1. Surgical Provider Orientation to CCHS Operating Rooms

2. Table of Contents Important Contacts……… Slides 3-6
Scheduling Cases………… Slides 7-14
H&P/Consent/DNR………. Slides 15-17
Universal Protocol……….. Slides 18-20
Intra-Op……………………. Slides 21-29
Positioning Aids, Hair Removal, Prepping, Counts, Specimens, Needlesticks/exposures, Brief Op Note
Resources.…..…………….. Slides 30-33
Surgical Attire, Traffic Patterns, Cell Saver, Specimens
Appendix……………… Slides 34-41
Informed Consent, Blood Consent, Massive Transfusion Protocol, Treatment Limitations, OR Maps

3. Perioperative Services
Gerald J. Fulda, MD
Chair, Department of Surgery
Mark Schneider, MD
Chair, Department of Anesthesia
Judy Townsley, MSN, CPAN, NEA-BC, FACHE
Vice President, Perioperative Services

4. Frequent Contacts Christiana CSC Wilmington RCA P & H 733-2548
PACU
Surgical Admissions
OR Charge RN
Clerk
Nurse Manager
Heather Pelkey
OR –
Monica Sullivan
Tom Zeidman
OR –
Lateshsha Collick
Amy Kohl
PACU–
Maryann Sosnowski
PACU –
Anesthesia Site Director
Jonathan Groden
Mark Mulvihill
Madeel Abdullah
Steve Tanner

5. Christiana OR Service Coordinators
Ann Bates
Cardiac
Deb Dibert
Neuro and Spine
Mark Hottes
Thoracic, Vascular and Gift of Live
Denny Quinones
Orthopaedics and Podiatry
Laura Schenck
ENT, Plastics, OMFS, GU, GYN,
Eye Trauma
Charmayne Walker
Colorectal, General, Robotics,
Minimally Invasive Surgery
Sean McTague
Day Shift Board Coordinator,
Trauma Services
Vishia Bullock
Evening Shift Board Coordinator, Trauma Services

6. Wilmington OR Service Coordinators
Joe Soja
Board Coordinator, Plastics, Neuro, GU, Podiatry, Ophthalmology, ENT, OMFS, Pain Management
Beth Lawson
MIS, Robotics, General, GYN, Vascular
Denise Root
Orthopaedics, Total Joint Replacement

7. Weekday Case Scheduling
For elective cases greater than 24 hours in advance
Book through central scheduling 8am to 5pm
Central Scheduling:
Scheduling Coordinator: Sue McNeilis
For emergent or add-on cases within 24 hours
Book via OR clerk
Christiana
Wilmington
Surgicenter
Arsht

8. Weekend Case Scheduling
In-patients only
Posting allowed only for current or next day
3 Operating Rooms run each weekend day
3 Blocks of OR time for scheduling on weekends:
Acute Care Surgery/General Surgery Block
Starts at 8:15am
Ortho Fracture Block
Starts at 8am
Open Block
Urology stent cases are booked in this block
Starts at 7:30am

9. Case Classification
Case classification is required for cases booked as an emergency or add-on
Emergent and urgent procedures (Class 1 and 2) require surgeon availability

10. Case Classification Class 1 – Immediate – Life or limb threatening
To the OR within 20 minutes, directly transported to the OR by the surgical team
Class 2 – Emergent – Anticipated to become life or limb threatening
To the OR in less than 2 hours
Class 3 – Urgent – Clinical deterioration is anticipated which would affect outcome
To the OR in less than 4 hours
Class 4 – Expedited – Clinical deterioration may occur without timely surgical intervention
To the OR in less than 8 hours
Class 5 – Add-ons – Cases that are scheduled outside of the daily elective schedule that do not meet the aforementioned classifications

11. “Bumping” Cases
Any case is subject to delay or “bump” due to emergency
As a professional courtesy, it is the expectation that the “bumping” surgeon will make every attempt to communicate with the “bumped” surgeon to explain the rationale for requesting a bump.
Class 1 emergencies are exempt from this courtesy.

