Joint Commission Releases Guidance on Surgical Attire, USP <797>
Fri, Dec. 13, 2019

In recent weeks, the Joint Commission (TJC) released guidance on two issues that may have an impact on local policies for physician anesthesiologists and their groups. In November, TJC posted several Frequently Asked Questions (FAQs) on their website describing elements of surgical attire that local facilities should include in their policies. TJC separately issued a statement on how hospitals can use either the old or the revised USP <797> chapter when updating policies on compounding. 


The Standards FAQ from TJC entitled "Attire - Determining Requirements for Operating Room / Surgical Attire" notes that while TJC does not prescribe operating room dress or surgical attire, there are certain elements that hospitals must include in their policies. Policy must reflect state rules and regulations as well as Centers for Medicare and Medicaid Services (CMS) infection control requirements. Manufacturer instructions should also be consulted. The TJC FAQ further states, "Organizations can choose which guidelines or consensus statements they will follow based on their own evaluation process" and that "Surveyors will survey to facility policy." Physician anesthesiologists may wish to consider the to the ASA Statement on Developing Policy for Infection Prevention Related to Surgical Attire and the ASA Guidelines on Surgical Attire when discussing surgical attire policies with their colleagues. Earlier this year, ASA was successful in working with the Association of periOperative Registered Nurses (AORN) to revise their surgical attire guidelines to better reflect available evidence. 

TJC also recently released a Statement on USP <797> - the US Pharmacopeial Chapter detailing compounding standards that is currently under review. With regard to this USP review period, TJC states, "during on-site surveys, compliance [with USP <797>] will be determined based on the organization's selection of one of the two available versions of the USP 797 chapter — either the 2008 version of the chapter or the 2019 revised chapter." Hospitals may not "independently choose specific discrete components from both versions but should adopt in full the version selected."  

Earlier this year, USP revised the chapter at the request of ASA and other stakeholders to remove the so-called "one-hour rule" from the revised chapter.

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