HHS publishes regs to permit technicians to circulate in the OR It finally happened. The Department of Health and Human Services (HHS) has published the Medicare regulation that would permit techni- cians and licensed practical (vocational) nurses to circulate in the operating room. It is part of the total revised regulations, “Medicare and Medicaid Programs: Conditions of Partici- pation: Hospitals,” published June 20 in the Federal Register.

The comment period ends Aug 19. Although we had anticipated a 90-day period, a 60-day period was specified. This apparently reflects a trend in the government to shorter comment periods.

The regulation itself doesn’t contain any surprises. As published in the Federal Reg- ister, it states:

Registered nurses, licensed practical (voca- tional) nurses, and surgical technologist circulators who are educated and trained in surgical (operating room) technology may be permitted to perform circulating duties if so specified in the medical staff bylaws. The circulator must have demonstrated super- visory capability and the knowledge and skills needed to ensure continuity of care and maintenance of a safe and therapeutic environment for the patient. In all cases a registered nurse must be immediately avail- able in the operating suite to respond to emergencies. The regulations also specify that the operat-

ing room service must be supervised by a reg- istered nurse with training, experience, and

M Editorial

competence in management of surgical ser- vices. This elaborates on the current wording and is supported by AORN.

The term surgical technologist circulator is new. It is defined in the regulations as an indi- vidual who:

(1) has successfully completed an educa- tional program for surgical technologists (operating room technicians) that is accredited by the Committee on Allied Health Education and Accreditation (CAHEA) of the AMA in cooperation with the Joint Review Committee on Education for Operating Room Technicians, Inc; and (2) is certified by the Association of Surgical Technologists.

There are currently 75 accredited surgical technologist programs and about 20,000 cer- fied surgical technologists. One does not have to attend an accredited program to take the examination.

Reflecting the controversy the regulation to circulate has generated, the introduction to the regulations notes that “a great deal of com- ment has been received on this proposal. . . .” AORN members as well as others have been inundating Washington with letters since the change was first proposed in 1977.

The introduction also cites reasons for revis- ing the Medicare regulations. “Changes in methods of health care delivery, the need to control the increasing cost of hospital care, and the Department’s commitment to simplify- ing HEW regulations are the principal reasons for the proposed revisions.” It mentions specif- ically that existing regulations are unnecessar- ily restrictive, especially for small, rural hospi- tals. It also notes that the regulations “recog- nize training and experience in lieu of purely academic credentialing .”

AORN Journal, August 1980, Vol32, No 2 177

Fact sheet: Medicare proposed rule on circulators Text: Registered nurses, licensed practical (vocational) nurses, and surgical technologist circulators who are educated and trained in surgical (operating room) technology may be permitted to perform circulating duties if so specified in the medical staff bylaws. The circulator must have demonstrated supervisory capability and the knowledge and skills needed to ensure continuity of care and maintenance of a safe and therapeutic environment for the patient. In all cases a registered nurse must be immediately available in the operating suite to respond to emergencies. Citation: HSQ- 16-P, paragraph 482.4 1 (a) (4) is part of the regulations for hospitals participating in Medicare. Refer to this in your letter. Who would be covered? In effect, this applies to hospitals certified as Medicare/Medicaid providers who are not accredited by the Joint Commission on Accreditation of Hospitals (JCAH) or the American Osteopathic Association (AOA). These are about 1,400 to 1,500 out of about 6,900 hospitals participating in Medicare/Medicaid. The government accepts JCAH and AOA accreditation in lieu of federal standards. Whom to write: Address letters to

Administrator, Health Care Financing Administration, Department of Health and Human Services, PO Box 17082, Baltimore, Md 21235.

When to write: During the public comment period, which ends Aug 19. Comments must be received on or before that date. Suggestions for letters: Stress facts and avoid generalizations. 0 Include the date and your name and

0 Include your job title and hospital. 0 Type your letter. 0 Be positive-avoid threats and inflammatory

language. 0 Do not send form letters, petitions, or post-

cards. 0 Stress facts: Explain how RNs in your

hospital perform nursing functions beyond what LPNs/LVNs and technicians are prepared to perform. Explain how RNs as circulators are cost effective. Explain how RNs in your hospital are involved in preoperative assessments and postoperative evaluations. Explain that patients in small, geographically isolated hospitals are entitled to the same quality of care as patients in larger hospitals.

