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Getting Survey-Ready in 2022: Resuscitation

Sandy Garcia, RN, BSN, MBA, NHA, CJCP, Certified Black Belt Lean Six Sigma, Certified Change Agent
Associate Vice President, Regulatory Affairs and Behavioral Health Services

I’m writing a series of blogs about getting survey-ready in 2022. To read my earlier blogs, click the links below:

Stay tuned for a future blog on performance improvement.

All accrediting bodies are increasing their focus on resuscitation. You may be asking what that looks like for your organization and where should you start. First, the Joint Commission Standards/Elements of Performance related to resuscitation were effective on January 1, 2022. The Center for Medicare and Medicaid Services (CMS) has an existing requirement that resuscitation research location services are provided to the patient according to your organization’s policy, procedures and protocols. This involves performing your risk assessment and indicating where the equipment is needed to successfully resuscitate a patient.

Resuscitation Survey Process

You are going to be surveyed to your existing hospital policy or procedure protocols, and if you are going through a CMS survey, they get very specific as to the contents of your crash cart. Make sure that you follow your policy and that you are doing your defibrillator checks accordingly and ensure everybody knows how to do it too. We know resuscitation equipment needs to be available, and it must be based on the needs of the population you serve. For example, if you have a pediatric population, you should have pediatric resuscitation equipment. Be sure to do your literature searches and make certain you can support your decisions when surveyed. Check that your policy is revised to match the conditions of participation in the Joint Commission manual. Likewise, I believe there is a similar requirement from the other accrediting bodies.

Resuscitation Equipment Required by Joint Commission

For hospitals that use Joint Commission accreditation for deemed status purposes, at a minimum, operating room suites need to have the following equipment available:

  • Call-in system – process to communicate with or summon staff outside of the operating room, when needed,
  • Cardiac monitor – a resuscitator, hand-held or mechanical device that provides positive airway pressure,
  • Defibrillator,
  • Aspirator – a hand-held or mechanical device used to suction out fluids or secretions, and
  • Tracheotomy set.

Resuscitation Education and Training Requirements

The hospital is required to provide education and training to staff involved in the provision of resuscitation services. The hospital determines which staff should complete this education and training based upon their job responsibilities. Education and training need to be provided at the following intervals:

  • At orientation,
  • On a periodic basis thereafter, as determined by the hospital, and
  • When staff responsibilities change and/or when staff is transferring from unit to unit where resuscitation services may be different

The format, training intervals and content of education are determined by the hospital. Topics may cover resuscitation procedures or protocols, use of cardiopulmonary resuscitation techniques, devices or equipment, the roles and responsibilities during resuscitation events, skills day or mock code. As always, make sure you document this information in your policy.

New and Revised Commission Standards

There is a big focus on post-cardiac arrest care to identify, treat and mitigate processes after the cardiac arrest has occurred. These standards stem from the CMS’ new and revised requirements.

The hospital develops and follows policies, procedures or protocols based on current scientific literature for interdisciplinary post-cardiac arrest care.

Post-cardiac arrest care is aimed at identifying, treating and mitigating acute pathophysiological processes after cardiac arrest and includes evaluation for targeted temperature management and other aspects of critical care management. This requirement does not apply to hospitals that do not provide post-cardiac arrest care.

The hospital develops and follows policies, procedures or protocols based on current scientific literature to determine the neurological prognosis for patients who remain comatose after cardiac arrest.

Because any single method of neuroprognostication has an intrinsic error rate, current guidelines recommend that multiple testing modalities be incorporated into organizations’ routine procedures and protocols to improve decision-making accuracy. This requirement does not apply to hospitals that do not provide post-cardiac arrest care.

The hospital follows written criteria or a protocol for inter-facility transfers of patients for post-cardiac arrest care when indicated.

Hospitals need to have a protocol or written criteria approved by the medical staff. Be sure that transfer forms are completed and perform audits to confirm they are completed to their entirety.

There is a large focus on closed record reviews. The hospital will need to collect data on the following:

  • The number and location of cardiac arrests (for example, ambulatory area, telemetry unit, critical care unit),
  • The outcomes of resuscitation (for example, return of spontaneous circulation (ROSC), survival to discharge), and
  • Transfer to a higher level of care.

An interdisciplinary committee reviews cases and data to identify and suggest practice and system improvements in resuscitation performance. Examples of the review could include:

  • How often early warning signs of clinical deterioration were present prior to in-hospital cardiac arrest in patients in non-monitored or non-critical care units,
  • Timeliness of staff’s response to a cardiac arrest,
  • The quality of cardiopulmonary resuscitation (CPR),
  • Post-cardiac arrest care processes, and
  • Outcomes following cardiac arrest.

These are the requirements if your organization is accredited by The Joint Commission, however, they stem from CMS. They are good examples of the review process and what you can include. By performing your risk assessment and keeping your policies, procedures, protocols and training current, you can stay ahead of warning signs and mitigate outcomes.