Out-of-Hospital Premises Inspection Program. Assessment Protocol for Premises Standards

Out-of-Hospital Premises Inspection Program Assessment Protocol for Premises Standards 1. OHP PHYSICAL STANDARDS: Policies and Procedures Common to all OHPs Indicator Meets Meets with recommen -dations a. The premises policy and procedure manual is current, complete and available for personnel b. Individual policies are signed by the Medical Director c. Past policies are retained and filed for legal purposes d. Specific manuals are available for the equipment used in the premises e. A process is place for annual review of manuals which is signed off by the Medical Director f. The policy and procedure manual contains but is not limited to the following: Administrative: Responsibility for developing and maintaining the policy and procedure manual Organizational chart Scope and limitation of OHP services provided g. Job Descriptions: Define scope and limitations of staff functions and responsibilities for patient care Define responsibility for supervising staff Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 1 of 36

Procedures Adverse events: monitoring, reporting and reviewing Adverse events: response to an adverse event Combustible and volatile materials Delegating controlled acts Emergency evacuation Equipment: routine maintenance and calibration Infection control Medications handling and inventory Medical Directives Patient booking systems Patient consent (written or verbal) based on the scope of the OHP practice Patient preparation for OHP procedures Response to latex allergies Safety precautions regarding electrical, mechanical, fire and internal disaster Urgent transfer of patients (see Section 6.5 OHP standards) Waste and garbage disposal Cleaning Protocols for Housekeeping staff OHPIP: Assessment Protocol for Premises Standards Page 2 of 36

2. OHP PHYSICAL STANDARDS: General Physical Standards Common to all OHPs Indicator Meets Meets with recommendations a. The premises is neat, comfortable and clean b. The environment is free of clutter c. Access for disabled persons complies with provincial legislation (Ontarians with Disabilities Act) and/or municipal bylaw d. Patient washrooms are wheelchair accessible e. The layout of the premise facilitates patient care and safety f. The following areas are physically separate, where appropriate, allowing adequate space to ensure patient safety, privacy, confidentiality, emergency protocols and infection control standards: administration and patient-waiting area procedure room and/or operating room recovery area clean utility area dirty-utility room non-sterile storage area sterile area staff change room and staff room g. The site complies with all applicable building codes, including fire safety requirements h. The size of the OHP is adequate for all procedures to be performed safely Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 3 of 36

Electrical Indicator Meets Meets with recommendations i. All electrical devices are safety certified by CSA or equivalent (visual inspection of CSA sticker on actual equipment) j. There are no overloaded wall plugs or overloaded extension cords in use k. The wires in use are not broken, worn or unshielded (e.g. no wires visible) l. There is an emergency power source available which provides for the safe completion of the procedure and recovery m. Any electrical renovation is approved with sign-off by the municipal inspector Physical Emergency Measures n. Hallways, stairways and elevators are sufficiently wide to allow emergency evacuation of a patient by emergency personnel and their equipment o. Stretchers, wheelchairs and other adequate methods of emergency transport are available p. The premises is equipped with a fire/smoke alarm system that conforms to local fire codes and fire safety training q. Fire exits are clearly marked and evacuation maps are located in patient areas r. There is emergency lighting in the patient care area Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 4 of 36

Comments on General Physical Standards Common to all OHPs: 2.1 OHP PHYSICAL STANDARDS: Physical Standards for Procedure Rooms Physical requirements* Indicator ****All levels Meets Meets with recommen -dations Does not meet Not applicable (please provide comments) a. All OHPs provide the following physical requirements: adequate lighting for the procedures performed the temperature is appropriately controlled floors and walls can be cleaned to meet infection control requirements (e.g. surfaces are smooth and washable) hand-washing premises and proper towel disposal (scrub sinks) are available openings to the outside are effectively protected against the entrance of insects or animals by selfclosing doors, closed windows, screening, controlled air current or other effective means ****Levels 2&3 b. Levels 2&3 meet the above requirements and must comply with the following: There is adequate space to accommodate the equipment and the staff required for the procedure There is ample space for the physician and assisting staff to move around the OR table with access to both sides of the patient, without contamination If a sterile field is required, the walls, floors and ceiling are covered with an easily cleaned material which is smooth and free from breaks or cracks OHPIP: Assessment Protocol for Premises Standards Page 5 of 36

