ScrippsMemorialHospital Encinitas

Surgery Department

Rules and Regulations

Approvals:

Surgery Supervisory - 2/9/96; 9/97; 5/98; 7/98; 7/99; 4/00; 7/00; 04/01; 01/02; 04/02; 07/02; 10/02; 10/04; 07/05; 5/08; 6/08; 11/08; 10/11; 7/12

Medical Executive Committee - 2/23/96; 9/97; 5/98; 7/98; 8/99; 4/00; 7/00; 5/01; 04/02; 07/02; 10/02; 12/04; 08/05; 5/08; 6/08; 11/08; 10/11; 7/12

BOT - 10/97; 6/98; 8/98; 9/99; 5/00; 8/00; 6/01; 05/02; 08/02; 11/02; 01/05; 09/05; 6/08; 7/08; 12/08; 10/11; 11/11; 8/12

Surgery Department
Rules and Regulations

I.Organization:

A.Membership:

The Surgery Department shall be comprised of physicians, dentists, podiatrists and allied health professionals who utilize the main surgical suites as well as other services at Scripps Memorial Hospital Encinitas. The Surgery Department shall be responsible for assuring the professional and ethical practices of its staff members, and shall be dedicated to providing quality patient care, and high standards of surgical practices. The same terminology and qualifications of staff membership as described in the medical staff bylaws, and rules and regulations shall apply to Department members.

B.Meetings:

1.The Surgery Departmentshall meet on a quarterly basis (1,4,7,10) or as often as necessary. Sections may meet immediately following the Department meeting, oras often as needed to address business.

2.Surgery Supervisory Committee:

The Surgery Supervisory Committeeshall meet at least quarterly or as often as needed. The Surgery Supervisory Committee is composed of the following members:

a.The Chair

b.The Vice Chair

c.The past Chair

d.The Section Chief(s)

e.The following ex-officio members:

(1)Representative(s) from Administration

(2)Representative(s) from Nursing Administration, normally the Chief Nursing Executive and/or leadership of the main operating room.

(3)Ad Hoc Representative from the Department of Obstetrics/Gynecology and Department of Anesthesiology

C.Sections:

All members will be assigned to only one section under Surgery Department, which are as follows. New sections may be formed and added to the Department at the discretion of the Surgery Supervisory Committee and following approval by the Medical Executive Committee and Board of Trustees.

a.General Surgery – including; General, Colon and Rectal, Thoracic and Vascular Surgery

b.Neurosurgery

c.Ophthalmology

d.Oral & Maxillofacial Surgery/Dentistry

e.Orthopaedic

f.Plastic Surgery

gPodiatry

h.Spine

i.Urology

D.The Surgery Supervisory Committee acts on behalf of the Surgery Department and shall be responsible for all matters of policy and discipline within the Department; including making any recommendations to the rules and regulations, policies and/or practices impacting the Surgery Department.

II.Surgeons:

A.Primary or Responsible Surgeon:

1.The primary or responsible surgeon is one who:

a.Has been granted privileges to perform procedure, and scheduled the case.

b.Has accepted the responsibility for the care of the patient.

c.Has received the patient's signed consent

B.Assistant Surgeons:

1.The selection of a qualified surgical assistant is an obligation of the primary or responsible surgeon.

2.The scope of services required by a surgical assistant should be commensurate with the procedure. The complexity of the tasks may well demand that the surgical assistant possess capabilities equivalent to those of the primary or responsible surgeon, or the intensity and nature of the procedure may permit a surgical assistant to be less qualified.

III.Surgery Scheduling:

A.Block Scheduling and Utilization Guidelines:

The purpose of these guidelines is to provide adequate operating time for physicians that are equitable and accessible, whileensuring efficient utilization of the perioperative team, equipment, and operating room time.

1.Guidelines:

  • Three (3) operating rooms will be available from 7:00 a.m. to 7:00 p.m., and two (2) operating rooms from 7:00 p.m. to 9:00 p.m.and one (1) operating room from 9:00 p.m. to 11:00 p.m., Monday through Friday.
  • Operating time will be available for physicians without block time.
  • Release times will be specialty specific. Physicians are requested to release their block time in advance if they will not be using the time.
  • Block time utilization must be maintained at 75% to retain scheduled block time
  • Physicians that are consistently late or who do not have a dictated history & physical on the chart preoperatively may not be eligible for 7:30 a.m. block time.

