Joint Commission Announces Survey Change for Office-Based Surgery Facilities in New York State

PUBLISHED: Jul 25, 2017
Relevant to: Ambulatory Care, Medical Office/Clinic

The Joint Commission (TJC) recently announced that, beginning January 31, 2018, it will be begin to assess compliance with capnography monitoring requirements that are required by the New York Department of Health Office of Quality and Patient Safety (NYC DOH). This change is only for TJC-accredited facilities located in the state of New York.

According to TJC, the NYS DOH requires that “…office-based surgery practices provide end tidal carbon dioxide (CO2) monitoring using capnography for patients receiving moderate sedation, deep sedation and general anesthesia.”

TJC states that office-based surgery practices will need to comply with the following to ensure compliance:

  • Provide monitoring of adequate ventilation during moderate or deep sedation and general anesthesia through continual observation of qualitative clinical signs.
  • Monitor for the presence of exhaled carbon dioxide using capnography, unless made impossible or restricted by the nature of the patient, procedure, or equipment.
  • Ensure that, when using capnography, the end tidal CO2 alarm is audible to staff monitoring the patient,
  • Capnography should be documented at frequent internals in the physiologic monitoring record.

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