12. Pre-Anesthesia Evaluation
Perioperative Evaluation and Preparation (PEP) contacts all outpatients scheduled for procedures requiring anesthesia via phone to review:
Recent labs
Past medical/surgical history
Medications and begin medication reconciliation process
Anesthesia/PEP phone number
Nurse Manager – Alicia Scarpato

13. MMF (My Medical Files)
Electronic document scanning system used by Perioperative Evaluation and Preparation (PEP) for clinical information
Documents are readily accessible via web to authorized personnel
Surgical office faxes H&Ps, diagnostic tests, etc. to one number:
Contact Physician Relations for access:

14. Carelink
An interdisciplinary team who are available to address clinical, behavioral, social and other care needs that patients may have that is affecting their ability to achieve optimal health and wellness
An information technology system that captures and analyzes volumes of clinical and claims data to support clinical decision making, identify gaps in care and assist providers in achieving quality outcomes
link

15. History and Physical
An H & P must be documented within 30 days or less from the time of the procedure for elective cases admitted on the day of surgery
An H &P update must be completed on the day of surgery
An H & P from the current admission and progress note from the surgical team within 24 hours must be documented for in-patient cases

16. Surgical Consents
Consent must be signed and dated by the patient, a witness, and the surgeon prior to entering the OR.
It is the physicians responsibility to explain the surgical procedure, risks, benefits, and alternatives.
Consents remain valid as long as there is no change in the patient’s condition which would change the risks and benefits of the planned procedure.

17. DNR in the OR
Surgeon performing the procedure and Anesthesiologist will review treatment limitations and/or existing DNR
Document the discussion and any changes applicable only to the OR and PACU with a notation in the appropriate section of the Treatment Limitations/DNR Order
If the patient chooses surgery with a Treatment Limitations/DNR Order, this decision will be honored
If the surgeon or anesthesiologist does not agree, the care of the patient shall be transferred to another physician
Upon returning to the floor/unit, the order will be resumed

18. Site Marking
Required for all cases involving laterality (brain, colon, paired organs, fingers, toes, hernias, etc).
Marking occurs in Prep and Holding.
Site marking must be visible once patient is prepped and draped.

19. Universal Protocol
Standardized approach to ensure correct patient, correct procedure, and correct site for procedures performed in perioperative services.
Includes 3 components:
Briefing
Time Out
Debriefing

20. Fire Risk Assessment
Patient is assigned one point for each of the following:
Open oxygen source
Available ignition source
Surgical site above the xiphoid or 12 inches from oxygen source
Score of 0-1  Low level risk of fire
Score of 2  Low level with potential to convert
Score of 3  High risk of fire
If the score is 3, the high risk protocol is initiated.

21. Positioning Aids Please assist in positioning your patient
Variety of positioning aids available – see Perioperative Service Coordinator of your service for details

22. Surgical Site Prep Surgery team completes prep (surgeon or assistant)
Skin preps available:
Chloraprep (preferred)
Allow the solution to completely dry for a minimum of 3 minutes
Betadine
Allow sufficient time for complete evaporation of prep solution

23. Instrument Counts
Patient cannot enter the OR until baseline counts have been completed
Closing and final counts will be verbally announced to the surgical team

24. Incorrect Instrument Counts
Surgeon will be notified of incorrect count and the surgeon should inspect the wound
A recount will be conducted
An X-ray will be performed on any anatomical areas in which an item may potentially be retained
Must be read by a radiologist or surgeon while the patient remains under anesthesia
Wound closure will not continue until X-ray result is obtained

25. Exceptions
If micro-suture needles (7-0 & smaller) are unaccounted for during the count process, X-ray may be waived by the surgeon.
Life-threatening emergency situations
Perform an X-ray before the patient leaves the room
An X-ray may be waived if the surgeon considers the patient’s condition too unstable to wait for an x-ray

26. Specimens
Tissues and other materials removed during a procedure will be sent to Pathology with a complete and signed pathology request
If the surgeon requests a photo of the specimen, this request will be documented on the lab request form by the surgeon. Photo will be taken in the lab and given to the physician by the lab
Confirm identity of specimen with circulator
See appendix for list of specimens not required to be sent to Pathology.

