Perioperative Services for HTM Technicians D McMahon 150106 rev cewood 2018-01-02
Key Points Perioperative Services: Perioperative Services includes: Pre-Op Clinic The Operating Room suite Post-Anesthesia Care Unit Know about attire in the surgical setting Know about etiquette in the surgical setting (subject to rules of individual hospital) Know when the checklist is used during a surgical case Review OR handwashing protocol Understand the range of charges for a surgical procedure Be aware of time management in the OR and the costs of delays Know the fire dangers present in the OR Know about typical equipment found in a PACU or Recovery Room Be aware of typical BMET coverage in Perioperative Services plan to read: The Checklist Manifesto: How to Get Things Right by Atul Gawande
Perioperative Services includes > Pre-Op Clinic patients visit before surgical day to be seen by an anesthesiologist, get an ECG, lab work, etc. > The Operating Room suite rooms where the surgeries are performed - most rooms are set up for a surgical sub-specialty > Post-Anesthesia Care Unit open-format room for where most patients are taken to be monitored immediately post-surgery - patients from open-heart and other major impact procedures are taken to the ICU
Pre-Op Clinic
Standards-Setters in the O.R. : Association of perioperative Registered Nurses ( AORN ) American Society of Anesthesiologists ( ASA ) American Association of Nurse Anesthetists ( AANA )
Standards-Setters in the O.R. : American Society of PeriAnesthesia Nurses ( ASPAN ) Association for the Advancement of Medical Instrumentation ( AAMI ) American Society for Healthcare Engineering ( ASHE )
Typical Surgical Personnel - Surgeon - Surgeon s Assistant - Scrub Person (Nurse or Scrub Tech) - Circulating Nurse - Anesthesia provider (MD or CRNA) - Anesthesia Tech
Anesthesia providers Anesthesiologist: MD who has training in an Anesthesia residency (3+ years). May also be ASA Board-certified. Anesthetist (Certified RN Anesthetist): a graduate RN with training in a CRNA program (2+ years).
Additional Personnel in the O.R. : - Surgical First Assistant(s) (may be Physician s Assistant or Nurse Practitioner) - Surgical Resident - Radiology Tech - EEG Tech - Perfusionist - Vendor Rep - Pathologist
Attire in the surgical setting: Scrubs, or a Jump Suit Head cover Hood (check about beards) Mask Shoe covers, or specific shoes Gloves
Etiquette in the surgical setting: > Hair must always be covered in the O.R. > Mask must always be worn if there is a sterile field. > Stay at least 18 from the sterile field. (i.e. back table, Mayo stand, patient draping, scrub staff) > Do not release liquid droplets or aerosols around a sterile field. > When out of the O.R., wear a white coat or gown. > Scrubs are not to be worn outside the building. > Never bring food or drink into the Operating Room suite.
protocol, protocol, protocol... http://www.infectioncontroltoday.com/articles/2001/05/how-to-perform-surgical-hand-scrubs.aspx http://www.who.int/surgery/publications/bestpracticeprotocolscpsafety07.pdf
Charges for the Surgical Patient > Hospital charges for O.R. > Professional fees for Surgeon(s) > Professional fees for Anesthesia provider > Charges for procedure-specific items e.g. blood, proprietary expendables, and implants (heart valves, joints, pacemakers, etc)
http://www.akrongeneral.org/portal/page/portal/agmc_pagegroup/price_guide
O.R. charges, Akron General Hospital 19-JAN-2017: In addition, there is an anesthesia charge for any operating room procedure: The above listed fees do not include the fees for drugs, appliances or supplies used as required for a particular surgery. Surgeon and Anesthesiologist professional fees are billed by the physician.
O.R. Schedule Management
These average numbers... O.R. Management Parameters give these hospital ratings Measurement: Poor Performance Medium Performance High Performance Excess Staffing Costs >10% 5-10% <5% Start-time delays (mean delay) >60 min 45-60 min <45 min Case cancellation rate >10% 5-10% <5% Post Anesthesia Care Unit admit delays >20% 10-20% <10% Contribution Margin (mean) per O.R.hour <$1,000/hr $1 2,000/hr >$2,000/hr Turnover Time >40 min 25-40 min <25 min Prediction Bias >15 min 5-15 min <5 min Prolonged turnovers (more than 60 min) >25% 10-25% <10% Start time delays and turnover times tend to be the most costly
Facilities Engineering Aspects of the O.R. Heating, Ventilation, and Air Conditioning Medical Gas Supplies Electrical Service O.R. Lighting Sterilizers
Heating, Ventilation, and Air Conditioning - Temperature: 13-18 C (55-65 F) - Humidity: was >30%, now >20% (2014) - Room Air flow: 12-15 turnovers / hour - Air flows must be positive to hallway
Medical Gas Supplies - Oxygen - Nitrous Oxide - Medical Air - Nitrogen - Specialty Gases - Vacuum - Zone Valves
Electrical Service - Room Circuits on Emergency Grid - Standards for ampacity & distribution - Line Isolation - Line Isolation Monitors
O.R. Lighting - Ceiling Lighting - w/ backup power - ambient lighting should be 750 to 1500 lux (AIA) - Overhead Surgical Lights - w/ backup lamp system - newer models use LEDs with color control
Sterilizers in the O. R. - Steam > usually medium capacity, one for each 2 rooms - Steris System 1 (peracetic acid) > for flexible endoscopes - Cidex (glutaraldehyde) > high-level disinfection for rigid scopes, instruments, and surgical cameras
Sticky mats at O.R. entries -
Safety Issues in O.R. - Infection Control: Standard Precautions (Sterile Technique) - Endoscopic Instrument Burns - Anesthetic Gas Pollution - Smoke from ESUs & Lasers - Surgical Site Fires
- Patient ID verification More Safety Issues - Patient positioning - Wrong-site surgery - Electrical distribution - Floor clutter: Cables, wires, tubing
Wrong-Side or Wrong Site Surgery
http://apps.who.int/iris/bitstream/10665/44186/2/9789241598590_eng_checklist.pdf
read: Atul Gawande Checklists!
Fire Safety in the O.R. Fire hazards specific to the surgical setting: > local pockets of enriched oxygen and nitrous oxide > adjacent flammable materials: -- drapes -- dressings -- gowns -- prep solutions > ignition sources: -- electrosurgical pens -- fiberoptic light cables and fiberoptic sources -- laser beams
O.R. Fire Prevention > minimize buildup of oxygen or nitrous oxide > precautions with electrosurgical technique > precautions with fiberoptics > prep or remove facial & body hair
O.R. Fire Management > Rescue anyone in immediate danger > Activate the alarm > Contain the fire if possible > Evacuate the area, if necessary > remove burning materials, d/c oxygen > smother flames with drapes, towels, etc
Fire Extinguishers Type A: Water Types B,C: Dry chemical Types A,B,C: Foam Types A,B,C were Halon (no longer produced, but available)
Patient positioning -
Post-Anesthesia Care Unit PACU (or Recovery Room ) > Basic role is to monitor post-surgical patients and intervene if their status declines. > Intensive nurse staffing. > Typical Equipment : Full-function monitors at each patient station, ECG recorders, Doppler flow meters, warmers, thermometers, SCDs.
Biomed Coverage in Perioperative Services > Stay in touch with the Managers - be involved in capital purchasing - be available for inservicing > Make rounds often in the O.R. > Schedule your PM s around the O.R. schedule > Keep track of demo & loaner equipment > Interface with Facilities Engineering on facility issues in O.R. > Interface with IT on network and wireless issues