Patricia Patterson

add ress .

In response to the publication of the regu- lations, AORN immediately sent a letter notify- ing each member. AORN supports the present wording of the regulation specifying that tech- nicians are not permitted to circulate but may serve as “scrub nurses” under the supervision of a registered professional nurse. AORN has contacted selected Congressmen and notified other health care organizations of the regu- lations. It is preparing an extensive statement to submit during the comment period.

The battle against the proposed change has been going on for three years. The Health Care Financing Administration, part of the US De- partment of Health and Human Services (for- merly US Department of Health, Education, and Welfare), initially notified AORN and other organizations of its intent to change the regula- tion in 1977. A meeting in November 1977 in

Washington was attended by representatives of AORN, the American Nurses’ Association (ANA), the Association of Operating Room Technicians (now Association of Surgical Technologists), practical nursing organiza- tions, the American Medical Association, the American Society of Anesthesiologists, the American College of Surgeons, and the American Hospital Association.

At this meeting, both technicians and licensed practical nurses claimed they cur- rently filled the role of circulator. AORN con- tended the appropriate role of the technician or practical nurse was to scrub and assist in cir- culating duties under the direct supervision of the registered nurse. It objected to the wordine“a registered nurse who is readily available to respond in emergencies.” AORN asked that the wording be eliminated or

180 AORN Journal, August 1980, Vol32, No 2

changed to state the necessity for the physical presence of an RN in a specific operating room.

In its arguments, HEW contended that small rural hospitals had difficulty staffing the OR with nurses, and the proposed changes were designed ”to allow a hospital greater flexibility in the utilization of its staff, equipment, and facilities.” The change also reflected a general trend, encouraged by the government, to sub- stitute performance and experience for educa- tional credentials.

A major contention was, What was curie=nt practice? Who was really circulating? Of the three hospitals HEW cited as examples of technicians circulating, two denied the prac- tice. In an effort to find the answer, the Health Care Financing Administration (HCFA), in March 1980, sent a survey to all hospitals in the country asking about circulating personnel. AORN alerted hospital administrators and supervisors to the survey. In late June, HCFA officials reported a 96% return on the survey and said the final results should be available in mid-July. The questionnaire sent to the hospi- tals asked whether operating room technicians and licensed practical (vocational) nurses were circulating routinely, in emergencies, or in relief situations. It also asked whether hospi- tals would use technicians and LPNs to circu- late if the regulations were changed.

One of the questions constantly raised is whether the Medicare/Medicaid regulations apply to all hospitals or only those hospitals certified under this program rather than the Joint Commission on Accreditation of Hospi- tals (JCAH). HCFA official Irene Gibson re- cently elaborated on this. She explained that the federal regulations apply to all hospitals that apply for Medicare. However, the JCAH or the state can choose to promulgate higher standards. Many state licensing regulations require an RN as circulator, and the new JCAH nursing service standards state that the cir- culator must be an RN but that the “technician may assist in circulating duties under the direct supervision of a qualified registered nurse.”

While waiting for publication of the regu- lations, AORN has communicated with many health care organizations and received official support from the ANA, the American College of Surgeons, and numerous specialty nursing organizations. At its recent convention, the ANA passed a resolution, which appears in

this issue, endorsing the operating room nurse as circulator. Through its Washington office and state nurses associations, ANA is actively supporting AORN’s campaign against the change. The Federation of Specialty Nursing Organizations and ANA sent a Mailgram sup- porting AORN’s position to the US Department of Health and Human Services during its June meeting.

If you haven’t written yet, there is still time to comment before Aug 19. There is no question that the number of responses counts. Despite its survey on circulating, HHS has specifically asked for comments and information on cur- rent practices in assignment of licensed practi- cal nurses and technologists to circulating duties and the impact on health and safety of patients. Do you know of incidents where the absence of an RN has had a negative effect on the safety of a patient? How often does this happen? Use facts and figures if you have them.

An important part of the rationale for the technician to circulate is cost savings. It is cited as such in the regulations. In your hospital, how are registered nurses cost effective? Do preoperative assessments mean cost savings in planning of supplies and use of equipment? Do nursing care plans mean that care is di- rected toward specific identified problems? Many OR suites are going to an all-RN staff. What is the rationale, and what data supported this change?

