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Everything your healthcare organization needs to confidently maintain accreditation compliance.
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Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
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Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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Helpful MCN Healthcare Resources
The Joint Commission (TJC) has issued revised requirements for Ambulatory Surgical Centers (ASC) in order to better align with Centers for Medicare & Medicaid Services (CMS) requirements. The revised elements of performance are applicable to ASCs that use The Joint Commission for deemed status and are effective December 19, 2014.
Today's notice reviews revisions to the ASC Human Resources chapter. TJC is now requiring that in addition to staff participating in ongoing education and training that they specifically participate in education and training about the staff member's specific role in the facility's fire response plan. Remember this revision applies only to ASCs that use The Joint Commission for deemed status.
StayAlert is currently reviewing the remainder of the new requirements and will publish additional information soon. Included with today's notice is an example policy reflecting TJC's revisions.
Baxter International Inc. is voluntarily recalling two lots of INTRAVIA containers in the U.S. and Canada due to complaints received for particulate matter found inside the fluid path. Intravenous administration of a solution containing sterile particulate matter may lead to adverse health consequences. The extent and severity of harm depends on the size, number, and composition of the foreign material, and patient's underlying medical condition. There have been no reported adverse events associated with this issue to date.
INTRAVIA containers are empty plastic containers with PVC ports and a sterile fluid path. The recalled lots are INTRAVIA Container, 150 mL Capacity, Lot Number UR13D15112, Product Code 2B8011, distributed to customers between April 26, 2013 and June 20, 2013; and INTRAVIA Container, Empty 500 mL Capacity, Lot Number UR13K14095, Product Code 2B8013, distributed to customers between November 27, 2013 and March 10, 2014. Unaffected lot numbers can continue to be used according to the instructions for use.
Baxter has notified customers, who are being directed not to use product from the recalled lots. Recalled product should be returned to Baxter for credit by contacting Baxter Healthcare Center for Service at 1-888-229-0001, Monday through Friday, between the hours of 7:00 a.m. and 6:00 p.m., Central Time. Unaffected lots of product are available for replacement. Consumers with questions regarding this recall can call Baxter at 1-800-422-9837, Monday through Friday, between the hours of 8:00 a.m. and 5:00 p.m. Central Time, or e-mail Baxter at email@example.com.
Consumers should be instructed to contact their physician or healthcare provider if they have experienced any problems that may be related to using this drug product.
CDC Issues Recommendations for Safely Performing Acute Hemodialysis in Patients with Ebola Virus Disease in U.S. Hospitals
The U.S. Centers for Disease Control and Prevention (CDC) has issued guidance in order to convey information to hospital-based dialysis providers about safely performing renal replacement therapy (hemodialysis) in persons confirmed to have Ebola virus disease (Ebola). Acute renal failure requiring renal replacement therapy can occur in critically ill patients infected with Ebola virus. The recommendations and information below are specific for hemodialysis and should be implemented with the precautions described in the document entitled, "Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals"
Below is a summary of the key recommendations for performing hemodialysis in patients with Ebola. Prior to initiating dialysis treatment on confirmed Ebola patients hospitals are strongly encouraged to contact the CDC for any updates or additional guidance.
Summary of Recommendations:
- Patient care of patients with Ebola should be provided in a hospital with capacity to perform continuous renal replacement therapy (CRRT). Efforts to minimize direct blood exposure to healthcare personnel and blood contamination of the environment are of principal importance due to the high concentration of Ebola virus that can be present in an infected patient's blood and the large volumes of blood involved in hemodialysis.
- Hemodialysis/CRRT should only be performed in the patient's isolation room.
- Only staff designated as "highly competent" and who have also been trained to follow CDC guidelines for use of personal protective equipment should be allowed to perform catheter insertion.
- Catheter placement location and insertion should be planned before the process is executed. The planning stage should include the following considerations:
o Establishing vascular access for dialysis
o The movement and number of healthcare personnel involved in hemodialysis /CRRT procedures
o Personal protective equipment use: all staff involved in providing dialysis shall be trained and follow CDC recommendations for PPE use
o Use of a dedicated hemodialysis/CRRT machine that is kept in the isolation room until terminal disinfection procedures are undertaken. The machine used should be familiar to the staff who will perform dialysis shall be used.
o Proper disposal of all other dialysis-related supplies, including dialyzer and effluent
o Appropriate selection and use of machines for CRRT and intermittent hemodialysis
o Machine decontamination/terminal disinfection
Featured Policy Library Manuals
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
MCN's Central Service Policy and Procedure Manual provides over 200 proven, up-to-date policies and procedures in a ready-to-customize format. This manual is cross referenced to federal regulations, as well as Joint Commission and NIAHO standards. References used include AAMI Recommended Practices, IAHCSMM Central Service Technical Manual, ASHCSP Training Manual for Health Care Central Service Technicians and AORN Recommended Practices.Read more »
MCN's Post Anesthesia Care Policy and Procedure Manual is a comprehensive resource that covers the latest "hot topic" regulatory and patient safety issues that are relevant to PACU! This manual includes administrative, operational, functional and patient-centered policies and procedures. Policies and procedures are cross-referenced to CMS regulations, Joint Commission standards and NIAHO standards.Read more »