HospitalInspections.org

Based on bylaws review and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment to the medical staff for 11 of 11 physicians (Physicians #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) providing electrocardiogram (EKG) and sleep study interpretation services through telemedicine. Failure to appoint practitioners to the medical staff places the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Cooperstown Medical Center Medical Staff Bylaws" occurred on 10/10/16 at 12:45 p.m. These bylaws, adopted 08/30/16, stated,
". . . Article VII. . . .
Section 7.07 Privileges to Practice Via Telemedicine
1) The Medical Staff shall determine which patient care services, if any, are appropriate for delivery at a distance via electronic or other technological means. . . .
b. Health Care Providers providing official readings of images, tracings or specimens through a telemedicine mechanism must do so under one of the following arrangements:
i. The HCP [Health Care Provider] is granted clinical privileges at both the originating and distant sites that include these services; or
ii. The hospital contracts for the provisions of these services by the provider. If the hospital contracts for the provision of these services, they must be provided consistent with the procedures addressed in the service contract. . . ."

Review of the governing board's "Bylaws of the Cooperstown Medical Center" occurred on 10/10/16 at 2:45 p.m. These bylaws, effective 12/02/14, stated,
". . . Article VII Medical Staff . . .
Section 2. Medical Care and its Evaluation . . .
The medical staff shall make recommendations of the Board of Directors concerning the following:
a. Appointments . . .
b. Granting of clinical privileges. . . ."

Upon request on 10/11/16, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved appointment/privileges for physicians providing EKG and sleep study interpretation services through telemedicine for the CAH's patients (Physicians #1 through #11).

During an interview on 10/11/16 at 4:55 p.m., an administrative staff member (#12) confirmed physicians #1 through #9 provided EKG interpretation and physicians #10 and #11 provided sleep study interpretation for the CAH's patients through telemedicine.

During an interview on 10/12/16 at 8:45 a.m., an administrative staff member (#12) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment/privileges of Physicians #1 through #11.

Based on observation, record review, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure registered nurses (RNs) administered medications in accordance with accepted standards of practice and the North Dakota Board of Nursing (NDBON) for 1 of 1 closed patient (Patient #14) record review who received anesthetic agents from an RN during an emergency procedure (rapid sequence induction/intubation (RSI)). This failure places patients undergoing RSI procedures at risk of adverse events.

Findings include:

The American College of Emergency Physicians (ACEP) Clinical and Practice Management Policy Statement, "Rapid-Sequence Intubation," dated April 2012, stated, "Rapid-sequence intubation (RSI) is an important technique for airway management of patients in the emergency department and is in the domain of emergency medicine practice. RSI is defined as a technique where a potent sedative or induction agent is administered virtually simultaneously with a paralyzing dose of a neruomuscular blocking agent to facilitate rapid tracheal intubation. . . ."

Review of information regarding RSI from the ACEP, the American Nurses Association, and the Emergency Nurses Association stated administration of medications for RSI by an RN is a specialized skill that requires a specific, advanced knowledge base and competencies including: airway management, cardiovascular support, the ability to recognize complications and intervene appropriately, and knowledge of the legal/liability ramifications associated with administering RSI medications. The institution must establish mechanisms to assure the RNs meet the knowledge and competency requirements. Evaluation and documentation of competency is recommended to occur on a periodic basis.

Review of the policy "Rapid Sequence Intubation" occurred on 10/11/16. This policy, dated 08/28/09, stated, "SCOPE: Healthcare Providers, RNs, LPNs, Respiratory Therapists. POLICY: Rapid sequence intubation is intended to assure a patent airway, prevent aspiration, and to oxygenate and ventilate the critically ill or injured patient. . . . PROCEDURE: . . . 8. Induction with sedative/hypnotic: Etomidate . . . (RNs may administer . . . 9. Defasciculate: Succinylcholine . . . (May be administered by RN. . . . 11. Neuromuscular blockade: Succinylcholine . . . (May be administered by RN. . . ."

Medication information from "Drugs.com," a trusted online resource for drug related information for healthcare professionals, about the medication Etomidate, revised June 2016, stated, "Etomidate . . . Indications and Usage . . . for the induction of general anesthesia. . . . Warnings . . . Etomidate should be administered only by persons trained in the administration of general anesthetics and in the management of complications encountered during the conduct of general anesthesia. . . ."

