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201708227

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Indirect Surgical Supervision in the Intraoperative Areas (1.63)

Indirect Surgical Supervision in the Intraoperative Areas (1.63) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Administrative

1.63


POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 2017

 ORIGINAL
REVISION


PAGE 1
OF 4
POLICY #

1.63
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INDIRECT SURGICAL SUPERVISION IN THE
INTRAOPERATIVE AREAS


I. PURPOSE
A. To establish guidelines for the care of patients who undergo a primary surgical
procedure while under anesthesia and at the same time need a secondary minor
procedure by a different surgical or medical service in the Intraoperative setting.
To establish standard of care including consent requirements, documentation,
and definition of the appropriate processes for the completion of minor
procedures performed concomitantly with a separate primary surgical procedure
by another service.

II. DEFINITIONS
A. Primary operative and invasive procedures are defined in the UW Health
Policy#8.48 Operative, Invasive and Other Procedures and their conduct is
clearly described in this policy.
B. Minor procedures: Procedures which can be performed under Indirect
Supervision as defined within the Graduate Medical Education Departmental
Policy # 43.19 - Supervision of Residents. In addition, a comprehensive
supervision table is available via the Residency Competency Roster (GME
Education Job Descriptions).
C. These minor procedures are currently performed at UW Health in the Emergency
Department, Surgical and Medical Hospital floors and Intensive Care Units and
in the Outpatient Clinics by practitioners, members of the Graduate Medical
Education program (residents/fellows) with direct or indirect supervision by
members of the Medical Staff. These procedures have a minimal chance to result
in an adverse outcome. Examples include but are not limited to placement of an
extremity cast, suturing of minor lacerations, dressing changes or performing
diagnostic arthrocentesis.
D. Direct resident/fellow supervision is provided when an attending physician is
present in the location where the procedure is performed and directly observes or
participates in the conduct of the minor procedure.
E. Indirect resident/fellow supervision can be with direct supervision available or
immediately available depending on whether or not the supervising physician is
physically present within the hospital. In these instances, the attending physician
has discussed the details of a minor procedure with the resident/fellow, including
the indications, planned procedure and strategies to minimize the chance of an
adverse outcome.



POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 2017

 ORIGINAL
REVISION


PAGE 2
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ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INDIRECT SURGICAL SUPERVISION IN THE
INTRAOPERATIVE AREAS


III. POLICY
A. Patients undergoing primary operative and invasive procedures and require a
secondary concomitant minor procedure will receive the same level of safe and
effective care throughout UW Health. Documentation in the medical record will
reflect the care provided including documentation of the consent pertaining to the
minor procedure, indirect supervising attending, and notes describing the details
of the minor secondary procedure. No resident/fellow will be allowed to take a
patient to the operating room for the performance of an isolated minor procedure
without indirect supervision.

IV. PROCEDURE SELECTION
A. If during preoperative workup of a primary operative and invasive procedure it is
determined that the patient needs a secondary minor procedure by a separate
clinical service line other than that service line performing the primary
procedure, this policy will take effect. The clinical service line performing the
secondary procedure will be responsible for implementation of this policy. Each
clinical department shall develop a review process for monitoring the adherence
of the residents/fellows with this policy which is consistent with the UW Health
Graduate Medical Education Departmental Policy # 43.19.
B. The resident/fellow intending to perform the secondary procedure will contact
the supervising attending to discuss the procedure. Under no circumstance will a
patient undergo a concomitant secondary minor procedure by residents or fellow
in the UW Health intraoperative suites without the knowledge and expressed
approval of an attending physician.
C. The secondary minor procedure must be a procedure that is currently performed
by residents/fellows in the Emergency Department, patient care units or clinics at
UW Health or with the direct or indirect supervision of attending physicians and
cannot expose the patient to more than minimal risk. The supervising attending
physician (separate from the attending who will be performing the primary
procedure and separate from the staff anesthesiologist who will provide local,
regional or general anesthesia) will be clinically responsible for the quality and
safety of the services provided to the patient and ultimately will be the
responsible attending physician for the outcome of the procedure.
D. The attending physician who is responsible for the primary procedure and the
attending anesthesiologist who will be providing or supervising the anesthesia
will each have the ability to require that the responsible attending physician be
present in the intraoperative suite to directly supervise the resident/fellow


POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 2017

 ORIGINAL
REVISION


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POLICY #

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ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INDIRECT SURGICAL SUPERVISION IN THE
INTRAOPERATIVE AREAS


performing the minor procedure if they feel it is in the patient’s best interest.
E. The intraoperative circulating nurse must feel comfortable and assent with the
resident/ fellow performing the secondary minor procedure. If they do not, they
will voice their dissent to the attending surgeon or anesthesiologist who will
ultimately decide whether to require the presence of the responsible second
attending.

V. PREPARING THE PATIENT FOR THE PROCEDURE
A. If the attending physician elects to supervise the resident/fellow indirectly, this
should be clearly documented by the resident/fellow in the medical record. As
the supervising physician is not present during an indirectly supervised
procedure, no charges will be placed for the minor procedure performed by either
the indirect supervising physician or the physician performing the separate
primary procedure.
B. The resident/fellow who will perform the secondary minor
procedure/intervention will obtain informed consent from the patient or his/her
family. Part of the consent should clearly explain that the secondary minor
procedure/intervention will be performed by the resident/fellow with indirect
supervision by the attending physician and the patient/family should clearly
understand the difference between direct and indirect supervision before
consenting to the procedure.
C. A pre-procedure note should be entered by the resident/fellow in the medical
record documenting the discussion with the attending physician, as well as the
discussion leading to the consent of the patient or the family.
D. To schedule the “Minor Procedure Under Indirect Supervision” the resident/fellow will
coordinate with the primary service to add the above minor procedure with a surgeon
description that identifies the intended procedure. Another option would be to call the
appropriate OR control station and ask that above minor procedure and surgeon
description be added to the surgical case.

VI. PRE-PROCEDURAL VERIFICATION PROCESS
A. The pre-procedural verification process will follow the details of the UW Health
Policy 8.48 (Operative, Invasive and other Procedures) including site marking,
time out, documentation, etc.

VII. POST- PROCEDURE DOCUMENTATION
A. At the end of the procedure a note will be entered by the resident/fellow


POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 2017

 ORIGINAL
REVISION


PAGE 4
OF 4
POLICY #

1.63
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INDIRECT SURGICAL SUPERVISION IN THE
INTRAOPERATIVE AREAS


performing the minor secondary procedure describing the procedure, outcome,
and final disposition and specifying that the procedure was done under indirect
supervision. This note will be approved and cosigned by the indirect supervising
attending.

VIII. REVIEWED/SIGNED BY
Christopher R. Turner, MD PhD, MBA, Director of Perioperative Services
Anne Mork, MHCDS, MS, RN, Director of Surgical Services University Hospital
Charles Heise, MD FACS, FASCRS, Director of Surgical Operations
Catherine Madsen, MSN, RN, CNOR, RNFA Director of Surgical Services – American Family
Children’s Hospital
Petros V. Anagnostopoulos, MD, MBA, Surgeon in Chief – American Family Children’s
Hospital
Deborah Rusy, MD, MBA, Director of Perioperative Services – American Family Children’s
Hospital
Michael Ford, MD, Chief of Anesthesiology - The American Center
Michael Garren, MD FACS, Clinical Director – The American Center
Bridget Shaffer, MBA, MSHA, BSN, RN, CNOR, Director of Surgical Services – The
American Center