Quick Tips for Developing Your Malignant Hyperthermia Policy

A policy is only as good as the safe, accurate and easy-to-apply guidance it provides.

“Striking this balance is an art,” according to Deborah Jones, MSN, RN, CNOR, perioperative educator at University of California Irvine Medical Center in Orange, Calif.

She says policy development requires perioperative executives to be very strategic in coordinating with other leaders representing nurses, surgeons, anesthesia providers and other key players within perioperative services.

“Taking the right approach to policy development is critical, otherwise you could end up talking in circles for months and risk shaping a policy that cannot be effectively implemented on the frontline,” Jones cautions.

Considerations for Shaping an Effective MH Policy

With a patient population where family histories are unknown in many cases, this hospital has treated more than one incident of Malignant Hyperthermia (MH) over the span of just a few years.

An effective policy was required to address MH in any procedural setting where general anesthesia is administered. The policy also had to be effective for regular education through annual MH drill training and online education for all newly hired staff and anesthesia providers.

Here are seven important steps this perioperative services team applied to create this MH policy that can serve as a model for policy development: 

1. Get the Right People Talking

   Representatives from all impacted specialties should be involved because “policy development is a collaborative process,” Jones says. Choosing the right representatives who understand the policy content who can also articulate this content will ensure smooth policy development and imentation.



2. Collect Widespread Input

   Everyone impacted by the policy needs to feel heard to ensure their buy-in to follow it. “We gather recommendations, considerations and concerns—the contemplated information gives us a comprehensive view of the scope of the policy,” Jones shares. “Not all of this input makes it into the policy, but it provides a good starting point for your policy development team to discuss.”



3. Begin With a Strong Policy Statement

   The policy statement is the author’s best chance to capture the interest of the reader so the statement must be concise and descriptive and reflect the exact content of the policy, Jones advises. “Our MH guideline is two pages and it begins with a policy statement clearly describing what the policy addresses and what users can expect to find in the document.”



4. Be Clear About Whom the Policy Affects

   Be very clear in describing every professional who needs to complete the policy through documented training, Jones says. “This sets expectations for accountability so there is no gray area when it comes to who is required to train on the policy.”



5. Address Special Considerations

   To ensure a policy doesn’t need immediate updating, any potential changes in practice that could impact the policy should be addressed. For example, Jones’ facility made the transition from using 36 vials of dantrolene to 5 ml vials of dantrolene sodium, a newer medication now available to treat MH, so the policy reflects use for either medication.



6. Don’t Skimp on the Evidence

   Any policy should include strong evidence-based rationale supporting actions outlined and this evidence should be easy to access for further review. To avoid a policy that is too long, Jones includes all of the evidence supporting practices in the policy as attachments that can be easily accessed for further individual study.



7. Use an Effective Electronic Approach for Dissemination

   Jones’ facility uses an online training program that all providers must take as part of employment. This electronic access to the policy gives all clinical educators an efficient way to share and track completed education training.

Jones recently posted this MH policy on ORNurseLink. Take a look.

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