OUTLINE
I ORIENTATION
II JOB DESCRIPTION
III PAPERWORK
IV GCA CRITERIA
V MEMORANDUMS
VI APPENDICES
This booklet is a compilation of instructions and information supplied by GCA physicians and RMC administration. By compiling this booklet, Colorado Anesthesia Services, LLC, is only relaying information to its contractors, and has no input as to its contents.
I ORIENTATION
Welcome to the RMC OB deck. Prior to your scheduled Obstetric Anesthesia Orientation, you must contact the individuals below to obtain an ID badge, parking access and PYXIS training.
To schedule your ID Badge and parking access contact:
Linda Clancy
Rose Medical Center
4567 E 9th Ave
Denver, CO 80220
Ph(303) 320-2097
Fax(303) 320-2369
NOTE: You cannot work at Rose without your ID badge
To schedule your PYXIS training and password contact:
Jeff Stroup (x7353)
Rose Medical Center
Department of Pharmacy Services
4567 E 9th Avenue
Denver, Colorado 80220
Ph (303) 320-7353)
Pager (303) 266-8736 pager
Contact Clarissa Seda Cotto at (303) 250-4008 to schedule your OB deck orientation. You will be provided with the name and contact information of the CRNA that will orient you and the date of the orientation. You cannot start work before your orientation is completed. Orientation is session. Two checklists need to be filled out and signed by the orienting CRNA after completion of each session. Please fax the forms to Clarissa Seda Cotto at (303) 344-1817. Below are the checklists with detailed explanations of some points.
OBSTETRIC ANESTHESIA ORIENTATION CHECKLIST- WEEKDAY
CRNA Name______
Orientation Date______
____ Operating Room and Emergency Equipment Setup
At the start of each shift, it is expected that the CRNA will check out the ORs and make sure that each one is ready to go for planned or urgent cases. This would include throwing away expired drugs, preparing numerous syringes for immediate use (but not labeled, which violates JHACO), and preparing the "emergency tray" which is located in the fourth drawer of the old anesthesia supply cart.
____ Routine and Emergency Drugs
The emergency tray should contain these items only: One vial each of Amidate, Succinylcholine, Propofol, Pitocin and syringes to draw up each drug. As well, there should be one pre-made syringe of ephedrine and phenylephrine. It is essential that at the end of every case, all drugs are reconciled. The emergency tray must be reset and the drugs used in the last case must be charged to that particular patient. Please make sure you charge for the exact number of syringes used (especially ephedrine). If needed, you can type in the patient name as "emergency tray" to pull drugs for the tray. Again, please note that the pharmacy requires a double signature waste record for the CLE bags, narcotics and Propofol. Please make sure all records are extremely legible, signed and dated.
____ Code White
It is essential to learn the Code White protocol.
____ Epidural Cart and Supplies
All carts and cabinets should be locked at the end of all cases, including epidural placements, and at all times when not attended. As well, the CLE bags on the pumps should be locked as this is mandated by Rose administration.
____ Epidural and Spinal Kits and Needles
____ Time Out and Debriefing
Time-outs must be done prior to each regional procedure: This includes the name and DOB of the patient, allergies, and the procedure to be done. Please note the time-out time on the Anesthesia Record.
Debriefing needs to occur after all “Code whites” and all other special circumstances as this is mandated by Rose administration.
____ WHO Checklist
WHO checklist initiative: Participation in this as outlined by the Rose administration is mandatory.
____ C-Section with primary CRNA
See the patient prior to the procedure, complete the history and physical and obtain consent whenever possible.
____ C-Section Paperwork
____ Epidural/follow-up with primary CRNA
Please call the GCA physician directly in no more than 30 minutes from the first request to evaluate, if the patient is still uncomfortable. Learn CLE pump set-up and troubleshooting.
____ Epidural Paperwork
____Procedure Line-up
If a line up of procedures occurs, you will be called and expected to help facilitate a quick turnover by setting up the CLE line, obtaining drugs, setting up the next patient, or various other ways as per the GCA physician on the deck at that time. Please respond quickly when called upon for this reason.
