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Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Administrative

Visitors in Surgical Services/OR: Students, Observers, Media Access (1.24)

Visitors in Surgical Services/OR: Students, Observers, Media Access (1.24) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Administrative

1.24

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
1
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS



I. PURPOSE

To ensure that students [with and without rotations through the University Hospital (UH), The American
Center (TAC) and the American Family Children’s Hospital (AFCH) Surgical Services Departments],
visitors, observers, etc. have been properly educated regarding Universal Precautions, Aseptic Technique
Principles, Surgical Services Dress Code, Hand Hygiene, and when appropriate Surgical Hand Antisepsis
(Scrub) prior to reporting to UH/TAC/AFCH Operating Room (O.R.). In addition, the infectious disease
screening criteria, as required by state statute, as well as, N-95 mask fit testing as identified below.

II. DEFINITIONS
A. Observer – An observer is an individual present for a defined period of time for purposes of
watching the performance of duties by others. Students enrolled in a school which has an
affiliation agreement with UW Health are not considered observers.

III. POLICY

A. MINIMUM REQUIREMENTS:
1. All individuals must be eighteen years of age or older.
2. All visits or observations must be scheduled two weeks in advance.
3. Tours of all Surgical Services Departmental areas by visitors will be guided by Surgical
Services leadership/management or their designee and will exclude any patient contact.
4. Any time it is determined by the surgeon, anesthesiologist, or nursing staff that the ability to
deliver optimal patient care is compromised, the visitor will be asked to leave.
5. In compliance with the UW Health Policy #9.16, “Dress Code and Appearance Policy” and
to assure maintenance of patient rights, all visitors will wear identification. Students (i.e.,
non-employees) will wear the student issued UW Health photo identification (ID) .
6. In compliance with UW Health Policy #1.06 “Dress Code in the Department of Surgical
Services” scrub attire will be worn. Disposable scrub attire will be provided for all
visitors/observers. Disposable scrub attire will be available in or near the OR Locker
Rooms or may be ordered in advance via the on-line Central Supply Catalog. For further
assistance contact Central Supply.
a. Cloth scrubs are dispensed via a scrub dispensing machine and are limited medical
students, surgical technology students, and physician assistant students on rotation at
UW Health. Cloth scrubs must be requested 24-48 hours (M-F) in advance of the
rotation. These may be requested by accessing the following link:
http://www.uwhealth.wisc.edu/uconnect/scrubs/index.html. For further assistance
contact Central Supply or e-mail scrubs@hosp.wisc.edu.


UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
2
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS


IV. PROCEDURES
A. All student educational programs must have an approved Clinical Affiliation Agreement on file
with UW Health Legal Services.
B. All Healthcare related “Student Clinical” rotations at UW Health are required to meet the
following criteria. These responsibilities must be met and maintained by the schools, colleges,
and universities sending students to the UH/AFCH/TAC:
1. All students are required to have met the criteria described in Policy #9.21, "Non Employee
Health Screening".
2. All students assisting at the surgical field (i.e. medical students, surgical technology
students, physician assistants, nursing-RN) must have prior training in principles of aseptic
technique, surgical hand antisepsis (scrub), gloving and gowning by program coordinators.
C. Descriptions of types of student, visitor, observer and individual requirements:
1. Nursing – RN; UW-Madison and Edgewood scheduled clinical observations will be
facilitated and approved by the Surgical Services Education Coordinator(s)/Specialist(s)
and/or Manager(s). It is the responsibility of the instructor requesting the observation to
provide information to the students to guide them to the O.R. suite (reference related
document associated with this policy entitled; General Information).
a. Nursing student curriculum requirements:
i. Nursing students may participate in patient care activities under the direct
supervision of the circulating nurse. (Refer to UWHC Nursing Administration
Policy #8.11, “Nursing Student Clinical Practice at UWHC".)
ii. Nursing students will not make observational visits to the O.R. until they have
completed all self-study modules as prescribed by the curriculum.
iii. Nursing students who have completed a scheduled, supervised experience in the
O.R. may be scheduled by their clinical instructor to return to the O.R. for
further learning experiences. Clinical instructors will obtain permission of the
attending/faculty surgeon.
iv. The clinical instructor will contact the Surgical Services Education
Coordinator(s)/Specialist(s) for permission. In the absence of the Surgical
Services Education Coordinator(s)/Specialist(s) the instructor will contact
another member of management or the charge nurse for assistance.
v. The coordinator of the observation will communicate to the appropriate
circulating nurse that a student nurse will be present.
vi. The nursing student will discuss his/her objectives for the experience with the
circulating nurse.
vii. UW-Madison (N449 clinical) students participating in a160 hour O.R. clinical
will be properly fit tested for the N-95 mask.
2. Surgical Technology Students on-boarding process will be facilitated by the Manager of
Education and Informatics (UH). The Surgical Technology Student clinical coordinator will

