MATERIALS MANAGEMENT NEWS

   

Working DRAFT

  • Hospital Administrative Manual                              

    John Dempsey Hospital

    University of Connecticut Health System

     

     

       PROTOCOL FOR:    Health Care Industry Sales Representatives in the Operative / Invasive Procedure Setting

       SEE FLOW CHART DIAGRAM: (Click Here)  

     

    POLICY:

     

    1.  The term Health Care Industry (HCI) representative refers to all health care industry employees who provide services in operative / invasive procedure settings (eg, clinical consultants, sales representatives, technicians, and repair / maintenance personnel).

     

     

     

     

     

    2. HCI representatives may be present during procedures under the conditions prescribed in this protocol and in compliance with accreditation requirements; local, state, and federal regulations; and UCHC infection control, patient privacy, and department- or unit-specific standards.

     

     

     

     

     

    3. The role of the HCI representative is to provide essential technical training and assistance related to the product, equipment, device or technology for the safe care of the patient. The HCI representative is not considered part of the clinical team and should not be requested to perform tasks outside his / her approved role.

     

     

     

     

     

    4.  HCI representatives must obtain specific authorization from nursing management or their designee’ and the attending surgeon / physician each time the operative / invasive procedure setting is entered.

     

     

     

     

     

    5.  Authorization to enter the operative / invasive procedure setting shall be specific to the product, equipment, device or technology that the HCI representative will be using, discussing or demonstrating in the operative / invasive procedure setting and will ideally be obtained at least 24 hours prior to scheduled cases.

     

     

     

     

     

    6.  The surgeon / physician or his/her designee’ must inform the patient or his/her legal agent (conservator, guardian, health care agent or next of kin) about the presence of any HCI representative during the procedure and consent will be documented on the Authorization for Medical-Surgical Procedure form HCH-127. Whenever possible, the consent should note the name of the HCI representative who will be present during the procedure.

     

     

     

     

     

    7. If a life-threatening emergency occurs, it will be considered a legitimate exception to the usual consent process. It is “reasonable” that the patient would consent to the presence of an HCI representative if it would increase the likelihood of a positive outcome. The surgeon / physician must make a note in the medical record and inform the family of the HCI representative’s presence as soon as possible after the procedure.

     

     

     

     

     

    8.  HCI representatives must check in with Materials Management during regular weekday hours prior to entering the operative / invasive procedure setting. Materials Management staff will clear the HCI representative for admission to the unit and provide an approved photo ID pass for the representative to wear at all times and that will include:
    a. name and company of the HCI representative;
    b. time and location of appointment;
    c. UCHC contact for the appointment;
    d. completion of basic educational requirements documented and on file.

    During non-weekday hours, permission will be obtained from nursing management or their designee’ and the HCI representative will wear identification. The HCI representative will register on the unit and staff will obtain contact information (eg, business card) for Materials Management follow-up.

     

     

     

     

     

    9.  After being cleared by Materials Management, the HCI representative will present their ID pass and register on the unit prior to entering any patient care area. If they will be working in a semi-restricted or restricted area, they will don scrub attire provided by the hospital, ideally colored to promote identification of their role, and will wear appropriate personal protective apparel.

     

     

     

     

     

    10. Any product, equipment, device or technology used in the operative / invasive procedure setting must be approved and / or prepared for use prior to the procedure:
    a. Clinical Engineering (CE) staff will inspect and approve any equipment or device not owned by the hospital prior to use; after hours, the operative / invasive procedure team either should determine if use of the item can wait until CE can inspect and approve it or they can be responsible for a visual check and permit patient use of the item. If CE is not available and the item is used, they will be notified of the item’s use;
    b. Instrument Room or OR staff will sterilize instrumentation or other items on site prior to use in the operative setting, as necessary. (HCI representatives will ensure that any necessary decontamination is performed before / after procedures.)

     

     

     

     

     

    11. The nursing staff should be informed before the procedure that an HCI representative will be present during a specific procedure as well as the purpose for being in attendance. Notification of staff will be done by nursing management or their designee’.

     

     

     

     

     

    12. The RN is responsible for monitoring patient safety, privacy, dignity, and confidentiality. HCI representatives will not be allowed into patient care areas until prepping and draping has been completed. RN monitoring may include restriction of the movement and number of people in the operative / invasive procedure location to prevent airborne contamination.

     

     

     

     

     

    13. The RN will document in the medical record the name and role / title of the HCI representative present during the procedure.

     

     

     

     

     

    14. The RN will monitor the HCI representative’s activities whenever possible and will facilitate their service to the patient and operative / invasive procedure team. Further, the HCI representative will only perform activities that facilitate use of the products, equipment, devices, or technology for which s/he has been authorized to enter the OR. Under no circumstances will the HCI representative scrub and assist in operative procedures; however, the HCI representative with specialized training and facility approval may perform calibration to adjust devices to the surgeon / physician’s specification (eg, pacemakers and lasers).

     

     

     

     

     

    15. Patient education materials will be provided as they are available from the manufacturer and patient care indicates.

     

     

     

     

     

    16. HCI representatives will provide education and training about products, equipment, devices, or technology prior to bringing them to the operative / invasive procedure setting whenever possible and as requested by the nurse manager, the attending surgeon / physician, the CNS or their designee’. If education and training cannot occur prior to the procedure, the sales representative will provide one-on-one training, 24-hour assistance through their employer, and /or operate the item, as appropriate.

     

     

     

     

     

    17. Materials Management will maintain documentation that the HCI representative has completed instruction in the principles of asepsis, fire and safety protocols, infection control practices, bloodborne pathogens and patients’ rights. The representative must be aware of and follow federal regulations and OSHA Bloodborne Pathogens Standard and any UCHC requirements related to them.

     

     

     

     

     

    18. Experienced HCI representatives who are accompanied by persons in training from their own organizations for the purposes of orientation will make arrangements with Materials Management and will comply with any accreditation requirements and local, state, and federal regulations.

     

     

     

     

     

    19. Trials of products, equipment, devices, or technology that require the presence of an HCI representative will comply with established Materials Management and Department of Nursing standards.

     

     

     

     

     

    20. Any departure from established policy will be addressed immediately:
    a. nursing management or their designee’ will be notified;
    b. Materials Management will be notified;
    c. if patient harm results, the RN will complete a Risk Identification Report;
    d. non-compliance with any policy statements will result in UCHC assuming no responsibility for payment of products used, lost, or damaged, and may lead to possible vendor restrictions at the facility.

     

     

     

     

     

    21. Failure to observe the policy statements contained within this protocol will be considered willful disregard and will result in the following actions:
    a. Nursing or Materials Management Staff:
        disciplinary action, as deemed appropriate by     management;
    b. Physicians:
        reporting to Chief of Service for disciplinary action;
    c. HCI Representatives (nature of offense may affect action     taken, but in general:
        1st offense: counsel with specific offender, along with     formal written warning;
        2nd offense” access to UCHC restricted with a letter     sent to his / her division manager;
        3rd offense: letter sent to the HCI representative and     his / her division manager, resulting in banning of the     representative from business with UCHC. Review of     current business between company and UCHC will be     evaluated to determine further actions with the     company.

     

     

     

    APPROVAL:

     

    OR Committee

    Nursing Standards Committee

     

    EFFECTIVE DATE:

     

    6/00

     

    REVISION DATE:

     

    11/03,  9/06