2.Requesting Block Time:

  • Available to any physician that has appropriate clinical privileges in accordance with medical staff bylaws, rules and regulations, and delineated clinical privileges.
  • A written request for specific day of the week, and time submitted to the Manager of Surgery. For any additional day(s) or time(s), a written request must be submitted to the Manager of Surgery
  • Block time will be granted on a first come, first serve basis.

3.Utilization Review of Block Time:

  • Quarterly reviews of block time will be conducted by the Surgery Operations Committee
  • Block utilization data will be distributed to the physicians.
  • Block time utilization must be maintained at 75% to retain scheduled block time; prior to reallocation of block time, conversation with individual physician to discuss data and address individual needs will take place.

B.Elective Surgery:

1.Cases may be scheduled with Surgery scheduling between the hours of 8:30 a.m. and 5:00 p.m., Monday through Friday inclusive. All elective cases must end no later than 7:00 p.m. Semi-emergent cases for the following day may be scheduled with the operating room staffafter 5:00 p.m.

2. Imaging Guided Breast Procedures need to be scheduled through the Imaging Services scheduling to insure OR time correctly follows localization procedure. Films need to be delivered to the ImagingCenter to be reviewed by a Mammography Qualified Reader, a minimum of one week before desired procedure.

C.Emergency Surgery:

Emergency surgery may be scheduled directly with the operating room staff between the hours of 7:30 a.m. and 10:30 p.m. Between the hours of 10:30 p.m. – 7:30 a.m., the nursing night supervisorwill notify the anesthesiologist and the operating room personnelon call.

D.EmergentScheduling during the Weekend:

1.Main Operating Room:

In the event a physician wishes to schedule Monday morning surgery, the nursing supervisor will leave an urgent memo for the operating room staff. First come, first serve basis will apply.

IV.General Operating Room Rules:

A.Start Time Policy:

1.Surgeon will be present in the OR and ready to mark the site for first patient of the day 20 minutes prior to stated incision time.

2.Anesthesia will not be induced unless the surgeon's presence is confirmed.

3.Timeliness of the surgical team is essential, and will be monitored. If a surgeon is consistently tardy, the Department Chair will issue a warning for the first offense; move the case to the end of the schedule for a second offense; and prohibit the surgeon involved from having 7:30 a.m. cases for two (2) months after the third offense.

B.Delaysor Scheduling Changesin Start Time:

1.The OR Supervisor may require that an operation be rescheduled if there is more than a fifteen minute delay by any member of the surgical team. Rescheduling usually means being placed in the first available time slot following scheduled cases, or at the end of the day’s surgery schedule. Notification to physician related to a change in start time is the responsibility of the nursing supervisor.

C.Emergency and Urgent Cases:

1.Emergencies are defined as any situation, which threatens life or limb or causes uncontrollable, agonizing pain. They take precedence over scheduled cases, and the physician declaring an emergency has the prerogative of inserting the emergency into the schedule, but must personally notify the surgeon he is displacing on the schedule.

2.Emergency cases must be discussed by the surgeon with the anesthesiologist to identify the condition of the patient and the medications which may have already been administered.

3.When an emergency is determined by surgeon and anesthesiologist requiring that it be added to the operating room schedule; thereby, "bumping" one of the scheduled cases, it is the responsibility of the surgeon with the emergency to personally contact and inform the surgeon of the elective case of the circumstances and necessity.

4.Urgent cases are those cases requiring surgery within 2 to 12 hours. They may take precedence over elective cases but are usually added to the existing schedule as soon as possible in cooperation with the nursing supervisor and anesthesiologist designated to be responsible that day. Surgery Chair or appropriate section chief may be called upon to settle any disputes related to implementing the bump policy.

D.Observers in the Operating Suites:

Recognizing the importance of confidentiality of all medical information, patient safety and good infection control practices, it is policy that no individual(s) will be allowed to be an observer in the operating suites, unless they have a signed medical education agreementwith the hospitalas outline in the medical staff rules/regulations. NOTE: The only exception to this policy would be obstetrical patients (in labor or having a c-section). Current medical staff members and hospital employees may be granted permission to be an “observer” only if observation would ultimately benefit patient care. The patient is fully informed and consents to observer’s presence, if observation is permitted.

An “observer” is defined as one who is watching the surgical procedure and has no “hands on” contact with the patient, the surgical field, equipment and/or instruments.

E.Admission to PACU:

All patients who have had general, spinal, or epidural anesthesia are admitted to the PACU. Patients who have had local or other regional blocks may be admitted to the PACU at the discretion of physician and/or anesthesiologist. Exceptions include:

a.Patients who go directly to ICU.

b.Infected patients who go either to ICU or ward room with PACU personnel.

c.OB patients who may be recovered on OB unit.

