgical Assisting (NBSTSA);
(2) Have completed a program for surgical technology accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP);
(3) Have completed an appropriate training program for surgical technologists in the armed forces or at a CAAHEP accredited hospital or CAAHEP accredited ambulatory surgical treatment center program...or
(4) Successfully complete the surgical technologists NBSTSA certifying exam.
(b) Any student who completes a surgical technology program that is in the process of becoming CAAHEP accredited on July 1, 2006, shall be considered a graduate of a CAAHEP accredited program..."

Review of Tennessee Code Annotated 63-6-219. Surgical assistants, dated 2020, showed "... The board shall register as a registered surgical assistant any applicant who presents satisfactory evidence that the applicant: (1) Holds and maintains a current credential as a surgical assistant or surgical first assistant issued by the National Board of Surgical Technology and Surgical Assisting, the National Surgical Assistant Association, or the National Commission for Certification of Surgical Assistants or their successors; (2) Has successfully completed a surgical assistant training program during the applicant's service as a member of any branch of the armed forces of the United States; or (3) Has practiced as a surgical assistant at any time in the six (6) months prior to July 1, 2017, provided the applicant registers with the board by December 31, 2019..."

Review of the American College of Surgeons "Surgical Assistant [SA] Job Description dated 3/29/2018, showed "...the first assistant in a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon completing the operation safely...SA should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment as a SA should include...specification of which surgeon the applicant will assist and the duties that will be performed...indication of which surgeon will be responsible for the supervision and performance of the SA...review and approval of the application by the hospital board....Surgeons are encouraged to participate of training of the allied health personnel...such individuals perform their duties under the supervision of the surgeon..."

Review of CAAHEP Surgical Assisting Occupational Description, undated, showed "...As defined by the American College of Surgeons, the surgical assistant provides aid in exposure, hemostasis, closure, and other intraoperative technical functions...In addition to intraoperative duties, the surgical assistant also performs preoperative and postoperative duties to better facilitate proper patient care. The surgical assistant to the surgeon during the operation does so under the direction and supervision of that surgeon and in accordance with hospital policy and appropriate laws and regulations...Job Description In general, surgical assistants have the following responsibilities: Determine specific equipment needed per procedure. Review permit to confirm procedure and special needs...Assist in moving and positioning of patient...Provide retraction of tissue and organs for optimal visualization with regard to tissue type and appropriate retraction instrument and/or technique. Assist in maintaining hemostasis by direct pressure, use and application of appropriate surgical instrument for the task, placement of ties, placement of suture ligatures, application of chemical hemostatic agents, or other measures as directed by the surgeon. Use electrocautery mono and bi-polar. Clamp, ligate, and cut tissue per surgeon's directive...Maintain integrity of sterile field. Close all wound layers (fascia, subcutaneous and skin) as per surgeon's directive...Select and apply wound dressings...Perform any other duties or procedures incident to the surgical procedure deemed necessary and as directed by the surgeon...Educational Programs Length. Current CAAHEP-accredited programs range from 12 months to 24 months. Surgical assisting is a specialty profession that requires specific training over and above a degree in science, nursing, physician assisting, or another health profession. Prerequisites. Recommended eligibility requirements for admission into a surgical assisting program are: Bachelor of Science degree (or higher), Associate degree in an allied health field, with 3 years of recent experience, CST, CNOR [Certified Nurse - Operating Room], or PA C [Physician Assistant Certified], with current certification, Three years of current operating room scrub and/or assisting experience within the last 5 years, Military medical training with surgical assistant experience...Students also must be able to show proof of successful completion of basic science (college level) instruction, including: Microbiology, Pathophysiology, Pharmacology, Anatomy and physiology, Medical terminology. Curriculum. Course content includes: Advanced surgical anatomy, Surgical microbiology, Surgical pharmacology, Anesthesia methods and agents, Bioscience, Ethical and legal considerations, Fundamental technical skills, Complications during surgery, Interpersonal skills, Clinical application of computers. Students must possess a working knowledge of operating room fundamentals, including aseptic principles and techniques, before moving on to the advanced levels of the program..."

Review of the facility's job description for a CST, last revised on 1/8/2020, showed "...facilitates patient care by assisting physicians and nursing staff before, during and after surgical procedures by creating and maintain a sterile field and providing the instruments and supplies required by the surgeons in a sterile manner according to the established plan of patient care...plans, sets up, performs, and cleans up the assigned surgical procedure as a circulator and/or as a scrub tech; demonstrates knowledge of equipment and instrumentation pertaining to case...maintains instrument and equipment integrity; performs room turn-over and terminal cleaning..." Further review showed "...licensure requirements: must hold current and active national Certified Surgical Technologist certification established by the National Board of Surgical Technology and Surgical Assisting [NBSTSA]..."

Review of the facility's job description for a CST II (2), created on 2/25/2020, showed "...under supervision of MD [Medical Doctor]/surgeon, facilitates patient care by providing surgical first assistant duties for the surgeon before, during, and after surgical procedures..." Further review showed "...minimum experience: 5 years of CST experience with concentrated training and demonstrated competency validated by direct Provider Experience and Surgery Department Manager or Director. Final review and approval for this level must come through competency checklist and System CNO [Chief Nursing Officer]...Licensure Requirements: must have and maintain current CST certification established by the National Board of Surgical Technology and Surgical Assisting [NBSTSA]..."

Review of the CST II (2)/Surgical First Assistant (FA) job competency, undated, showed "...demonstrate techniques to assist the surgeon with tissue dissection...demonstrate appropriate intraoperative behaviors which include handling tissue, providing exposure, using instruments appropriately and safely, providing hemostasis with suction, sponging, electrocautery...demonstrate different means of exposure for surgeon...able to articulate rationales for use of various techniques and demonstrate proper techniques for suture: continuous running, interrupted, mattress, buried, subcuticular, skin staples, topical adhesive...demonstrate proper application of sterile dressings..."

Review of facility job descriptions and competencies revealed there was no job description or competency for a Surgical Assistant (SA).

During an interview on 6/22/2020 at 3:20 PM, the Director of Surgical Services, stated the CST role was to pass surgical instruments to a surgeon during surgical procedures. The director stated because the facility did not have a job description for a SA, the facility created the CST II (2) role approximately one month ago. The facility reclassified SAs who met certain criteria as a CST II (2). The director stated the criteria required to be a CST II (2) included long term employment with the facility, the completion of 200 surgical cases, and a surgeon recommendation.

Review of CST #3's personnel file revealed she was employed as a CST/Surgical Assistant. Further review revealed no documentation of a surgeon recommendation that CST #3's job titles include CST II (2).

Review of facility documents showed no documentation the facility tracked or monitored suturing done by CSTs for performance or quality.

During a telephone interview on 6/23/2020 at 10:05 AM, CST #3 stated she had been employed at the facility for 15 years and her job title changed from a CST to CST II (2) on 5/23/2020. CST #3 stated she had not taken the CST-FA exam because she failed to meet the deadline to submit the required documentation for testing. CST #3 confirmed she had performed suturing on surgeries involving vascular, gynecology, and orthopedic procedures after the procedure was complete and the surgeon had exited the room.

During an interview on 6/23/2020 at 2:45 PM the Director of Surgical Services stated "...the CST can pass instruments and hold retractors as directed by the physician. Under the CST 2 role the CST can assist with closures and assist the surgeon with the case...[CSTs 2] have had additional training...[CST #3] was the only CST who was currently suturing, but there were 3 additional CSTs who were designated as CST 2..." The Director of Surgical Services confirmed there was no scope of practice for the CST II (2) role, to include suturing of surgical sites.