Turkoski, Lance, and Bonfiglio's "Drug Information Handbook for Nursing," 8th edition, 2007, pages 1149-1151 stated, "Succinylcholine . . . Neuromuscular Blocker Agent . . . Adjunct to general anesthesia to facilitate both rapid sequence and routine endotracheal intubation . . . Contraindications . . . personal or familial history of malignant hyperthermia . . . Nursing Actions: Physical Assessment: Only clinicians experienced in the use of neuromuscular blocking drugs should administer and/or manage the use of succinylcholine. . . ."

Turkoski, Lance, and Bonfiglio's "Drug Information Handbook for Nursing," 8th edition, 2007, pages 1098-1099 stated, "Rocuronium . . . Neuromuscular Blocker Agent . . . Adjunct to general anesthesia to facilitate both rapid sequence and routine endotracheal intubation . . . Nursing Actions: Physical Assessment: Only clinicians experienced in the use of neuromuscular blocking agents should administer and/or manage the use of rocuronium. . . ."

Review of the NDBON practice statement, "Role of the RN in Administration of Anesthetic Agents," occurred on 10/11/16. The practice statement, reviewed/revised July 2013, stated, "A licensed nurse who is not a Certified Registered Nurse Anesthetist may not administer general anesthesia or conscious /moderate sedation. The NDBON has determined there may be an exception to the above statement in the clinical settings described below: It is within the Scope of Practice for the Registered Nurse to administer pharmaceutical drugs classified as anesthetic agents used for the purpose of sedation for the client if the following requirements are met: . . . 2. During the intubation procedure in an emergency when assisting the licensed physician or anesthesia provider. . . . The facility must meet the following requirements: 1. Written policies and procedures are approved by the organization; 2. The Registered Nurse has completed a facility approved education program related to the above, and includes the following: Documentation of satisfactory completion of the education program; Supervised practice is on file with the employer, and there is supervised clinical practice during the educational process, which may be simulated; 3. The Registered Nurse is authorized to administer anesthetic agents by the organization; and 4. There must be qualified backup available as determined by facility policy to ensure client safety. Administration or management of patients receiving anesthetic agents used for the purpose of sedation is outside the scope of practice of the LPN [Licensed Practical Nurse]."

Observation of the emergency room (ER) occurred on 10/10/16 at 4:10 p.m. with an administrative nurse (#1). A refrigerator located within the ER contained a plastic bag of medications including: Succinylcholine, Rocuronium, and Etomidate, which the nurse (#1) identified as "RSI" medications. During an interview at this time, the nurse (#1) stated the charge nurse or RN administered the medications during an RSI procedure and confirmed all current RNs worked in the ER and as charges nurses. The administrative nurse (#1) stated she helped care for patients in the ER as needed.

Review of Patient #14's closed medical record occurred on the morning of 10/12/16 and identified the patient presented to the ER on 07/25/16 with shortness of breath and throat tightness. An admission history and physical (H&P) revealed the patient experienced throat tightness, chest tightness, edema, shortness of breath, and wheezing; and identified diagnoses of an anaphylactic reaction and respiratory distress. A provider order, written at 11:15 a.m., stated, "Prepare to intubate, give . . . Etomidate 20 mg [milligrams] IV [intravenous] . . . Rocuronium 70 mg IV . . ." A nurse note stated, ". . . [11:15 a.m.] . . . Orders received to prepare to intubate. [11:30 a.m.] [Patient] given meds. . . ." Review of the medication administration record showed an administrative nurse (#1) administered Etomidate 20 mg at 11:29 a.m. and Rocuronium 70 mg at 11:30 a.m. Patient #14's record identified an unsuccessful intubation after two attempts. A lifeflight crew arrived at 11:33 a.m., intubated the patient with success, and transferred the patient via airflight to a higher level of care.

Review of the CAH's current list of employees occurred on the afternoon of 10/11/16. The list showed eight RNs (Staff Members #2, #3, #6, #7, #8, #9, #10, and #11) and also identified the administrative nurse (#1) as an RN. During an interview at this time, when asked whether the RN's received training regarding administration of RSI medications, an administrative nurse (#1) stated the nurses received training a number of years ago prior to her role as an administrative nurse, but did not know whether the CAH kept documentation of the training.

During an interview on the morning of 10/12/16, an administrative nurse (#1) confirmed the CAH had no evidence of education/training or competency/evaluation for the RNs in regards to the RSI procedure or administration of RSI medications.