____ Obstetric PACU
____ Patient Census Board
____ Post Partum Rounding
Post partum rounding will be done by the next day’s shift on all patients discharged by Anesthesia prior to midnight the previous day. This list of patients to round on will be a joint responsibility of the GCA physician and the CRNA; the list should be divided. The GCA physician will review the list and determine the division of labor. GCA business cards will be handed to each patient at the post-operative visit. Rounding will be accounted for in the rounding book at the nurses’ station. Please restrict your comments to “done” or “very satisfied” or a brief comment about a complaint such as “itching”, with your initials beneath your comments. Please mark your comment with a red dot to signify that the GCA physician or the next shift needs to visit this patient, either because they were not in their room, or they had a complaint that needs further follow up. A note in the chart is mandatory at the time of the post-operative visit, and it needs to be dated and timed. Comments you write in the rounding book should be the same as those in the chart note. The chart note should clearly state any issue or complaint. Complaints should be
reported to the on call GCA physician for further follow up. Restrict comments in the rounding book to pertinent remarks in order to facilitate rounding/follow-up. GCA is tracking nausea/vomiting/itching through the rounding book, so these comments are pertinent.
Orientation Performed by ______
Submit completed checklist to Clarissa Cotto
Scan to or fax to (303) 344-1817.
OBSTETRIC ANESTHESIA ORIENTATION CHECKLIST- WEEKEND
CRNA Name______
Orientation Date______
____ Operating Room and Emergency Equipment Setup
____ Routine and Emergency Drugs
____ Code White
____ Epidural Cart and Supplies
On the weekends, there is no anesthesia tech available. As the CRNAs are more frequently up on the deck than any one anesthesiologist, it is expected that the CRNAs restock the epidural anesthesia carts as they become depleted, mostly with epidural tray kits and tubing for the pumps. Become familiar with where anesthesia supplies are located, as the rooms need to be ready for a code white at all times. The compartment on the CLE cart where the patient stickers are placed should be looked at every time the CRNA is rounding on the epidurals (presumably every 2-4 hours). Due to the new computer charting program, many of the RNs do not know how or where to place the checkmarks for patients with epidurals. If you go to the screen and do not see that an epidural is running on a patient, do not assume that they do not have one. Please check the compartment on the CLE cart for patient stickers.
____ Epidural and Spinal Kits and Needles
____ Time Out and Debriefing
____ WHO Checklist
____ C-Section with primary CRNA
____ C-Section Paperwork
____ Epidural/follow-up with primary CRNA
____ Epidural Paperwork
____ Procedure Line-up
____ Obstetric PACU
____ Patient Census Board
____ Post Partum Rounding
Orientation Performed by ______
Submit completed checklist to Clarissa Cotto
Scan to or fax to (303) 344-1817.
II JOB DESCRIPTION
The CRNA is required to report to the OB deck at 6:30am for the day shift and at 6:30pm for the night shift. The following guideline for the daily routine is suggested:
1) At the start of each morning shift, please get a complete report from the CRNA regarding CLEs, complex patients, scheduled procedures, and any other matter that needs immediate attention. Make sure that the ORs are set up and make rounds on running epidurals. For scheduled C-sections, please see the patient prior to the procedure, complete the history and physical and obtain consent whenever possible.
Please touch base with the incoming anesthesiologist to establish expectations, plans for the shift, and divide the rounding responsibilities.
2) CLE troubleshooting parameters: Opinions vary on how to first approach this situation. A good history and understanding of what has previously transpired is essential. GCA physicians suggest that you first start with <10cc of 0.2% Ropivacaine with or without Fentanyl 50-100mcg after your evaluation of the patient. If the patient is not comfortable after your initial efforts, please call the GCA physician directly, in no more than 30 minutes from the first request, to evaluate a troublesome CLE and certainly at any time prn.
3) Scheduled C-sections: Please see the patient prior to the procedure, complete the history and physical and obtain consent whenever possible.