Ventilation Indicator Meets Meets with recommen dations ****All levels c. Ventilation system ensures patient and staff comfort d. Ventilation and air circulation is augmented to address procedure-related air-quality issues (e.g., cautery smoke, anesthetic gases, endoscopy, disinfecting agents [Glutacide fumes are vented directly to the outside] ****Level 2&3 only e. Where gas sterilization is used, a positive pressure outbound system is used, vented directly to the outside f. HVAC -Heating, Ventilating and Air Conditioning (HVAC) equipmant is maintained and inspected as per manufactureers recommendations (preventative Records are kept on site) Equipment **** All levels g. Equipment is maintained and inspected regularly for functionality (documentation of a minimal yearly maintenance inspection program is available) h. The following documentation for equipment is available: equipment operating manuals equipment maintenance contracts log for maintenance of all medical devices (e.g. suction machines) Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 6 of 36

i. A biomedical technician annually inspects all equipment (including electrical outlets, breaker/fuse boxes, and emergency light and power supplies) and reports in writing that the equipment is safe and operating according to the manufacturer s specifications j. Only inspected equipment is used in the procedure room k. The equipment s specifications are kept in an organized file l. All equipment is on a maintenance schedule with records kept for a minimum of at least three (3) years m. Stickers are placed on individual equipment as appropriate and written records are maintained. n. All equipment repairs and changes are done by a biomedical technician with records kept for a minimum of three (3) years o. Personal protective equipment is available for all appropriate procedures p. The following equipment is provided in all OHPs: cleaning equipment as required for the specific procedures accessible anesthetic material and equipment blood pressure and oxygen saturation monitoring equipment ****Levels 2&3 q. Levels 2&3 meet the above requirements and must comply with the following: small equipment table sterilized packs and instruments table/chair that permits patient restraints and Trendelenberg positioning table/chair/stretcher that accommodates procedures performed and provides for adequate range of movement for anesthetic procedures including an adjustable headrest to facilitate intubation OHPIP: Assessment Protocol for Premises Standards Page 7 of 36

suction equipment and backup suction -battery operated for emergencies separate suction for anesthesia provider s exclusive use 2.2 OHP PHYSICAL STANDARDS: Physical Standards for Recovery-Area Indicator Meets Meets with recommendations ****Levels 2&3 only Physical requirements a. A sink for hand washing is immediately accessible b. Electrical outlets that meet required codes are available Size and layout c. The size of the recovery area corresponds with planned use and accommodates the volume of patients expected for a minimum of two hours operating room time. 1 hour procedure = 2 patients 0.5 hour procedure = 4 patients d. The recovery area allows for transfer of patients to/from a stretcher and performance of emergency procedures Does not meet Not applicable (please provide comments) Equipment Indicator Meets Meets with recommen -dations e. In the recovery area, appropriate monitoring, suction, oxygen, and bag-valve-mask devices, adequate Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 8 of 36

intravenous and other medical/surgical supplies are immediately available as: Blood pressure monitoring equipment Separate pulse oximeter available for each patient Temperature Monitoring Device Stethoscope Blood glucose monitoring equipment Resuscitation Equipment and Emergency Drugs as per OHPIP standard 4.4.3.1 and 4.4.3.2 Easy access to the following: Difficult Intubation Cart MH Cart if applicable Cutaneous warming device Comments: OHPIP: Assessment Protocol for Premises Standards Page 9 of 36