The anesthesiologist will provide orders for the patient during the post-anesthetic period in the PACU. The physician must write orders on all patients prior to leaving surgery or PACU areas, which cover the patient's care during and after discharge from the PACU.

F.NPO Requirement:

Patients undergoing surgery in the operating rooms will have no solid food intake for a least eight hours and no liquid intake for at least six hours, prior to surgery, emergencies excepted. This rule applies for all forms of anesthesia, including local infiltration anesthesia and intravenous sedation. Exceptions may be made at discretion of anesthesiology, which may include:

a.Patients taking medication with small amounts of water and

b.Pediatric patients.

G.Pre-Operative Guidelines:

The Surgery Department in collaboration with Anesthesia Section require pre-operative evaluation on all patients who are scheduled to undergo invasive procedures, such as surgery or procedures that require an anesthesiologist or sedation of patient. All laboratory tests may have been obtained within the previous year, as long as the patient’s health status and medication regimen have not changed. If there have been more recent medical events, laboratory tests should be obtained within the timeframe that reflects these changes. For acutely ill patients (e.g., hospitalized patients) lab work should be obtained within seventy-two (72) hours pre-operatively, refer to guidelines noted below. Hospital personnel will ensure that this work has been done, and that abnormal results are reported ASAP to the surgeon and anesthesiologist. Ordering of tests should be individualized for each patient by the physician(s) involved, depending on that patient’s medical problems, medications, and anticipated procedures. Very few patients may require extensive evaluation, such as liver function tests,pulmonary function tests, ABGs, or cardiac stress testing. Many healthy people scheduled for outpatient procedures involving little blood loss will not require any lab tests.

These guidelines have significantly decreased the number of laboratory tests suggested.

Note that there are certain age triggers.

  • At age 50, patients with risk factors for coronary artery disease should have an ECG.
  • At age 60, an ECG and Hb should be obtained for each patient.
  • At age 75, BUN, creatinine and if indicated, a chest x-ray should be requested.
Laboratory Pre-Operative Guidelines

Following are the guidelines for laboratory testing of patients.

Lab work within seventy-two(72) hours of surgery:

A.Suggested for day of surgery for A.M. admissions:

  1. Blood glucose = patients with diabetes mellitus
  2. HCT = patients with active bleeding
  3. PT/PTT = patients on anticoagulants; e.g., Coumadin, Heparin, Lovenox
  4. Electrolytes = diarrhea, vomiting

B.Suggested for 48-72 hours before surgery:

If the patient requires a type & screen or a type & cross for blood products AND has recently received blood or blood products or was pregnant within the last three months THEN the type & screen or the type & cross will be done 48-72 hours before surgery.

Laboratory Test and Patient Indications that may be obtained within previous year:

  1. Hb or CBC:
  • Infants less than 6 months old
  • Females over age 12 (after menarche)
  • Males over age 60
  • Not needed if procedure will cause minimal blood loss.

2.Hb and type and screen:

  • Any patient undergoing surgical procedure with anticipated significant blood loss.

3.ECG:

  • Over age 60
  • Over age 50 if patient has HTN, hypercholesterolemia, obesity, or over 20 pack/year smoking history.
  • Patients with cardiovascular disease (angina, CHF, dysrhythmias, peripheral vascular disease)
  • Diabetics
  • Digoxin use
  • CNS disease
  1. Chest x-ray:
  • If indicated, over age 75
  • Relevant history (recent pulmonary infarction, productive cough, increase in SOB, more than 20 pack/year)
  1. BUN/Creatinine:
  • Over age 75
  • Renal disease
  • Peripheral vascular disease
  • Cardiovascular disease
  • Diuretic use
  1. Electrolytes:
  • Renal disease (Na,K)
  • Digoxin use (K)
  • Steroid use (Na,K)
  • Diuretic use (Na,K)

7.Urinary/Serum HCG:

  • Recommended for females of child-bearing age

8.PT/PTT:

  • Hepatic disease
  • Bleeding history (also platelet count, bleeding time)
  • Anticoagulant use (Coumadin, Heparin, Lovenox)
  1. Glucose:
  • Diabetics (fingerstick on day of surgery)
  1. Consider ABG, PFTs, short course of steroids pre-op:
  • Severe COPD
  • Severe asthma

EXCEPTIONS:

  1. Patients on dialysis should have Hb, platelets, electrolytes, BUN, Cr drawn after or at the end of most recent dialysis. May need CXR, ECG, bleeding time depending on surgery.
  2. Cataract patients need no routine tests.

