STANDARD 14: Surgical Services

14.1 General

1. If the healthcare organization provides surgical services, all inpatient and outpatient services shall be well organized and provided in accordance with acceptable standards of practice and the complexity of services offered.

2. A qualified surgeon and/or anesthesiologist shall be appointed as a Director of surgical services by and shall oversee all surgical services.

3. The surgical service shall include provisions for pre, intra, and post-operative care, including appropriate follow-up indicated by acceptable standards of care.

4. Monitoring and measurement of surgical procedures for quality of patient care at levels consistent with organizational needs and established regulatory requirements shall be established and ongoing. Results shall be reviewed by the director of surgical services, medical staff, and top management of the healthcare organization for continual improvement and patient satisfaction.

14.2 Organization and Staffing

1. The healthcare organization shall provide the appropriate equipment and the appropriate types and numbers of qualified personnel necessary to furnish the surgical services offered by the healthcare organization in accordance with acceptable standards of practice.

2. The scope of surgical services shall be defined in writing and approved by the medical staff. The medical staff credentialing committee and surgical Director shall evaluate each individual practitioner’s training, education, experience, and demonstrated competence in deciding upon their recommendation of the privileges to be granted.

3. The body of information required in 2 above shall form the surgical register and be immediately available at the point of use to establish the scope of practice for each surgical practitioner.

4. There shall be a circulating RN in the operating room, immediately available to respond to ongoing requirements and emergencies.

NOTE 1 The supervising RN would not be considered immediately available if the RN was located outside the operating room or engaged in other activities/duties. A licensed practical nurse (LPN) may assist an RN in carrying out circulatory duties in accordance with medical staff approved healthcare organization policy.

14.3 Delivery of Service

1. Policies governing surgical care delivery shall be designed so as to achieve their intended outcome consistent with high standards of medical practice and patient care.

2. These policies shall include but are not limited to the following:

a) sterile technique, including infection prevention and control surveillance (See also 22.2.2. and 22.2.3.);

b) sterile processing and decontamination within the healthcare facility as described in STANDARD 29;

c) identification of infected and non-infected cases;

d) housekeeping requirements and procedures to maintain operating room infection control consistent with regulatory requirements and recommendations of accepted advisory organizations;

e) job descriptions of all support personnel;

f) operating room safety requirements, practices, and personnel policies unique to the operating room;

g) conduct of surgical counts in accordance with accepted standards of practice;

h) appropriate care and identification of surgical specimens including monitoring, and measuring of miscreant pathology reports;

i) surveillance to prevent and policy to treat malignant hyperthermia;

j) appropriate protocols for all surgical procedures performed. These shall be procedure-specific or general in nature and shall include a list of equipment, materials, and supplies necessary to accomplish all approved surgical procedures;

k) acceptable operating room entry, exit, and general traffic control while in either scrub or street attire;

l) handling of infectious and biomedical/medical waste;

m) outpatient surgery post-operative care planning, coordination, and provisions for follow-up care.

3. Patient safety requirements shall include but are not limited to:

a) preoperative requirements consistent with the healthcare organization, medical staff, and medical records policy to include patient identification and scheduling procedures;

b) patient rights considerations to include informed consents, advanced directives, and methods of reconciliations;

c) inclusion of timely and appropriate "checkpoint control" including "time outs" and "prep-resistant" pre-operative surgical site identification to protect patients from unintended errors in delivery of service (See requirements of 4.1.3–4.1.5);

d) availability of personnel qualified in resuscitative techniques and the integration of consultative care by related support services.

4. When alcohol-based skin preparations are used in anesthetizing locations, this shall be done in strict accordance with manufacturer’s recommendations and documentation of this adherence shall be noted in the medical record.

5. Prior to surgery procedure requiring anesthesia services (except in the case of emergencies) a medical history and physical examination shall be completed and documented as per STANDARD 8.9.

NOTE 1 When available, unit dose packaging of alcohol-base skin prep shall be preferred to prevent excessive flammable accelerants introduced within the operative field. Additionally, the surgical field should be inspected to confirm complete drying prior to initiation of field draping.

14.4 Operating Room Record

1. The operating room schedule shall document all elective or emergency surgical cases. It shall include at least the following information:

a) patient’s name and age;

b) all additional identifiers;

c) date of the procedure;

d) inclusive times;

e) name of the surgeon and any assistant(s);

f) name of associated nursing personnel (scrub and circulating);

g) type of anesthesia and provider;

h) operation performed;

i) pre and post-operative surgical diagnosis;

2. This record shall be retained as documented information.

NOTE 1 A projected schedule of planned surgery is customary for planning purposes. It may contain elements of the above operating record. Distribution of this document may be restricted if protect patient health information is included.

14.5 Post-surgical Anesthesia Care

1. There shall be adequate provisions and facilities for immediate post-operative and post-anesthesia care. These shall be in accordance with acceptable standards of practice and include:

a) the PACU shall be a self-contained and designated area of the healthcare organization;

b) access shall be limited to authorized personnel;

c) policies and procedures shall specify transfer requirements to and from the recovery room

(See requirements of 4.1.3–4.1.5);

d) depending on the type of anesthesia and length of surgery, these transfer requirements shall include parameters as determined by the anesthesia service or other relevant authority. (See 15.5.5. through 15.5.9.).

2. If patients are not transferred to the PACU, policies shall include provisions for appropriate observation until discharge to the next level of care. (The requirements of 14.6 and 4.1.3–4.1.5) shall apply).

3. PACU patients shall not be discharged in the absence of post-operative report containing the elements as required in 14.6.1. below. In the absence of said report an immediate post-operative evaluation containing the elements of 14.6.2. shall be recorded on the patient record.

14.6 Reporting and Documentation

1. A post operative report describing techniques, findings, and tissues removed or altered shall be written or dictated immediately following surgery and signed by the surgeon. This shall be accomplished prior to patient discharge from the recovery area. If dictation delays are inherent, an immediate brief post-operative note shall be written. (See requirements of 4.1.3–4.1.5).

2. The immediate report shall include at least:

a) name(s) of the surgeon(s) and all assistants and practitioners who were present;

b) a description of those procedures done by each specific practitioner including:

i. opening and closing;

ii. harvesting of grafts;

iii. dissecting, removing, or altering tissues;

iv. implant or removal of any device;

c) pre-operative and post-operative diagnosis;

d) name of the specific surgical procedure(s) performed;

e) type of anesthesia administered;

f) complications;

g) a description of techniques, findings, and tissues removed or altered;

h) prosthetic devices, grafts, tissues, transplants, or devices implanted, if any;

i) blood or blood products administered;

j) any other pertinent information potentially effecting immediate recovery care including requires for post-operative analgesia required by the Opioid Oversight and Use Committee.