3. MEDICATION STANDARDS General Medication Standards Indicator Meets Meets with recommen -dations ****All levels a. A general medication inventory record is maintained b. Medications are periodically inspected for: drug name drug dosage expiration date D.I.N. c. Medications are labeled in accordance with the Food and Drug Act (FDA) and the Controlled Drugs and Substances Act (CDSA) and its regulations d. Medications are stored according to the manufacturer s recommendations (e.g., refrigeration if required, fridge is at correct temperature and checked daily, refrigerator is not used for food storage) e. Medications are stored in a manner suitable for security and restocking: f. stock drugs are stored in designated non- patient care area g. organized for easy access in appropriately labeled bins/cupboards h. Medications administered are documented in the patient record i. Medications dispensed at discharge are accompanied by verbal and written instructions that are given to the patient and/or accompanying adult Does not meet Not applicable (please provide comments) OHPIP: Assessment Protocol for Premises Standards Page 10 of 36

j. OHPs should make available resources to determine appropriate drug dosages and usage. Resources may include: CPS- Compendium of Pharmaceuticals and Specialties: The Canadian Drug Reference for Health Care Professionals Electronic Medication References such as Lexi- Comp and e-cps electronic medication references tool that provides decision support for health care professionals. k. Pediatric doses are available for that population Controlled Substances Standards l. Controlled substances are handled and administered in accordance with Food and Drug Act (FDA) and the Controlled Drugs and Substances Act (CDSA) and its regulations m. There is one qualified designated staff (e.g. RN, RPN with medication skills, physician) assigned to managing controlled substances n. Controlled substances are stored in a designated locked cabinet and double locked. o. Controlled substances are accounted for in a Log of Controlled Substances p. For each controlled substance, the following information is specified: name quantity date received expiry date loss (damaged, expired, spilled) date and quantity and stock balance OHPIP: Assessment Protocol for Premises Standards Page 11 of 36

q. For patient administration, the following information is collected: patient name drug name amount removed from inventory and stock balance date and time quantity used and waste name of staff administering the medication r. An end-of-day balance of the inventory of controlled substances is calculated by physical count and verified by the signatures of two qualified (regulated) staff s. In the event of a discrepancy, is an investigation conducted and documented with the appropriate action taken Comments: OHPIP: Assessment Protocol for Premises Standards Page 12 of 36

4. INFECTION CONTROL STANDARDS General Standards Indicator ****All levels Meets Meets with recommen -dations Does not meet Not applicable (please provide comments) a. Premises adhere and maintain documentation for the following: Accepted standards of infection control practices pertinent to the specific procedures performed b. Universal precautions (i.e. all human blood and human body fluids are treated as if known to be infectious for HIV, HBV, and other blood borne pathogens) are followed c. Infection Control in the Physicians Office published by the College is available d. In order to minimize risk of infection in the OR, the following actions are undertaken: Disinfectants are properly used for the sterilization of instruments and equipment e. Medical equipment that uses water is properly maintained (e.g. automated endoscope reprocessors). f. Proper ventilation requirements for specialized care environments (e.g. airborne infection isolation, protective environment and ORs ) g. Water intrusion into OHP structural elements in the OR are managed promptly h. Accepted standards of waste handling are implemented OHPIP: Assessment Protocol for Premises Standards Page 13 of 36

i. Policies are in place for the following: Documentation of staff mantoux tests kept Documentation of staff immunization kept Flu Shots MMR Hep B TDP Chickenpox Immunity j. Written work exclusion policy for: Dermatitis on hands Disseminated shingles Diarrhea Written policy on Bloodborne Pathogen Follow-up k. All patient care areas have: Soap and water available Alcohol-based hand rubs available l. Waiting room has: infection control signs at entry Infection control signs at reception desk Alcohol-based hand cleaner at Reception with signage Tissue boxes available Garbage Cans available Patient segregation area available Clean toy and soiled toy bins available m. Reception area has: Personal Protective Equipment (PPE) available Patient masks Staff fluid resistant masks Staff gloves Reception staff can maintain 1 meter distance with patients Telephone screening protocol has been developed and implemented n. Examination/Consultation rooms have: Hand washing sinks with soap available in all rooms Exam rooms only have essential supplies OHPIP: Assessment Protocol for Premises Standards Page 14 of 36

