ED Accreditation Update

Use of the Universal Protocol in the ED: Clarifications and recommendations for enhanced procedural safety

Expert advice: Adapt the UP to fit the risk profile of the ED

Since mid-2004, The Joint Commission (TJC) has held all accredited hospitals to task for enforcing use of the Universal Protocol (UP), a practice designed to improve procedural safety by having clinicians go through a three-step process to insure that when they perform a procedure, they are performing the right procedure, on the right patient, in the right place.

While the UP applies to the ED, many emergency providers find the practice to be less applicable to their work environment than to surgical settings. Jesse Pines, MD, MBA, MSCE, FACEP, director of the Center for Health Care Quality and an associate professor in the Departments of Emergency Medicine and Health Policy at George Washington University in Washington, DC, and colleagues discussed these views and made some recommendations for future work on procedural safety in the ED in a recent paper published in The Joint Commission Journal on Quality and Patient Safety.1

"The perception by emergency physicians is that the UP is something that was retrofitted for the ED from the operating room (OR), and that the importance or salience of the UP to a lot of procedures in the ED is not really there," says Pines.

The main issue is that while the UP has been shown to provide an extra level of safety in preventing surgeons from operating on the wrong patient or the wrong site, it mainly serves this purpose with respect to patients who have been anesthetized, which is not the way procedures are typically carried out in the ED, explains Pines. "If someone comes in with an abscess, you are probably never going to drain the wrong abscess because the pathology is obvious," he says, noting that the patient is also fully conscious in this situation.

In the course of reviewing this paper, Pines explains that TJC reviewers clarified that their intention is for the UP to be applied only in the case of invasive procedures. While this still leaves some procedures open to interpretation, Pines suggests that he would not consider a simple incision and drainage to be an invasive procedure.

On another matter, however, TJC reviewers tightened the reins. Regarding the "emergency exception," a provision that enables providers to bypass the UP when life or limb is threatened, the reviewers made clear that such exceptions should not be a common occurrence. "The Joint Commission still expects the UP to be performed in almost all invasive procedures," says Pines. With this understanding, providers performing run-of-the-mill intubations, for example, could not say that these are "life or limb" emergencies that fall under the emergency exception provision, he explains.

Use UP for elements of care

James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians in Canton, OH, and a co-author of the paper, adds that the UP is important for ED procedures that still feature an element of care that is not completely obvious to the patient. In the case of a patient who has a laceration that requires sutures, he notes that the provider might communicate the following:

"I am here to perform a closure of the wound on your right arm with plastic sutures. I will be using an iodine cleaning solution and bupivacaine numbing medicine, both of which you said you are not allergic to. Is that correct, Mr. Smith?"

Another procedure in which use of the UP clearly applies is the insertion of a chest tube. "A safety-based protocol would include the need for the physician to identify — with the patient's help, if he/she is able — which side is the correct one for insertion, and which is the incorrect side," says Augustine.

"There are procedure-related complications that have occurred in EDs through the years that have been similar to those in other parts of the hospital," adds Augustine. "There is an opportunity to improve quality and insure patient care in the ED through the same applications of the UP. However, the application of the UP should be modified to the risk profile of the ED."

Look beyond use of the UP

While there are instances in which use of the UP will improve safety, Pines stresses that ED leaders interested in improving procedural safety need to look well beyond this tool. "There are a lot of errors that can happen in the ED that aren't captured with the Universal Protocol," he says.

For instance, Pines says that a poor layout, or not having the right equipment in place when it is actually needed in an emergency situation is a real safety issue not covered by the Universal Protocol. When a direct laryngoscopy doesn't work, it is critical to have a difficult airway box available in the ED, he says. Similarly, Pines notes that not having the right person in place to do a procedure is a safety issue as well.

"A lot of the issues related to procedural safety in the ED have very little to do with the UP, so ED leaders who really want to improve procedural safety have to think about their own local issues related to their hospital and related to emergency care," says Pines.

One issue deserving of particular attention in emergency care is the reality that emergency physicians are commonly called upon to perform procedures that they may have done only once or twice in their careers. "A cricothyrotomy or a transvenous pacer are all part of the ED scope of practice, but these are things that we don't perform very often," says Pines. "This can be an issue with procedural safety because you will have this person in extremis who needs a procedure, and the person who is doing it may not have a lot of experience actually doing that procedure."

How can EDs respond to this challenge? On- going quality improvement efforts are important, but it may also make sense to require regular simulation exercises just to make sure that all the providers can do these procedures, says Pines. "In this specialty, we are asked to do these uncommon invasive procedures," he says. "These are high-risk procedures that we are expected to do with a high level of competence that we don't do every day."

Another issue of high importance to the ED is the process of monitoring patients. Augustine stresses that this needs to be done in a reliable manner as procedures are being performed. "The ED is the site of care for patients with high acuity, and there is little opportunity for preparing patients in the same manner as a conventional operative site," he explains. "Active monitoring is very important related to procedural safety."

Augustine adds that ED leaders are responsible for modifying workplace factors that impact patient safety to allow rapid application of the Universal Protocol. "Technological solutions will enhance patient safety and facilitate rapid documentation," he says. "The proper placement of tools like capnography, airway intervention carts, and cardiac monitoring systems will improve quality as well as the application of the Universal Protocol."


  1. Pines J, Kelly J, Meisl H, Augustine J, et al. Procedural safety in emergency care: A conceptual model and recommendations. The Joint Commission Journal on Quality and Patient Safety 2012;38:516-526.


  • James Augustine, MD, FACEP, Director, Clinical Operations, Emergency Medicine Physicians, Canton, OH. E-mail: jaugustine@emp.com.
  • Jesse Pines, MD, MBA, MSCE, FACEP, Director, Center for Health Care Quality, and Associate Professor, Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC. E-mail: pinesj@gwu.edu.