Dear ENA Members,

On February 8, 2008 CMS sent revised interpretive guidelines to State Survey Agency Directors across the country. These revised guidelines are intended as direction to CMS surveyors on how standards are to be interpreted during inspections. In these revised guidelines was language affecting the way ED nurses and physicians handle standard treatment protocols and standing orders.

According to the memo, “If a hospital uses other written protocols or standing orders for drugs or biologicals that have been reviewed and approved by the medical staff, initiation of such protocols or standing orders requires an order from a practitioner responsible for the patient’s care.”

ENA first became aware of this situation following reports from ED physicians who had experienced "difficulty" with the Joint Commission surveyors in regards to advance treatment protocols during their accreditation surveys. Whether this more restrictive, and potentially dangerous, interpretation of accreditation standards was first initiated by the Joint Commission or CMS is unclear. What is clear is that this new interpretation will have a strong negative impact on our patients and departments.

ENA, the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM) have been in contact with the Joint Commission. Each organization has expressed deep concerns about this new, more restrictive interpretation of standards. Not only do these restrictions slow patient care, they also infringe on a nurse’s scope of practice as determined by state nursing boards and the like.

Thanks to the collaborative efforts of ENA, ACEP and AAEM, the Joint Commission has begun both internal discussions and has said they will be conferring with CMS about these more restrictive interpretations of the current standards. As the voice of our profession, ENA will continue to monitor this situation while working to educate CMS and the Joint Commission as to the negative impact of these actions.

ENA will provide updates as the situation unfolds and as more information becomes available.

Sincerely,

Denise King, RN MSN, CEN
2008 ENA President