o. Staff perform hand hygiene: Before direct patient contact. After direct patient contact After removing gloves Before performing invasive procedures (e.g., placing an IV) After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn) p. Gloves for routine practices are: Worn for procedures that might involve contact with blood or body fluids Worn when handling potentially contaminated patient equipment Removed before moving to the next task and/or patient q. Cleaning procedures Written protocols and procedures for cleaning the office setting are available Approved and appropriate disinfectant products are available for patient surfaces Approved and appropriate disinfectant products are available for equipment and instruments OHPIP: Assessment Protocol for Premises Standards Page 15 of 36

r. Protocol development and staff training Annual staff training or updating is completed on the following: Infection prevention Annual staff training on proper PPE use s. Disinfection/sterilization of medical devices Manufacturer's instructions are followed There is a process for cleaning semi-critical and critical devices There are written protocols for: o disassembly o sorting and soaking o physical removal or organic material o rinsing o drying o physical inspection and wrapping Sterilization must follow manufacturer s recommendations Internal and external indicators must be used with sterilization Biological indicators must be used daily Recording of indicators must be done High level disinfection must be done according to manufacturer s recommendations Product used for high level disinfection must have a DIN number t. Cleaning of procedure/operating rooms Procedure/Operating rooms are cleaned and disinfected after each surgical or invasive procedure with a registered disinfectant Procedure/Operating rooms are terminally cleaned daily High-touch surfaces in patient care areas are cleaned and disinfected with an registered disinfectant A procedure is in place to decontaminate gross spills of blood. OHPIP: Assessment Protocol for Premises Standards Page 16 of 36

u. Aseptic technique is maintained for sterile procedures including: Scrub attire Operating room attire Sterile field Clean air exchanges Storage of sterile supplies v. Injection practice (injectable medications, saline, other infusates) Needles are used for only one patient. Syringes are used for only one patient. Medication vials are always entered with a new needle. Medication vials are always entered with a new syringe. Medications that are pre-drawn are labeled with the time of draw, initials of the person drawing, medication name, strength, and expiration date or time Single dose (single-use) medication vials are used for only one patient Manufactured prefilled syringes are used for only one patient. Bags of IV solution are used for only one patient Medication administration tubing and connectors are used for only one patient Multi-dose injectable medications are used for only one patient. If they are not, the rubber septum must be disinfected with alcohol prior to each entry. Multi-dose medications used for more than one patient are dated when they are first opened and discarded within 28 days of opening or according to manufacturer s recommendations, whichever comes first Multi-dose medications, used for more than one patient, are not stored or accessed in the immediate areas where direct patient contact occurs OHPIP: Assessment Protocol for Premises Standards Page 17 of 36

w. Prevention of sharps injury All sharps are disposed of in a puncture-resistant sharps container (e.g. needles, blades, razors and other items capable of causing punctures) Sharps containers are replaced when the fill line is reached Staff are trained to use safety engineered devices Safety engineers are provided to reduce risk to staff re. sharp injury During operative procedures, sharps are passed using a transfer tray Post-exposure prophylaxis is available for staff with blood and body fluid exposure x. Cleaning of glucometer A new single-use, auto-disabling lancing device is used for each patient The glucose meter is not used on more than one patient unless the manufacturer s instructions indicate this is permissible The glucose meter is cleaned and disinfected after every use y. Management of infectious diseases Patients are screened for MRO's and Infectious Diseases and assessed if appropriate for OHPs Appropriate additional precautions are applied as necessary re: Airborne, Contact/Droplet or Contact Precautions Staff wear appropriate PPEs Patients are isolated from other patients upon admission OHPIP: Assessment Protocol for Premises Standards Page 18 of 36

z. Disposal of waste General, biomedical and pathological. GENERAL office waste, used gloves or non-sharp medical equipment, may be disposed of in regular waste and requires no special handling other than containment during disposal and removal BIOMEDICAL waste is handled and disposed of in such a way as to avoid transmission of potential infections. Non-anatomical waste, such as liquid blood or body fluid drainage (e.g. chest tube drainage containers, IV blood filled tubing), must also be packaged as biomedical waste Anatomical waste such as body parts is classified as PATHOLOGICAL waste and must be disposed of according to the regulations for handling pathological waste Comments: OHPIP: Assessment Protocol for Premises Standards Page 19 of 36