4) Rounding will be attempted every 2 hours on patients with running epidurals. Ideally, the CRNA rounds every 4 hours, and the GCA physician rounds every 4 hours, resulting in a patient visit every 2 hours. This is a GCA guideline.
5) Post partum rounding will be done by the next day’s shift on all patients discharged by Anesthesia prior to midnight the previous day. This list of patients to round on will be a joint responsibility of the GCA physician and the CRNA – the list should be divided. The CRNA will be responsible for collecting patient stickers and placing them in the rounding book which is kept at the nurses’ station with the billing sheets. Please help the GCA physicians by writing the name of the anesthesiologist and the type of procedure next to the sticker in the rounding book. In this way, if they need to contact that anesthesiologist, they can easily do so. From this point forward, the primary anesthesiologist will be responsible for follow up and treatment of complications. For example, a PDPH will be managed by the physician who performed or supervised the epidural/spinal. If they cannot take care of it promptly, they will make arrangements for such to be done.
GCA business cards will be handed to each patient at the post partum visit. Rounding will be accounted for in the rounding book at the nurses’ station. Please restrict your comments to “done” or “ok” or a brief comment about a complaint “itching” or comment “very satisfied” and your initials or mark it with a red dot. A red dot will signify that the GCA doctor or the next shift needs to visit this patient, either because they were not in their room, or they had a complaint that needs further follow up, etc. A note in the chart is mandatory at the time of the post partum visit, dated and timed. Whatever comment you will write in the rounding book cannot be different from the chart note. The chart note should clearly state any issue or complaint. Complaints should be reported to the on call GCA physician for further follow up. Restrict comments in the rounding book to pertinent remarks to facilitate rounding/follow-up. GCA is tracking nausea/vomiting/itching through the rounding book – so those comments will be pertinent.
6) If a line up of procedures occurs, you will be called and expected to help facilitate a quick turnover by setting up the CLE line, obtaining drugs, setting up the next patient, or various other ways as per the GCA physician on the deck at the time. Please respond quickly when called upon for this reason.
7) Time-outs must be done prior to any procedure: This includes the name and DOB of the patient, preferably from the patient’s input, allergies, and the procedure to be done. Please note the time-out time on the Anesthesia Record.
8) WHO checklist initiative: Participation in this as outlined by the Rose administration is mandatory.
9) All carts and cabinets should be locked at the end of all cases, including epidural placements, and at all times when not attended. As well, the CLE bags on the pumps should be locked as this is mandated by Rose administration.
10) Debriefing after all code whites and other special circumstances is mandated by Rose administration
11) Prompt returning of pages and responding to requests for service is required.
12) Removing the Fentanyl CLE bag from the lock box and taking it with the patient back to the OR to waste needs to happen during a controlled move to the OR or a "crash" situation. Leaving the narcotics in the patient’s room and moving the patient back to the OR is not acceptable.
The CRNA must not withdraw controlled substances (fentanyl, midazolam etc) from the Pyxis machines until the patient has arrived in the OR. If the patient is not in the OR, the CRNAs should not yet have the controlled substances out of the machines. If a CRNA needs to administer a controlled substance in the preoperative area, the medication needs to be removed from the Pyxis machine in that area. RMC is auditing the exact time that the medications are removed from the Pyxis and the time the patient enters the OR on all cases. If there is a discrepancy, the CRNA will be contacted by the Director of Pharmacy or Dr. Theil. Furthermore, the CRNA should never leave any medications on top of the anesthesia carts or the anesthesia machines when not in the room. If the CRNA is not in the OR, there should not be any medications left out on the anesthesia carts or machines. When the CRNA leaves with the patient for the PACU or ICU, the controlled substances should remain with them and when finished with the patient, the CRNA should dispose of the medications properly (with a witness). As much as possible before the CRNA leaves the OR, they should remove any remaining medications and syringes from the top of the carts and dispose of them, and then lock the cart. The only exception is if the patient is demanding constant attention and the CRNA cannot safely attend to the cart.