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The Joint is Coming, The Joint is Coming: The JCAHO's new focus is on moderate sedation, pain management, restraint management, and peer review

Davidson, Steven J. MD, MBA

doi: 10.1097/01.EEM.0000334176.80092.0a

Dr. Davidson is the chairman of the department of emergency medicine at Maimonides Medical Center, a professor of clinical emergency medicine at SUNY-Health Science Center in Brooklyn, NY, and a principal in Emerging Medical Concepts (, a medical leadership development and support consulting organization. He can be reached at

Every three years or so, most of our hospitals are visited by the Joint Commission on Accreditation of Healthcare Organizations. Its mission, according to the JCAHO, is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits nearly 18,000 health care organizations and programs in the United States. An independent, non-profit organization, the JCAHO is the nation's predominant standards-setting and accrediting body in health care.”

For the emergency physician, “Joint Commission year” includes reviewing ED policies and procedures with our nursing colleagues, and addressing issues in hospital-wide policies and procedures that include aspects relevant to the ED. We're asked to review and update these so the policies and procedures reflect current reality. This is important work but routine.

What's not routine and critically important is reviewing any of the issues cited by the Joint Commission on its last review of your hospital and any new or revised standards with particular relevance to the ED. This year we are looking toward our Joint Commission survey in October or November, and we're particularly focused around the areas of moderate sedation (formerly “conscious sedation”), pain management, and restraint management. Peer review is always an area for JCAHO scrutiny, and recent standards updates are prescriptive in their requirements. We've substantially increased the detail in our peer-review policy, and have been part of an effort that revamped peer review across all departments that resulted in a new hospital medical staff peer review committee.

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Moderate Sedation

Moderate sedation in the ED is an increasingly common practice to avoid the pain associated with procedures ranging from fracture and dislocation reduction to incision and drainage of abscesses. As a colleague recently put it on the emed-l mailing list, “Expectations have changed. It isn't OK to use Brutane [two nurses and an aide holding down a patient] for a painful procedure in this day and age.”

Credentialing for moderate sedation is a hospital medical staff function that is delegated to department chairpersons. A single hospital-wide standard is required, but that does not mean that the standard must be that of the department of anesthesia alone. In fact, once the chairman of anesthesia realizes how much moderate sedation is administered in your ED, he will be delighted to support your credentialing process, which should ensure that emergency physicians are experienced with airway management (usually not an issue) and familiar with the pharmacology of sedating agents.

The latter is usually tested with a single multiple-choice test used across the hospital for credentialing any physician who wishes to include moderate sedation as part of his practice. Working with the department of anesthesia to create the test will help win friends and influence people, especially because it will bring the clinicians' perspective to an exercise that might otherwise be excessively focused on pharmacology. Your colleagues in gastroenterology, orthopedics, and radiology will thank you.

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Pain and Restraints

How might you address the pain management and restraint management standards? Your hospital and nursing staff almost certainly already have addressed this issue, and created the policy and procedures necessary for implementing these standards. They've discussed what is expected from physicians as part of pain management and restraint management, and have probably cajoled you to exhort your physician colleagues to do a better job in documenting pain evaluation and ordering restraints.

You and your colleagues can contribute effectively by working with your nursing staff through open record audits. Using the audit form your QA reviewers used on closed, completed records, a staff emergency physician arriving 30 minutes early for a shift can review the records of several patients present in the ED at that time who have complained of pain or have been restrained. Engaging the department's own physician staff in the open record review helps convince nursing leadership and hospital administration of your interest.

The review with on-the-spot criticism from a physician colleague will speed learning and necessary behavior change so that the one year of compliance necessary in advance of your JCAHO survey will be more easily achieved. The effort of coming to work early for a few shifts each is not much but will impress those with whom you work.

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Peer Review

Peer review is a specifically physician-focused aspect of the JCAHO survey process. Standards promulgated more than 18 months ago now require a great deal of attention to and documentation of process that may have been handled less formally in previous years.

Particularly with smaller, single hospital groups, the process now required including advance specification of who may participate in peer review, a process for gaining input from the physician whose care is under review, and explicit criteria for seeking an external review must now be incorporated into your departmental process. Consistently reporting determinations so that data can be aggregated across departments and the medical staff can be assured that a sufficient number of cases are reviewed are part of the new standard.

Getting started on the JCAHO review at least one year ahead of your anticipated survey will give you sufficient evidence of compliance with JCAHO standards, but living day by day in accordance with the standards, while a worthy goal, is a challenge made all the greater by the constant changes in standards.

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Emergency Medicine News welcomes opinion pieces from physicians on any topic related to emergency medicine. Articles should be about 800 words, and submitted if possible by e-mail. Contact:

Lisa Hoffman, Editor

Emergency Medicine News

345 Hudson St., 16th Fl.

New York, NY 10014

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Restricting Contact between Trainees and Pharmaceutical Representatives Affects Future Behavior

A survey of Canadian physicians finds that restricting contact between internal medicine residents and pharmaceutical company representatives appears to influence physicians' future attitudes and behavior, according to an article in the Oct. 24/31 issue of the Journal of the American Medical Association.