5. QUALITY ASSURANCE STANDARDS Indicator ****All levels Meets Meets with Recomme ndations Does not Meet Not Applicable (please provide comments) Quality Assurance Committee a. A OHPIP committee has been established and is comprised of all staff providing patient care with documentation maintained of this activity Monitoring Quality of Care b. The premises has a written quality improvement program in place which includes surveys or projects which: Monitor and evaluate patient care c. Evaluate methods to improve patient care d. Identify and correct deficiencies within the premises e. Alert the Medical Director to identify and resolve problems f. The OHP has a documented process in place to regularly monitor the quality of care provided to patients. These activities include, but are not limited to a review of the following: Non medical staff performance g. Individual physician care performance to assess: Patient selection to ensure appropriateness h. Procedure selection to ensure appropriateness i. Patient outcomes j. Evaluation of complications and adverse events k. At least annually, a random selection of approximately 5- OHPIP: Assessment Protocol for Premises Standards Page 20 of 36

10 patient records is reviewed to assess the following: Record completion and documentation of informed consent l. The percentage and types of procedures m. Appropriate patient selection n. Appropriate patient procedure o. Where required, reporting requirements are met in a timely manner p. Evaluation of complications q. Assessment of transfer to hospital r. Abnormal pathology and laboratory results follow-up s. A selection of individual patient records to assess completeness and accuracy of entries by all staff t. Activities related to cleaning, sterilization, maintenance and storage of equipment Monitoring and Reporting Adverse Events u. There is an internal process to document and investigate incidents v. There is a process in place to record both staff and w. patient adverse events (e.g. needle stick injuries, x. technique breaks, unsterile equipment) y. There is a standardized process for identifying infections and calculating surgical site infection rates z. There is a process in place for the reporting and documentation of errors, unsafe practice, incompetence or professional misconduct aa. Adverse events are reported immediately to the Medical OHPIP: Assessment Protocol for Premises Standards Page 21 of 36

Director, and submitted in writing to the Medical Director within 24 hours of the event bb. A report is completed for all incidents cc. The written report includes the following: Name, age, and sex of the person(s) involved in the incident (inclusive of staff and patients) Name of witness(es) to the event (if applicable) Time, date and location of event Description of the incident and treatment rendered Date and type of procedure (if applicable Analysis of reasons for the incident Outcome dd. Copies of incident reports are stored in a separate file ee. Incident reports are reviewed annually by the Medical Director Monitoring and Reporting Adverse Events ff. There is a mechanism of surveillance and review of postoperative infections gg. If yes, the policy/procedure includes immediate notification of the Medical Coroner and notification of the College OHPIP: Assessment Protocol for Premises Standards Page 22 of 36

Review of Adverse Events and other OHPIP Monitoring hh. The Medical Director: Reviews all adverse events reports and OHPIP monitoring findings that occur over a 12 month period Documents the review and any relevant corrective actions and quality improvement initiatives taken Provides feedback to all staff OHPIP: Assessment Protocol for Premises Standards Page 23 of 36

6. Anesthetic and Ancillary Equipment Indicator ****Levels 2&3 Meets Meets with recommendations Does not meet Not applicable (please provide comments) a. Anesthetic and ancillary equipment (selection, installation, maintenance) comply with both the Canadian Standards Association (CSA) standards and applicable recommendations arising from provincial legislation. b. Medical compressed gas and pipelines comply with both Canadian Standards Association (CSA) standards and applicable recommendations arising from provincial legislation. c. A second supply of oxygen (normally a spare cylinder) with pressure gauge, regulator, and wrench is available. ****Level 3 only a. Level 3 OHPs provide the following: b. An anesthesia machine c. An anesthetic drug cart *Note: depending on the procedure performed, not all standards may apply. Comments: OHPIP: Assessment Protocol for Premises Standards Page 24 of 36

