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Admission of Patients to Surgical Services and Requirements for Initiation of Surgical Procedures (2.01)

Admission of Patients to Surgical Services and Requirements for Initiation of Surgical Procedures (2.01) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Clinical

2.01

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

NOVEMBER 1983
ORIGINAL
 REVISION

AUGUST 2017
PAGE 1
OF 5
POLICY #

2.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
ADMISSION OF PATIENTS TO SURGICAL SERVICES AND
REQUIREMENTS FOR INITIATION OF SURGICAL
PROCEDURES


I. PURPOSE

To establish a procedure for accurate patient identification and assessment to ensure the patient will
receive safe and effective care and to identify the requirements necessary to begin an operative case
at UWHC.

II. POLICY

A. All patients are identified with an identification (ID) band worn on their wrist (preferred)
or ankle (non-operative extremities if this applies) UW Health Policy # 3.2.1 Patient
Identification).
B. For patients with like or similar sounding names refer to UW Health Policy #3.2.1 Patient
Identification.
C. All discrepancies in the ID band information will be corrected with either the preoperative
unit or the Admission/Registration.
D. Inpatient work-ups including consents should be completed prior to transferring to the
FDS/Holding Area.
E. All adult patients should be addressed by their formal name Mr., Mrs., Dr., unless they
choose to be called by their first name. Name preference is noted on the Pre-op Checklist
in the patient care record or in the case of computer down time on the Pre-Operative/Pre-
Procedure Check List (1280544-DT).
F. Review/completion of the checklist is done by a Registered Nurse. Other care providers
may assist in the information gathering, with final assessment oversight by the Registered
Nurse.
G. “Block” patients may be admitted by Holding Area/FDS/Ambulatory staff prior to being
transported to the Block Room.
H. For all non-emergency cases to ensure OR readiness the OR RN will review the Pre-op
Checklist information for completeness prior to transferring patient to the Operating Room
(O.R.). The admitting RN will provide a handoff utilizing the SBAR format to the O.R.
nurse prior to transferring the patient to the O.R. The “Ready for Procedure” tracking event
will be recorded in the patient care record when this has been completed.
I. With the exception for emergency and cases under indirect supervision, the
Attending/Faculty or the Advanced Practice Provider that is credentialed to perform the
procedure must be in-house prior to induction of anesthesia. For non-emergency cases a
member of the surgical team, Attending/Faculty Surgeon, Surgical Resident/Fellow will be
present at all times. For a definition of emergency and non-emergency cases refer to

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

NOVEMBER 1983
ORIGINAL
 REVISION

AUGUST 2017
PAGE 2
OF 5
POLICY #

2.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
ADMISSION OF PATIENTS TO SURGICAL SERVICES AND
REQUIREMENTS FOR INITIATION OF SURGICAL
PROCEDURES


Surgical Services Policy #1.25 - "Scheduling and Management of Operating Room Cases
at University Hospital".
J. The Attending/Faculty Surgeon will participate in one of the verifications of correct
patient/procedure/site; pre-operatively or prior to the induction of anesthesia.
H. The Surgical Resident or Fellow performing a procedure under indirect supervision, as
described in UW Health Policy 1.63 Indirect Surgical Supervision in the Intraoperative
Areas, will participate in one of the verifications of correct patient/procedure/site; pre-
operatively, prior to the induction of anesthesia or prior to incision


