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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Anesthesia Safety Equipment & Agents Regulations
Policy Number: 12.19
Effective Date: August 1, 2015
Chapter: Environmental Safety
Hospital personnel will follow safety regulations so that appropriate precautions are taken to ensure safe
administration of anesthetic.
A. Only "surgical services" approved scrub attire is to be worn in the Department of Surgical
Services. (See Hospital Administrative policy 9.29-Scrub Suit Attire and Surgical Services
Departmental policy 1.06-Dress Code in the Department of Surgical Services).
B. All anesthetic apparatus will be inspected and tested by the anesthesia provider utilizing
Department of Anesthesiology protocols. If a significant defect is observed, the equipment will
not be used until appropriate repairs have been made. Only an anesthesia provider who is familiar
with the operation of each item of anesthesia equipment will use that equipment.
C. Each anesthesia machine will be equipped with a functioning inspiratory oxygen monitor, a
breathing system pressure and disconnect alarm, a pin-indexing safety system, and an oxygen
pressure interlock system.
D. Each anesthesia machine will be inspected and serviced on a regular basis by vendor approved
technician. Preventive maintenance and service records will be kept in the anesthesia equipment
manager's office and Clinical Engineering's equipment maintenance management database.
E. Each anesthesia machine will be equipped with a suitable scavenging device for the disposal of
waste anesthetic gases.
F. A sample of surgical cases is to be monitored for nitrous oxide levels on a regular basis. Cases
that generate nitrous oxide levels over 25 ppm require an investigation to determine the source of
nitrous oxide exposure. Trace Gas monitoring will occur at least annually, and periodically as
needed. Reports of the Trace Gas Monitoring Program will be issued by the Anesthesia Clinical
Engineer to the hospital Safety Officer, Environment of Care Safety Committee, the Chairman of
the Anesthesiology Department, the Director of Perioperative Services, and the Director of
G. Flammable anesthetic agents are not permitted in anesthetizing locations. Ether may not be used
for preparation of the surgical field.
H. Clinical Engineering personnel will periodically check all electrical equipment used in
anesthetizing locations. (See Hospital Administrative policy 12.63-Electrical Safety.)
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I. All electrical equipment in contact with patients in anesthetizing locations where surgical or wet
procedures are conducted will be connected via an audio-visual line isolation monitor (LIM). All
personnel will follow safety procedures for the use of line isolation monitors. LIMs will be tested
semi-annually by Plant Engineering and/or contracted certifier. (See Surgical Services
Departmental policy 3.02-Line Isolation Monitors.)
J. Ventilation for each operating room is monitored daily and tested annually for particulates and air
exchange rates, maintained at or above code requirements, by Plant Engineering. Test results will
be distributed to the Medical Director of Surgical Services.
K. Major regional or general anesthesia shall be routinely administered only in anesthetizing
locations designated by the Hospital Medical Board and approved by the Chairman of the
Anesthesiology Department. These locations are listed in the Operative Services Scope of Service
L. All anesthetists will follow the Department of Anesthesiology's "Standards for Basic
Intraoperative Monitoring" during the provision of anesthesia care. (See Department of
Anesthesiology Policy and Procedures).
M. All anesthesia equipment will be cleaned utilizing approved infection control procedures. (See
Surgical Services Departmental policy 3.01-Anesthesia Daily and Monthly Cleaning Procedures.)
III. CROSS REFERENCE
Department of Anesthesiology Policy and Procedure entitled: "Organization and Delivery of Anesthesia
Care" and "Standards for Basic Intraoperative Monitoring."
Hospital Administrative policy 9.29-Scrub Suit Attire
Hospital Administrative policy 12.63-Electrical Safety
Hospital Administrative policy 12.25-Hazardous Materials and Gases
NFPA 99: Recognition of Hazards and Responsibility.
Surgical Services Departmental policy 1.06-Dress Code in the Department of Surgical Services
Surgical Services Departmental policy 3.02-Line Isolation Monitors
Surgical Services Departmental policy 3.01-Anesthesia Daily and Monthly Cleaning Procedures
Sr. Management: VP, Facilities & Support Services
Author: Director, Life Safety
Review/Approval Committee(s): Environment of Care Safety Committee; Administrative Policy &
President, University of Wisconsin Hospitals and Chief of Clinical Operations
Previous revision: 082012
Next revision: 082018