7. Monitoring and resuscitation equipment required on OHP premises Level 1 only Yes No N/A a. AED All levels a. IV setup b. Adequate equipment to manage local anesthetic toxicity i.e. BP Cuff, Stethoscope, ability to manage airway and do CPR, drugs as per OHPIP Standards 4.4.8.2 c. Appropriately sized equipment for infants and children, if required. Levels 2 and 3 only a. Assortment of disposable syringes, needles, and alcohol wipes b. Cardiopulmonary resuscitation equipment with current ACLS/PALScompatible defibrillator c. ECG monitor d. Intubation tray with a variety of appropriately sized blades, endotracheal tubes, and oral airways e. Laryngeal mask airways f. Means of giving manual positive pressure ventilation (e.g., manual self-inflating resuscitation device) g. Means to verify end-tidal CO 2 h. Oxygen source i. Pulse oximeter OHPIP: Assessment Protocol for Premises Standards Page 25 of 36

j. Suction with rigid suction catheter k. Torso backboard Comments: OHPIP: Assessment Protocol for Premises Standards Page 26 of 36

The following drugs for resuscitation are required to be available on the premises: Drugs for Resuscitation 8. Drugs required on OHP premises: All levels Yes No N/A a. Diphenhydramine b. Epinephrine for injection c. Oxygen d. Salbutomol e. Intralipid if Bupivicaine/Ropivicaine is used Levels 2 and 3 only a. Amiodarone IV b. Antihypertensive IV (at least one of Labetalol, Hydralazine) c. ASA 81mg po d. Atropine IV e. Benzodiazepine IV (at least one of: Midazolam, Diazepam, Lorazepam) f. BETA Blocker IV (at least one of Metoprolol, Propranolol, Esmolol) g. Calcium IV (chloride or gluconate) h. Dextrose 50% IV i. Diphenhydramine IV OHPIP: Assessment Protocol for Premises Standards Page 27 of 36

j. Flumazenil IV k. Hydrocortisone IV 100mg or 500mg l. IV agent for SVT (at least one of Adenosine, Esmolol, Verapamil) m. MHAUS treatments if triggering agents present, following MHAUS guidelines n. Morphine IV o. Naloxone IV p. Neuromuscular blocking agents, if qualified staff available q. Nitroglycerine spray 8. Drugs required on OHP premises: Levels 2 and 3 only 2 and 3 o Yes No N/A r. Pressor IV (at least two of: Epinephrine, Ephedrine, Vasopressin, Phenylephrine) s. Sodium bicarbonate IV elevel 3 only a. Antihypertensive IV (at least two of Labetalol, Hydralazine or Nitroglycerine) b. IV agent for SVT (at least three of Adenosine, Esmolol, Verapamil, Metoprolol c. Lasix IV d. Lidocaine 2% (pre-filled syringe) e. Magnesium Sulfate IV f. Pressor IV (at least two of Epinephrine, Ephedrine, Vasopressin, Phenylephrine) OHPIP: Assessment Protocol for Premises Standards Page 28 of 36

Comments: OHPIP: Assessment Protocol for Premises Standards Page 29 of 36

Out-of-Hospital Premises Inspection Program Observational Assessment Protocol PROCEDURAL STANDARDS: Observational Component Comprised of observations/ review of policies and procedures/documentation within the patient record 1. Patient Admission requirements Indicator ****All levels Meets Meets with recommen -dations Does not meet Not applicable (please provide comments) a. The patient is admitted to premises by a registered nurse b. The following information is obtained and documented by a health care provider under the supervision of a physician: Pulse oximetry Vital signs Allergies NPO status Height, weight Medication taken on morning of surgery c. A preoperative checklist is utilized OHPIP: Assessment Protocol for Premises Standards Page 30 of 36