How is quality affected? The introduction to the regulations states that the revisions are intended to hold down costs while maintaining an acceptable level of patient care. What does “acceptable” mean? AORN’s philosophy is di- rected toward quality patient care. What will be the impact of “acceptable” care? Will it jeopar- dize the health and safety of the patient?

AORN defines circulating as one function of the perioperative role-a role that includes nursing during the preoperative and post- operative phases as well as the intraoperative phase.The role, which is based on the nursing process, includes assessment and evaluation as well as implementation. It goes beyond the functions of circulating. AORN believes a technician does not have the educational background and skills to perform the nursing functions of the perioperative role

It is not too late to write: Address your com-

AORN Journal, August 1980, Vol32, No 2 183

ments to Administrator, HHS Health Care Financing Administration PO Box 17082 Baltimore, Md 21235.

In your communication, refer to HSQ-16-P. The reference to the surgical circulator regula- tion is 482.41 (a) (4). In addition, you might want to write to your congressmen in the House of Representatives and Senate. You can write to your senators at the Senate Office Building, Washington, DC 20510, and to your representative at the House Office Building Washington, DC 20515.

Consumer response is also important. Many chapters had activities planned to inform the public and consumers of the possible impact of the surgical circulator regulation on quality pa- tient care.

Don’t expect to see the final regulations pub- lished as soon as the comment period is over. Depending on the debate and the nature of the comments, there may or may not be a hearing. Pressure on Congress, which is concerned about how regulations reflect legislation, may be a factor. Before final publication, the regu- lations will again be revised, then travel through the bureaucratic maze-a process that may take months or longer.

But now is the time to make sure your voice is heard in Washington. Operating room nurs- ing is your specialty practice. Protect it now.

Elinor S Schrader Editor

Suggested reading from AORN Journal “HEW considers Medicare revisions re OR cir-

culator,” (President’s message) March 1978,

“AORN’s response to HEWS proposed Medicare revisions,” April 1978, 813-814.

“Members’ action needed on HEW regulations for OR circulator,” (Headquarters report) August

“VA reiterates policy for RN as circulator,” February

“AORN leaders meet with HEW officials on cir- culator rules,” (President‘s message) March

“HEW regs purpose of Washington visit,” March

“HEW officials say perioperative role not in prac-

“JCAH standards specify RN for OR staffing,” April

605-606.

1978, 197-198.

1979, 212.

1979, 61 3-61 4.

1979, 61 7-61 8.

tice,” (Editorial) April 1979, 825-826.

1979, 831-832. “Johns Hopkins writes HEW on circulator role,” (Let-

“HCFA to survey hospitals on OR circulators,” ters to the editor) May 1979, 1103, 1107.

March 1980, 568.

Legionnaires ’ disease may kill thousands Unrecognized cases of Legionnaires’ disease may be killing more than 70,000 Americans annually, says a research report in the June 13 Journal of the American Medical Association.

In Columbus, Ohio, scientists examined lungs from 224 patients at autopsy and found a number of them had been infected with the organism of Legionella pneumophila, although deaths had been ascribed only to pneumonia.

Legionnaires’ disease may cause up to 3.6% of the pneumonias in central Ohio, says Dale Fay, MD. If this local incidence is extrapolated to the number of annual adult deaths in the United States, an estimate of 71,370 unrecognized adult Legionnaires‘ disease associated deaths annually may be made, Dr Fay declares.

Many of the Legionnaires’ disease patients will have terminal illness of another type, so they would not benefit from appropriate therapy, the report points out. However, a substantial number may be basically healthy, and therapy may be lifesaving.

difficult for the physician, Dr Fay emphasizes, and “until prospective diagnostic techniques become available, recognition of the disease must depend on clinical acumen if mortality is to be kept within acceptable limits.”

Some of those individuals whose lungs revealed the Legionnaires’ disease organisms had shown no important respiratory symptoms or fever, although pneumonia contributed considerably to their deaths, the study found. Only if the hospital conducts a routine laboratory examination of lung tissue at autopsy will a community know the true incidence of Legionnaires’ disease, the physician says.

Diagnosis of Legionnaires’ disease is

184 AORN Journal, August 1980, Vol32, No 2