III. PROCEDURE

A. Identify the patient by verifying the information on the ID band with the patient, or parent
if patient is a minor, or caretaker if appropriate. Check for accuracy of spelling of the
name, matching birth date. If the patient is an inpatient and discrepancies are identified
bring to the attention of the patient’s Primary Nurse, Charge Nurse, or Senior Team
member, or designee to correct prior to transferring patient to the OR. If the patient is non-
communicative notify the above named individuals to verify patient information on all
non-communicative patients if caretaker or family member is not present.
B. Review/complete the Pre-op Checklist in the patient care record, or in the case of computer
down time on the Pre-Operative/Pre-Procedure Check List (1280544-DT). Assess both the
physical and emotional status. Pastoral Care will be contacted as spiritual needs arise.
C. Ensure consent is present. Verify accuracy with patient. Refer to UW Health Policy #4.17 -
"Informed Consent".
D. Ensure H&P, update completion, and timeframe requirements are met.
E. Ensure pre-op labs/other diagnostic test results are available.
F. Ensure the pre-op orders have been completed.
G. Refer any abnormal lab values, discrepancies/problems with the informed consent, H&P,
or patient concerns to the appropriate surgical or anesthesia staff member.
H. Refer to UW Health Policy2.1.22 Patient Belongings and Valuables. Within APC/GI
belongings are secured by the patients and /or families.
I. Personal items should be removed prior to transporting patient to the O.R. If items
accompanied the inpatients down to the Holding/FDS area, the inpatient unit will be called
to send a staff member to retrieve the items so they can be returned to the unit for
safekeeping.
J. Due to extensive edema caused by fluid shifts following cardiopulmonary bypass, tight

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

NOVEMBER 1983
ORIGINAL
 REVISION

AUGUST 2017
PAGE 3
OF 5
POLICY #

2.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
ADMISSION OF PATIENTS TO SURGICAL SERVICES AND
REQUIREMENTS FOR INITIATION OF SURGICAL
PROCEDURES


fitting rings could restrict circulation to the finger all rings must be removed/cut from the
patient. Exception: short duration cases less than three hours or cases with low risk fluid
shift or non-operative extremity. Consideration for any procedure where fluid shifts and/or
inability to assess the hand should be given by both Nursing and Anesthesia care
provider(s).
K. Follow these guidelines for patient modesty and privacy related to patients wearing
undergarments:
1. Adult and pediatric patients must have undergarments removed unless requested for
valid reasons such as menses, modesty and or special needs. Undergarments removed
in the OR should be placed in a plastic bag and with a patient label attached.
L. Blankets and toys that accompany pediatric patients are discouraged in the operating room.

M. The surgical patient will be seen and assessed by the Attending/Faculty Anesthesiologist.
The Attending/Faculty pre-induction note is completed prior to being transported to the
O.R.
N. Prior to the patient being transported to the O.R. the RN assigned to care for the patient
will complete/or review the Pre-op Checklist or in the case of computer down time
complete the Pre-Operative/Pre-Procedure Check List (1280544-DT).
O. Verify informed consent for the correct surgical procedure with the patient.
1. For all non-emergent cases, verification of correct patient, procedure, position and site
(if applicable) and correct implants and any special equipment (if applicable) should
occur prior to entering the surgical suite.
2. All operative sites involving right/left distinction, multiple structures (such as fingers
or toes), or multiple levels (spines) must be marked. For spinal surgery the level will
also be routinely confirmed radiographically in most instances. Site marking must be
done by the Attending/Faculty Surgeon, Surgical Resident/Fellow or Advanced
Practice Provider who will be immediately involved in the procedure, prior to entering
the O.R. suite. Marking should take place with the patient involved, if possible.
3. The operative site may be marked as the physician or Advanced Practice Provider
desires, appropriate to the operation and operative site and in an unambiguous manner
(i.e. initials, “YES”, or a line representing the proposed incision; “X” may be
ambiguous). The mark should be positioned to be visible after the patient is prepped
and draped.
4. When it is technically or anatomically impossible or impractical to mark the site, the
Attending/Faculty Surgeon, Surgical Resident/Fellow, or Advanced Practice Provider
will verify the site prior to entering the O.R. suite and reconfirm the site prior to

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

NOVEMBER 1983
ORIGINAL
 REVISION

AUGUST 2017
PAGE 4
OF 5
POLICY #

2.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
ADMISSION OF PATIENTS TO SURGICAL SERVICES AND
REQUIREMENTS FOR INITIATION OF SURGICAL
PROCEDURES


