Surgical Provider Orientation to CCHS Operating Rooms - PowerPoint Presentation

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Surgical Provider Orientation to CCHS Operating Rooms

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Important Contacts……… Slides 3-6

Scheduling Cases………… Slides 7-14H&P/Consent/DNR………. Slides 15-17Universal Protocol……….. Slides 18-20Intra-Op……………………. Slides 21-29Positioning Aids, Hair Removal, Prepping, Counts, Specimens, Needlesticks/exposures, Brief Op NoteResources.…..…………….. Slides 30-33Surgical Attire, Traffic Patterns, Cell Saver, SpecimensAppendix………………...... Slides 34-41Informed Consent, Blood Consent, Massive Transfusion Protocol, Treatment Limitations, OR Maps

Table of Contents

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Perioperative Services

Gerald J. Fulda, MDChair, Department of SurgeryMark Schneider, MDChair, Department of Anesthesia

Judy Townsley, MSN, CPAN, NEA-BC, FACHE

Vice President, Perioperative Services

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Frequent Contacts

ChristianaCSCWilmingtonRCA

P & H

733-2548

733-6940

320-6917

320-1023

PACU

733-2619

733-6941

733-6908

320-2728

320-1160

Surgical Admissions

733-4887

733-1005

OR Charge RN

733-2656

733-6937

320-2788

320-1178

Clerk

733-2650

733-6900

320-2725

320-1000

Nurse Manager

Heather Pelkey

OR – 733-4719

Monica Sullivan

733-6117

Tom

Zeidman

OR – 320-6362

Lateshsha

Collick

320-1107

Amy Kohl

PACU–733-4813

Maryann

Sosnowski

PACU – 320-4913

Anesthesia Site

Director

Jonathan Groden

Mark

Mulvihill

Madeel Abdullah

Steve

Tanner

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Ann Bates

733-2923CardiacDeb Dibert

733-2155

Neuro and Spine

Mark

Hottes

733-4360

Thoracic, Vascular and Gift of Live

Denny Quinones

733-6762

Orthopaedics and Podiatry

Laura Schenck

733-2287ENT, Plastics, OMFS, GU, GYN, Eye TraumaCharmayne Walker733-2851Colorectal, General, Robotics, Minimally Invasive SurgerySean McTague733-2656Day Shift Board Coordinator, Trauma ServicesVishia Bullock733-2656Evening Shift Board Coordinator, Trauma Services

Christiana OR Service Coordinators

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Wilmington OR Service Coordinators

Joe Soja320-2828Board Coordinator, Plastics, Neuro, GU, Podiatry, Ophthalmology, ENT, OMFS, Pain Management

Beth Lawson

320-4962

MIS, Robotics, General, GYN, Vascular

Denise Root

320-2830

Orthopaedics, Total Joint Replacement

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For elective cases greater than 24 hours in advance

Book through central scheduling 8am to 5pm Central Scheduling: 302-623-7450Scheduling Coordinator: Sue McNeilis 302-623-7587For emergent or add-on cases within 24 hoursBook via OR clerk Christiana 302-733-2650Wilmington 302-320-2725Surgicenter 302- 733- 6937Arsht

302-225-1193

Weekday Case Scheduling

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In-patients only

Posting allowed only for current or next day3 Operating Rooms run each weekend day3 Blocks of OR time for scheduling on weekends:Acute Care Surgery/General Surgery BlockStarts at 8:15amOrtho Fracture Block Starts at 8amOpen Block Urology stent cases are booked in this blockStarts at 7:30amWeekend Case Scheduling

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Case classification is required for cases booked as an emergency or add-on

Emergent and urgent procedures (Class 1 and 2) require surgeon availabilityCase Classification

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Class 1 – Immediate –

Life or limb threateningTo the OR within 20 minutes, directly transported to the OR by the surgical teamClass 2 – Emergent – Anticipated to become life or limb threateningTo the OR in less than 2 hours Class 3 – Urgent – Clinical deterioration is anticipated which would affect outcomeTo the OR in less than 4 hoursClass 4 – Expedited – Clinical deterioration may occur without timely surgical interventionTo the OR in less than 8 hoursClass 5 – Add-ons –

Cases that are scheduled outside of the daily elective schedule that do not meet the aforementioned classifications

Case Classification

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Any case is subject to delay or “bump” due to emergency