2. Verification Process a. The marks are made by the physician performing the procedure and must be: Placed using a permanent marker at or near the incision/insertion site Visible at time of patient preparation and visible at time of incision Explicit (e.g. initials) to indicate the intended site of incision or insertion b. If site marking meets exemption criteria as outlined in 6.1.3.1 of the OHP standards, this is documented in the patient s record First Verification c. The first verification takes place in the pre-procedure area. d. The patient is awake and aware e. The nurse preparing the patient for the procedure Confirms the patient identity, procedure, site and/or side with the patient/substitute decision-maker/legal guardian Documents the first verification on the Surgical Safety Checklist OHPIP: Assessment Protocol for Premises Standards Page 31 of 36

Second Verification f. The second verification must be conducted during the time-out in the location where the procedure takes place, immediately before starting the procedure g. The entire procedure team confirms the patient identity, procedure, site and/or side and acknowledges their agreement: nurse(s), attending physician, attending anesthesiologist [if applicable], and physician-assistant [if applicable] OHPIP: Assessment Protocol for Premises Standards Page 32 of 36

3. Intra-operative Patient Care a. The nurse assisting in the procedure room/or: Completes an operative record with appropriate and accurate documentation regarding the procedure (e.g. pre-procedure assessment, consent form) Verifies with the physician the correct patient position and availability of correct implants or special equipment required for the procedure prior to starting the procedure Patient monitoring e.g., pulse, blood pressure and electrocardiography are in continuous use for the duration of anesthetic care Audible and visual alarms are activated OHPIP: Assessment Protocol for Premises Standards Page 33 of 36

4. Post Procedure Patient Care level 2 & 3 a. Staffing requirements for the recovery area meet the premises standards b. If written orders are not provided, there is a verbal report provided to appropriate recovery-area staff which includes but is not limited to the following: Name and age of patient Procedure performed Pertinent history including allergies, medical/physical limitations Types of anesthesia/sedation used Other medications given Any unusual or adverse events pertaining to patient Estimated fluid or blood loss Anesthetic course Post-Anesthetic Recovery Room Record c. Registered nurse trained in recovery room procedures remain in continuous attendance to the patient d. Recovery area staff caring for patients in phase I, II, or III recovery provide care and document the following in the patient record. Information includes but is not limited to: Patient identification Date and time of transfer to recovery area Initial and routine recording of blood pressure, pulse respiration, temperature, level of consciousness, OHPIP: Assessment Protocol for Premises Standards Page 34 of 36

oxygen saturation, pain score, procedure site and general status Continuous monitoring of vital signs until the patient has met requirements of discharge criteria using an objective scoring system from time of transfer to recovery area until discharge from Phase II recovery Any medications administered including dose, time, date, route, site, reasons and effects Any treatments given and effects of such treatments The name and signature of the post anesthetic care nurse Is the post-anesthetic recovery room record included in the patient record? e. The anesthesiologist/physician remains on site until the patient has met discharge criteria f. Recovery area staff carry out action(s) according to a direct order or a medical directive as described in the premises policies and procedures OHPIP: Assessment Protocol for Premises Standards Page 35 of 36

5. Patient Discharge Indicator Meets Meets with recommen -dations a. An anesthesiologist or physician is responsible for writing the discharge order based on the discharge criteria b. The anesthesiologist or other physician qualified to administer IV sedation remains on the premises of the facility until the patient meets the documented predetermined recovery criteria c. A minimum of one ACLS certified staff member must be present in the facility until all patients recovering from anesthesia have met criteria for discharge from the facility d. The patient is accompanied from the facility by a responsible adult e. Appropriate verbal and written post-discharge instructions are given to the patient and accompanying adult. f. The patient and accompanying adult are instructed to notify the OHP of any unexpected admission to hospital within 10 days of the procedure g. Appropriate protocols and/or transfer arrangements to hospital are in place for ongoing care if patients do not meet required discharge criteria Does not meet Not applicable (please provide comments) Comments: OHPIP: Assessment Protocol for Premises Standards Page 36 of 36