incision.
5. Any discrepancies in site confirmation will be directed to the Attending/Faculty
Surgeon, Advanced Practice provider or by the Surgical Resident/Fellow performing
the procedure under indirect supervision, as described in UW Health Policy 1.63
Indirect Surgical Supervision in the Intraoperative Area. If a patient refuses site
marking the Attending/Faculty Surgeon will be notified and will verify the site prior to
entering the O.R. suite and will re-confirm the site prior to incision.
6. Site marking of bilateral procedural sites is not required as long as the procedures are
identical.
P. Prior to induction of anesthesia there will be an active verification time-out to confirm the
correct patient, procedure, site, availability of special equipment/implants, antibiotic
verification, and VTE prophylaxis administration (refer to UW Health Policy # 8.48 -
Operative, Invasive, and Other Procedures). Verification will occur with the participation
by all disciplines (Attending/Faculty Surgeon, Advanced Practice Provider,
Anesthesiologist or by the Surgical Resident/Fellow performing the procedure under
indirect supervision, as described in UW Health Policy # 1.63 Indirect Surgical
Supervision in the Intraoperative Area). If the patient’s orientation is changed with
positioning (i.e. prone to lateral, supine to lithotomy, etc.), the site will be re-confirmed
prior to incision.
Q. The Attending/Faculty Surgeon, Advanced Practice Provider or the Surgical
Resident/Fellow performing the procedure under indirect supervision, as described in UW
Health Policy 1.63 Indirect Surgical Supervision in the Intraoperative Area will participate
in one of two verifications of correct patient/procedure/site: pre-operatively in
Ambulatory/FDS, or prior to induction of anesthesia in O.R. suite.
R. An additional "Timeout” will be performed whenever a second service is performing a
“separate” procedure on the same patient (if not present at the initial Timeout). This is
merely to confirm the patient, procedure and site (including Left/Right as appropriate) with
the second service Attending/Faculty Surgeon or by the Surgical Resident/Fellow
performing the procedure under indirect supervision (refer to UW Health Policy 1.63
Indirect Surgical Supervision in the Intraoperative Area) when a new procedure will begin
R. During the time-out any member of the team who disagrees has an obligation to verbalize
their concern. A discrepancy at any point in time must stop the case from proceeding until
resolved. All team members must agree on the resolution(s) to the identified discrepancy.
S. Documentation of verification will occur in the patient care record or in the case of
downtime on the paper record UWHC Surgical Verification Checklist UWH# 4005929.
T. A debriefing will occur at the completion of the case, during the period of closure of the

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

NOVEMBER 1983
ORIGINAL
 REVISION

AUGUST 2017
PAGE 5
OF 5
POLICY #

2.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
ADMISSION OF PATIENTS TO SURGICAL SERVICES AND
REQUIREMENTS FOR INITIATION OF SURGICAL
PROCEDURES


incision and prior to the patient leaving the O.R.
1. The anesthesiology team, prior to the patient leaving the O.R., will affirm antibiotic
administration and documentation, including re-dosing if applicable, and beta-blocker
administration and documentation if the patient has been taking a beta-blocker prior to
surgery.
2. The nursing staff, prior to the patient leaving the O.R., will confirm completion of the
correct count of surgical instruments and accessories.
3. The Attending/Faculty Surgeon, Advanced Practice Provider or by the Surgical
Resident/Fellow performing the procedure under indirect supervision, as described in
UW Health Policy 1.63 Indirect Surgical Supervision in the Intraoperative Area prior to
leaving the O.R., will confirm with the circulating nurse specimen labeling.
U. The surgical, anesthesiology and nursing teams, prior to the patient leaving the O.R., will
identify key concerns for recovery and management of the patient.

IV. REFERENCE

A. The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery ™” (Universal Protocol | Joint Commission)
B. SCIP Standards

REVIEWED BY

Surgical Services Policy and Procedure Committee 4/2017
Dr. Charles P. Heise, Director of Surgical Operations 4/2017
Ann White, Manager, Surgical Services Education and Informatics 8/2017
Katharine Holley, Nursing Education Specialist, AFCH 4/2017
Christopher R. Turner, MD PhD, MBA, Director of Perioperative Services 8/2017

SIGNED BY
Cathy Madsen MSN, RN, CNOR
Director Surgical Services –AFCH 4/2017
Bridget Shaffer Director Surgical Services & Emergency Department – TAC – 4/2017
Anne Mork, MHCDS, MS, RN Director, Surgical Services 4/ 2017