As a professional courtesy, it is the expectation that the “bumping” surgeon will make every attempt to communicate with the “bumped” surgeon to explain the rationale for requesting a bump. Class 1 emergencies are exempt from this courtesy.“Bumping” Cases

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Perioperative Evaluation and Preparation (PEP) contacts all outpatients scheduled for procedures requiring anesthesia via phone to review:

Recent labsPast medical/surgical historyMedications and begin medication reconciliation processAnesthesia/PEP phone number 623-7700Nurse Manager – Alicia Scarpato 623-7755Pre-Anesthesia Evaluation

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Electronic document scanning system used by Perioperative Evaluation and Preparation (PEP) for clinical information

Documents are readily accessible via web to authorized personnelSurgical office faxes H&Ps, diagnostic tests, etc. to one number: 888-744-1470Contact Physician Relations for access: 623-0595MMF (My Medical Files)

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An interdisciplinary team who are available to address clinical, behavioral, social and other care needs that patients may have that is affecting their ability to achieve optimal health and wellness

An information technology system that captures and analyzes volumes of clinical and claims data to support clinical decision making, identify gaps in care and assist providers in achieving quality outcomeshttp://www.christianacare.org/christiana-care-care-linkCarelink

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An H & P must be documented within 30 days or less from the time of the procedure for elective cases admitted on the day of surgery

An H &P update must be completed on the day of surgeryAn H & P from the current admission and progress note from the surgical team within 24 hours must be documented for in-patient casesHistory and Physical

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Consent must be signed and dated by the patient, a witness, and the surgeon prior to entering the OR.

It is the physicians responsibility to explain the surgical procedure, risks, benefits, and alternatives.Consents remain valid as long as there is no change in the patient’s condition which would change the risks and benefits of the planned procedure.Surgical Consents

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Surgeon performing the procedure and Anesthesiologist will review treatment limitations and/or existing DNR

Document the discussion and any changes applicable only to the OR and PACU with a notation in the appropriate section of the Treatment Limitations/DNR OrderIf the patient chooses surgery with a Treatment Limitations/DNR Order, this decision will be honoredIf the surgeon or anesthesiologist does not agree, the care of the patient shall be transferred to another physicianUpon returning to the floor/unit, the order will be resumedDNR in the OR

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Required for all cases involving laterality (brain, colon, paired organs, fingers, toes, hernias, etc).

Marking occurs in Prep and Holding.Site marking must be visible once patient is prepped and draped.Site Marking

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Standardized approach to ensure correct patient, correct procedure, and correct site for procedures performed in perioperative services.

Includes 3 components:BriefingTime OutDebriefingUniversal Protocol

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Patient is assigned one point for each of the following:

Open oxygen sourceAvailable ignition sourceSurgical site above the xiphoid or 12 inches from oxygen sourceScore of 0-1  Low level risk of fireScore of 2  Low level with potential to convertScore of 3  High risk of fireIf the score is 3, the high risk protocol is initiated.Fire Risk Assessment

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Please assist in positioning your patient

Variety of positioning aids available – see Perioperative Service Coordinator of your service for detailsPositioning Aids

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If it is necessary to remove hair, the

clipping method is preferredPerformed the day of surgery, in a location outside of the ORPhysician order is required for hair clipping (must state site and area of required hair clipping and type of antiseptic solution)Hair Removal

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Surgery team completes prep (surgeon or assistant)

Skin preps available:Chloraprep (preferred)Allow the solution to completely dry for a minimum of 3 minutesBetadineAllow sufficient time for complete evaporation of prep solutionSurgical Site Prep

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Patient cannot enter the OR until baseline counts have been completed

Closing and final counts will be verbally announced to the surgical teamInstrument Counts

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Surgeon will be notified of incorrect count and the surgeon should inspect the wound

A recount will be conductedAn X-ray will be performed on any anatomical areas in which an item may potentially be retainedMust be read by a radiologist or surgeon while the patient remains under anesthesiaWound closure will not continue until X-ray result is obtainedIncorrect Instrument Counts

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If micro-suture needles (7-0 & smaller) are unaccounted for during the count process, X-ray may be waived by the surgeon.