V.Short Stay Unit (SSU)

A.Admission Criteria:

1.Patients whose procedures are beyond the scope of the physician's office, or the outpatient department, whose post-operative care can be managed at home, and who fall within the risk categories as outlined by the American Society of Anesthesia.

a.Risk I - normally healthy patients.

b.Risk II - mild systemic disease that does not limit activity and is not incapacitating.

c.Risk III - serious systemic disease that is stable and not of immediate risk to life.

2.Unacceptable patients, include those with poorly controlled chronic disease, risk categories other than I-III, and surgical procedures involving significant post operative care.

B.Appropriateness of Procedure:

In the event a question arises over the appropriateness of a procedure being performed via the SSU, decision will be made between the Department Chair, the Operating Room Supervisor, Chief Nursing Executive, the requesting surgeon, and the Section Chief(s) as deemed appropriate.

C.NPO Requirement:

and SSU patients will have no solid food intake for the previous eight hours and no liquid intake for the previous six hours. This rule applies for all forms of anesthesia, including local infiltration anesthesia and intravenous sedation.

D.Laboratory Tests:

Laboratory tests will be performed in accordance with pre-op requirements as addressed in these rules and regulations.

E.Discharge of Patients from the SSU and Units:

1.All patients will be discharged from the unit only when appropriate discharge criteria are met.

2.If the patient is unable to be discharged by the close of the usual recovery room hours, the attending surgeon will arrange for admission of the patient to the hospital.

3.All patients will be discharged to the care of a responsible adult who will transport the patient home.

VI.Procedures Requiring An Assistant:

A.General Surgery:

1.Thoracotomy (except exploratory thoracotomy and thoracotomy for biopsy).

2.Lung

3.Pneumonectomy

4.Sternal splitting mediastinal procedures.

5.Esophagus, almost all procedures except esophagoscopy; i.e., esophagoplasty, esophogojejunoplasty, esophagogastrophasty, esophagogastrectomy.

6.Hiatus hernia repair.

7.Whipple procedure (pancreatoduodenectomy).

8.Abdominal perineal resection.

9.Hepatectomy

10.Pancreatectomy

11.Adrenalectomy

  1. Neurosurgery:

1.Any craniotomy that requires tumor dissection requires an assistant. Other neurosurgical procedures shall be at the discretion of the primary surgeon.

C.Ophthalmology:

1.The need for an assistant in ophthalmic surgery shall be at the discretion of the primary surgeon.

D.Oral and Maxillofacial Surgery/Dentistry:

1.Osteotomies of the maxillofacial bones (i.e. orthognathic surgery) (not including isolated simple sliding genioplasty

2.Harvesting and placement of bone grafts (hip, rib, calvarium) [at discretion of the operating surgeon]

3.Temporomandibular joint surgery

4.Operative TMJ arthroscopy

5.Open reduction of maxillofacial fractures - at the discretion of the primary surgeon.

6.Excision of salivary gland tumors

E.Orthopedic Surgery:

1.Spinal fusion

2.Total joint replacement requires an assistant. Hemi-arthropasty shall be at the discretion of the primary surgeon.

F.Otolaryngology:

1.Temporal bone resection.

2.Maxillectomy

3.Mandibulectomy

4.Radical neck dissection.

5.Diverticulectomy (esophageal)

6.Laryngectomy - partial or total

7.Laryngeal fracture repair

8.Thyroidectomy - partial or total

9.Pharyngectomy

10.Cervical esophagectomy

11.Parotidectomies

12.Major head and neck surgery and reconstructions

13.Lateral rhinotomies

G.Plastic Surgery:

Procedures needing an assistant shall be at the discretion of the primary surgeon.

H.Podiatry:

Advanced and Special Procedure(s)privileges shall be at the discretion of the primary surgeon.

I.Urology:

  1. Nephrolithotomy
  2. Nephrectomy - radical.
  3. Nephrourecterectomy
  4. Symphysiotomy or horseshoe kidney with or without pyeloplasty
  5. Ilioloop
  6. Supravessical urinary diversion continent
  7. Ureterovesical fistula
  8. Cystectomy - radical with lymphadenectomy
  9. Pelvic exeteration
  10. Penectomy - radical
  11. Radical prostatectomy
  12. Retroperitoneal lymphadenectomy
  1. Vascular:

1. Open aortic surgery

2. Extremity bypass with vein

Surgery Department Rules & Regulations

Approved 8/12

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