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SDS Accreditation Update
Document every step of tissue transport, handling
Monitor temps in freezers, OR if tissue stored in area
A set of recently added frequently asked questions (FAQs) related to tissue standards on The Joint Commission web site was developed when staff members noticed an increasing number of questions related to the tissue standards from accredited organizations rather than an increased number of recommendations for improvement related to tissue standards.
There have been no changes in the tissue standards, but the FAQs were posted to help organizations interpret, implement, and clarify tissue handling processes, says Virginia McCollum, RN, MSN, associate director of standards interpretation for ambulatory organizations. "Ambulatory and office-based surgery programs are doing a good job complying with the standards," she says.
Detailed records are a must
The tissue standards (PC.17.10 to PC.17.30) are well written and straightforward, but they do require very detailed documentation, points out McCollum. In a hospital, there are often lab personnel in charge of tissue receipt, storage, and documentation, but surgery centers face a different challenge because the staff is smaller, she says. "It is important to assign a person or a group of people the responsibility for documentation related to tissues," she adds.
"The most challenging part is the overall record keeping to track and trace tissues from the donor to the recipient with bidirectional tracing," McCollum says. Bidirectional tracing means that you not only know what patient received the tissue, but you also have the donor's information, she says. If there is a problem with an adverse reaction, you must be able to trace the tissue back to the source to identify other potential adverse reactions for other patients, she explains.
Put one person in charge
Although your outpatient surgery program may require the person receiving the tissue document the receipt of tissue, and other staff members may document the use of the tissue for different procedures and patients, one person should be responsible for making sure that all items related to tissue are documented, McCollum suggests. Your records should document how the tissue has been handled and stored, even in transport to your facility, she says.
"We worked with our tissue distributor to create a log that collects the data we need to comply with the standards so that all of the information is in one place," says Barbara McDonnell, RN, MSN, director of surgical services at Inova Loudoun Hospital in Leesburg, VA. When documenting handling of the tissue while in transport, ideally you would have the driver sign a statement verifying the condition and temperature of the package, but that is not realistic, she points out. A driver for a general delivery service that handles hundreds of packages on one route will not guarantee that the package stayed at a certain temperature, she says. "Instead, our tissue supplier gives us a document that verifies that the tissue was packaged in the right amount of dry ice to maintain the appropriate temperature during transport," she says.
They've also become stricter about the condition of the packages they receive, says McDonnell. "Previously, we would never accept a package if it appeared to be leaking or it was crushed," she says. Now, McDonnell's staff refuse delivery of packages if there is a minor problem such as torn tape, she says.
Detailed documentation that her surveyor expected to see included signature of the person receiving the tissue, signature of the person removing the tissue from the freezer, and a description of how it was thawed, says McDonnell.
Storage temperature for all tissue must also be documented, points out McDonnell. "We've always had thermometers in our refrigerators and freezers, and we regularly monitor the temperature in those areas, but our surveyor pointed out that we needed to monitor the ambient temperature in our clean core in the operating room as well," she says. "We didn't have a thermometer in that area, so we added one."
For more information about tissue standards from The Joint Commission, contact:
To view Joint Commission frequently asked questions related to tissue standards, go to www.jointcommission.org. Highlight "Accreditation Programs," and select "Ambulatory Care" or "Hospitals." Under "What's New," select "Tissue Storage and Issuance FAQs."