Life-threatening emergency situationsPerform an X-ray before the patient leaves the roomAn X-ray may be waived if the surgeon considers the patient’s condition too unstable to wait for an x-rayExceptions

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Tissues and other materials removed during a procedure will be sent to Pathology with a complete and signed pathology request

If the surgeon requests a photo of the specimen, this request will be documented on the lab request form by the surgeon. Photo will be taken in the lab and given to the physician by the labConfirm identity of specimen with circulatorSee appendix for list of specimens not required to be sent to Pathology.Specimens

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Complete necessary first aid

Complete needlestick report on portal Employee Health Services (EHS) NP will call with rapid HIV, Hepatitis B and Hepatitis C results within 48 hoursDraw source patients bloodIf the source patient is known to be HIV+Call/page the EHS NP at once 733-1900Prophylactic medication may be necessaryNeedlesticks/Exposures

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A brief op note is entered in the medical record immediately after the procedure

It shall consist of:Postoperative diagnosisProcedures performed and description of the procedureName of the primary surgeon and assistantsEstimated blood lossSpecimensOperative findingsA full operative note must be documented within 48 hours after surgeryBrief Operative Note

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Lab coats are optional for personnel in scrub attire when leaving the department

When returning from outside of hospital, scrubs must be changedChange scrub attire when soiledScrub attire is to completely cover any clothing worn underneathHair and jewelry must be confinedClean, fluid resistant mask will cover nose and mouth completely and be secure as to prevent venting at sidesRemove and discard mask after every caseReusable hat may be worn only if covered completely by blue disposable hats and must be laundered dailyBoots/shoecovers are not to be worn outside of the operating roomProtective eyewear is highly recommendedSurgical Attire

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Unrestricted Areas

(Street Clothes)Christiana OR- Entrance to trauma elevators, physician consult room, lounge/locker area, on-call rooms, Prep & Holding, PACU, connecting hallway in front of PACUWilmington OR – Offices, lounge/locker areas, Prep & Holding, PACU, and connecting hallway in front of PACUSurgicenters – Office, reception and waiting areas, pre-testing, admission, special procedures (staff will wear scrub attire and cap), PACU, and lounge/locker areaSemi-Restricted Areas (Scrubs and cap required)Christiana OR – Inner hallways surrounding core areas, scrub sink areas, and sterile storage areaWilmington OR – Office area (front inner hall), inner hallway, scrub sink areas, workroom areasSurgicenters – Inner hallway in operating room suite and sterile processing areaRestricted Areas (Scrubs, cap, mask, protective eyewear)All Sites – Core areas, sub sterile rooms, and operating rooms

OR Traffic Patterns

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Intraoperative blood salvage program

Trained autotransfusionists operate equipment, overseen by the perfusionistsCan be requested and scheduled when scheduling a case24 hour coverage is providedCell Saver (Blood salvage program)

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Consent for procedure

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Specimens which need not to be sent to pathology

In accordance with the rules and regulations of Christiana Care Health Services, Christiana and Wilmington Hospital Medical/Dental Staff (Item 608.0), “all tissues and other materials removed at operation, whether from an inpatient or an outpatient, shall be sent to Pathology with a complete and signed pathology request, except for certain specimens that need not be sent to the pathologist”: • Bone fragment • Bone from ostectomy site • Bunion • Cataract •

Certain foreign bodies, in particular, bullets and other foreign bodies needed by the police for use as legal evidence

•

Debrided tissue following trauma

•

Fingernail and toenail

•

Foreskin • Gingival fragment

•

Hernia and hydrocele sac

•

Intrauterine device • Lipomas of the spermatic cord • Metallic or other implanted prosthetic device • Normal iris in iridectomies • Normal muscle removed in the course of muscle shortening operations of the eye • Placenta removed at the time of Cesarean section • Scars • Teeth • Tissue removed in plastic repairs such as ectropion •

Vaginal mucous membrane removed incidental to vaginal repair

•

Varices

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Blood/Blood Products Consent

Blood Products Refusal/Restriction Form

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MTP should be considered upon transfusion of

> 6 units RBCs or development of microvascular bleedingTRAUMA MTP Includes:6 Units Red Blood Cells6 Units Thawed Plasma1 Unit Apheresis Platelets**Cryoprecipitate will be ordered separately as needed during trauma casesMassive Transfusion Protocol (MTP)

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Blood Products Thawing/Prep Time

Uncrossmatched Blood7 MinutesType-Specific Blood15 MinutesType and Crossmatch (Initial)30-4

0 Minutes

Platelets

10-15 Minutes

Thawed Plasma

20-25 Minutes

Cryoprecipitate

20-25 Minutes

Transportation

time to OR via dumbwaiter

2 Minutes

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Treatment Limitations/DNR Order Form

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