Investigators at the University of Toronto, Mount Sinai Hospital and University Health Network in Toronto surveyed physicians to determine if the presence of a restrictive policy and the frequency of contact with pharmaceutical company representatives during internal medicine training predict attitudes and behavior several years after completion of training. Surveys were sent to physicians who trained at the McMaster University Department of Medicine in Hamilton, Ontario, which implemented a policy restricting pharmaceutical representatives from having contact with trainees in 1992, and the University of Toronto, which has no such policy.

The authors mailed surveys to 242 former University of Toronto and 57 former McMaster trainees who completed their internal medicine training between 1990 and 1996. A total of 163 (67%) of Toronto graduates and 42 (74%) of McMaster graduates responded. The authors compared responses of McMaster graduates who trained under the restrictive contact policy with Toronto graduates and McMaster graduates who trained before the restrictive policy went into effect.

Post-policy McMaster graduates were significantly less likely to find pharmaceutical representatives information helpful in guiding their practice compared with Toronto graduates [56% less likely], the authors reported. There was a similar trend comparing post-policy with pre-policy McMaster graduates [post-policy graduates 61% less likely to find pharmaceutical representatives' information helpful].

The study did not address whether permitting or restricting contact with pharmaceutical representatives during residency training affects future prescribing behavior. The authors say they do not believe all contact with industry results in inappropriate prescribing.

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Fatal Adverse Drug Events a Major Hospital Problem

Fatal adverse drug events are a significant cause of deaths in hospitalized patients, especially for elderly patients with multiple diseases, according to an article in the Oct. 22 issue of the Archives of Internal Medicine.

Investigators at the Central Hospital of Akershus, Nordbyhagen, Norway, studied the clinical records, autopsy results and findings from drug analyses performed before and after death for 732 patients who died after admission to the Department of Internal Medicine at the Central Hospital of Akershus in Norway. The study was conducted from October 1993 through November 1995 to assess the two-year incidence of drug-related deaths in a major medical department and search for patient characteristics associated with an increased risk of fatal adverse drug events.

The authors found that in 18.2 percent of the patients (133 out of 732), death was classified as directly or indirectly associated with one or more drugs. This equals 9.5 deaths per 1,000 hospitalized patients. The most common drugs associated with fatal adverse drug events were cardiovascular drugs, anti-thrombotic drugs, and sympathomimetic agents.

Adverse drug reactions may be among the six leading causes of in-hospital deaths in the United States. Reported frequencies of fatal adverse drug reactions or fatal adverse drug events vary between 0.9 and 6.5 per 1,000 hospitalized patients.

The authors report that men with fatal adverse drug events were significantly older than those without fatal adverse drug events; there was no age difference found among women. The number of drugs used on hospital admission was higher in the fatal adverse drug events cases; the proportion of adverse drug events was higher in those who died of gastrointestinal diseases and lower in those who died of cancer and respiratory diseases. The median time to death was three days.

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The Mechanisms of Environmental Disease

The National Institute of Environmental Health Sciences (NIEHS) has allocated $37 million over five years to create a Toxicogenomics Research Consortium to study how individual genetics affects the way people respond to various environmental agents, from asbestos to tobacco smoke.

The studies are expected to help answer puzzling questions such as why some people who have never smoked develop lung cancer while others who have smoked heavily for years show no signs of the disease. The NIEHS expects that a better understanding of how disease occurs will shed light on ways of identifying at-risk individuals, recognizing potential environmental hazards, and predicting and preventing many diseases.

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Geriatricians Question DEA Medical Knowledge

Do Drug Enforcement Agency agents understand the medical complexities of end-of-life treatment? The American Geriatrics Society says not, and expressed concern about the implications of the recent directive from U.S. Attorney General John Ashcroft giving the agency authority to investigate physicians for the possible use of controlled substances to help terminally ill patients commit suicide.

“Statements from the DEA that it is easy to tell the difference between proper sedation and euthanasia indicate a basic lack of understanding of the medical complexities of end-of-life treatment issues,” said AGS President Kenneth Brummel-Smith, MD.

“DEA officers simply are not properly trained to review medical charts, and make determinations about palliative treatment for seriously ill and terminal patients. The involvement of the DEA is not likely to solve problems of assisted-suicide, but rather to exacerbate them.”

The AGS opposes physician-assisted suicide, but says it is even more concerned over the new role DEA agents will be playing and the effect it may have on prescribing practices. “Physicians who know they are being officially second-guessed may reduce the amount of medication they authorize and underprescribe pain medication,” said Dr. Brummel-Smith. “We fear that DEA oversight will cause an exacerbation of end-of-life pain and suffering for many sick, elderly, and dying patients.”

© 2002 Lippincott Williams & Wilkins, Inc.