27. Needlesticks/Exposures
Complete necessary first aid
Complete needlestick report on portal
Employee Health Services (EHS) NP will call with rapid HIV, Hepatitis B and Hepatitis C results within 48 hours
Draw source patients blood
If the source patient is known to be HIV+
Call/page the EHS NP at once
Prophylactic medication may be necessary

28. Brief Operative Note
A brief op note is entered in the medical record immediately after the procedure
It shall consist of:
Postoperative diagnosis
Procedures performed and description of the procedure
Name of the primary surgeon and assistants
Estimated blood loss
Specimens
Operative findings
A full operative note must be documented within 48 hours after surgery

29. Surgical Attire
Lab coats are optional for personnel in scrub attire when leaving the department
When returning from outside of hospital, scrubs must be changed
Change scrub attire when soiled
Scrub attire is to completely cover any clothing worn underneath
Hair and jewelry must be confined
Clean, fluid resistant mask will cover nose and mouth completely and be secure as to prevent venting at sides
Remove and discard mask after every case
Reusable hat may be worn only if covered completely by blue disposable hats and must be laundered daily
Boots/shoecovers are not to be worn outside of the operating room
Protective eyewear is highly recommended

30. OR Traffic Patterns Unrestricted Areas (Street Clothes)
Christiana OR- Entrance to trauma elevators, physician consult room, lounge/locker area, on-call rooms, Prep & Holding, PACU, connecting hallway in front of PACU
Wilmington OR – Offices, lounge/locker areas, Prep & Holding, PACU, and connecting hallway in front of PACU
Surgicenters – Office, reception and waiting areas, pre-testing, admission, special procedures (staff will wear scrub attire and cap), PACU, and lounge/locker area
Semi-Restricted Areas (Scrubs and cap required)
Christiana OR – Inner hallways surrounding core areas, scrub sink areas, and sterile storage area
Wilmington OR – Office area (front inner hall), inner hallway, scrub sink areas, workroom areas
Surgicenters – Inner hallway in operating room suite and sterile processing area
Restricted Areas (Scrubs, cap, mask, protective eyewear)
All Sites – Core areas, sub sterile rooms, and operating rooms

31. Cell Saver (Blood salvage program)
Intraoperative blood salvage program
Trained autotransfusionists operate equipment, overseen by the perfusionists
Can be requested and scheduled when scheduling a case
24 hour coverage is provided

32. Consent for procedure

33. Specimens which need not to be sent to pathology
In accordance with the rules and regulations of Christiana Care Health Services, Christiana and Wilmington Hospital Medical/Dental Staff (Item 608.0), “all tissues and other materials removed at operation, whether from an inpatient or an outpatient, shall be sent to Pathology with a complete and signed pathology request, except for certain specimens that need not be sent to the pathologist”:
• Bone fragment
• Bone from ostectomy site
• Bunion
• Cataract
• Certain foreign bodies, in particular, bullets and other foreign bodies needed by the police for use as legal evidence
• Debrided tissue following trauma
• Fingernail and toenail
• Foreskin
• Gingival fragment
• Hernia and hydrocele sac
• Intrauterine device
• Lipomas of the spermatic cord
• Metallic or other implanted prosthetic device
• Normal iris in iridectomies
• Normal muscle removed in the course of muscle shortening operations of the eye
• Placenta removed at the time of Cesarean section
• Scars
• Teeth
• Tissue removed in plastic repairs such as ectropion
• Vaginal mucous membrane removed incidental to vaginal repair
• Varices

34. Blood Products Refusal/Restriction Form
Blood/Blood Products Consent
Blood Products Refusal/Restriction Form

35. Massive Transfusion Protocol (MTP)
MTP should be considered upon transfusion of > 6 units RBCs or development of microvascular bleeding
TRAUMA MTP Includes:
6 Units Red Blood Cells
6 Units Thawed Plasma
1 Unit Apheresis Platelets
**Cryoprecipitate will be ordered separately as needed during trauma cases

36. Blood Products Thawing/Prep Time
Uncrossmatched Blood
7 Minutes
Type-Specific Blood
15 Minutes
Type and Crossmatch (Initial)
30-40 Minutes
Platelets
10-15 Minutes
Thawed Plasma
20-25 Minutes
Cryoprecipitate
Transportation time to OR via dumbwaiter
2 Minutes

37. Treatment Limitations/DNR Order Form

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