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
3
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS


communicate with the specific clinical site managers/supervisors at UH and AFCH
regarding the number of students that can be accommodated each semester. The names of
the students and the rotation dates are then communicated to the managers/supervisors of
each clinical site. It is the responsibility of the student clinical coordinator and the on-site
clinical instructor to provide information to the students to guide them to the O.R. suite
(reference related document associated with this policy entitled; General Information).
3. Physicians/Visiting Professors are coordinated via the Medical Staff Affairs Office. The
Medical Staff Affairs office is required to notify the Surgical Services Director(s) of the
visit for observation as well as participation in care.
4. Physician Assistant Student rotations are pre-approved as part of the Physician Assistant
Program.
5. Third and Fourth Year Medical Student (MS) rotations are pre-approved as a part of the
Medical School Clerkship.
6. First and Second Year Medical Students (MS) are required to attend the Surgery Interest
Group training offered periodically by the Department of Surgery. For information contact
the Medical Student Education Office (MSEO) in the Department of Surgery. Upon
completion of the training the approved student list is maintained by the MSEO. MS first
year (MS1) and MS second year (MS2) students require Surgical Faculty sponsorship. The
MS1/MS2 students are managed by the sponsoring Surgical Faculty. It is the responsibility
of the Surgical Faculty sponsoring the visit to guide the MS to the O.R. suite.
7. Pre-Medical Student Undergraduate program observations are coordinated by the
Medical Student Education Office (MSEO) in the Department of Surgery. The approved
programs are as follows; The Alpha Epsilon Delta Premed Honor Society (AEDPHS),
Professional Associate of Latinas for Medical School Access (PALMA) and American
Medical Student Association (AMSA).
8. Paramedic Students are coordinated by the Paramedic Student Medical Director,
appointed by the Department of Anesthesia. The Anesthesia Department appointed
designee will communicate and coordinate in advance any training needs with the Surgical
Services Nursing Educators in the respective sites. The Paramedic Student coordinator
communicates student names and dates of rotation to the Anesthesia Department appointed
designee and the respective Surgical Services Nursing Educators to post and make available
at the clinical site. It is the responsibility of the Paramedic Student Medical Director
appointed by Anesthesia to provide information to the students to guide them to the O.R.
suite.
9. Perfusion Students onboarding process will be facilitated by the Perfusion Manager. The
Perfusion Manager is responsible for coordinating the training needs of the perfusion
students. Perfusion students will participate in patient care activities under the direction of
the perfusionist.
10. Audiology Doctoral Students clinical rotations are facilitated and lead by the Head of

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
4
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS


Section within the Audiology Department. The Head of Section within the Audiology
Department is responsible for coordinating and storing all training documents for the
students. The audiology doctoral student accompanies a UW Health Audiologist to the UH
and AFCH O.R.
11. Hospital Personnel observers are limited to the following roles; Nursing Resident, RN,
Nurse Practitioners, Physical Therapy Resident, Athletic, Spine and Sports Trainers.
These titles require observation of surgical procedure(s) as part of their training and
orientation. These visits will be facilitated and pre-approved by the Surgical Services
Education Coordinator(s) or management at the respective sites (e.g., UH, AFCH, TAC). It
is the responsibility of the party requesting the visit to provide information to guide the
Hospital Personnel visitor to the O.R. suite (reference related document associated with this
policy entitled; General Information).
12. Other types of observers may be approved when it is to the benefit of the institution or
individual departments to approve the observership. All non-healthcare
visitors/observers, research personnel or healthcare related visitors/observers not
listed in III B1-B11 interested in observing in the a UW Health O.R. are required to submit
an electronic request via the following link: http://www.uwhealth.org/31995. Requests are
evaluated by the following representatives for appropriateness;
a. UH - Christopher Turner, MD, the Director of Perioperative Services, Director
of UH Surgical Services and Charles Heise, MD, the Director of Surgical
Operations.
AFCH – Cathy Madsen, Director of AFCH Surgical Services and Deborah
Rusy, MD, Medical Director of AFCH –OR.
TAC – Bridget Shaffer, Director of TAC, Perioperative and Emergency
Services.
b. Process and responsibilities:
i. For the approved observer: The Vendor Liaison Office (VLO) is notified
to coordinate and expedite the necessary paperwork. The VLO notifies
the UW Health sponsor, observer and approving body when the
paperwork has been completed and is on file in the VLO. The observer
will report to the VLO for identification verification (e.g., valid drivers
license or other valid government-issued identification), to receive a UW
Health OR-Observer identification badge before the observation. The
observer makes the necessary arrangements to meet the sponsor. The
OR-Observer identification badge must be worn at all times and will be
returned to the VLO office after completing the OR observation.
ii. Sponsor: It is the responsibility of the sponsoring faculty surgeon or
designee to guide the visitor to the OR suite, and arrange for appropriate
supervision of the observer by a qualified clinician who is not scrubbed

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
5
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS


into the surgical procedure.
iii. Unapproved observer: The sponsor and requestor are notified
electronically that the observation was not approved.
13. Family members/significant others of the patient will not be present during
surgical procedures except during pediatric induction. (Refer to Surgical
Services. Policy #1.15, “Parents/Support Person Present with Child at Induction
and Recovery Phase of Anesthesia”).
V. Public Media Access
1. All requests will be channeled through the Public Affairs Office. Public Affairs personnel
are on call 24 hours a day. (Reference Policy #4.16, “Release of Patient Information to the
News Media”).
2. All requests will be made one week in advance of the visit.
3. All media requests require prior approval of the Medical Director(s):
a. UH Inpatient O.R.
b. UH Outpatient O.R.
c. AFCH O.R.
d. TAC O.R.
4. Once approval has been granted for further arrangements contact the respective sites
representatives;
a. UH - Clinical Operations Manager
b. AFCH –OR Supervisor
c. TAC – Manager Perioperative Services
5. Public Affairs personnel will assure that the proper consent is completed.
6. Public Affairs personnel will notify the Inpatient, Outpatient or AFCH Surgical Services
contact before news media representatives arrive in the O.R. Alternate contacts are the
Directors, O.R. Supervisors, and/or Charge Nurses.
7. Public Affairs personnel will accompany news media representatives at all times in the
O.R. to assure their activity is in accordance with policy. This frees the O.R. staff to
perform their job without the need to monitor the media.
8. Public Affairs representatives will be oriented to the Surgical Services Department to
function independently while in the O.R.

REVIEWED BY:

Surgical Services Policy and Procedure Committee 12/2016
Ann White, Surgical Services Education and Informatics Manager 12/2016
Dr. Charles Heise, Director Surgical Operations 12/2016
Dr. Christopher Turner, Director Perioperative Services 12/2016
Cathy Madsen, Director, AFCH Surgical Services 12/2016

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

APRIL 1986
ORIGINAL
 REVISION
DECEMBER 2016
PAGE
6
OF
6
POLICY #

1.24
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
– Administrative Manual
TITLE

VISITORS IN SURGICAL SERVICES/OR:
STUDENTS, OBSERVERS, MEDIA ACCESS


Dr. Deborah Rusy, Medical Director AFCH – OR 12/2016
Bridget Shaffer, Director of TAC Perioperative Services 12/16

SIGNED BY:

Sandy Schoenmann, BSN, RN
Interim Director, Surgical Services Department