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Standards and guidelines for the organization of the operating department and anesthesia care, for better patient care and utilization of resources.
- ELECTIVE CASE: are routine planned procedures, on scheduled lists e.g.: Total abdominal hysterectomy, inguinal hernia repair etc.
- SEMI- EMERGENCY: Are cases, which are emergency but not life threatening, and can wait for some time e.g.: caesarian section for failure to progress in labour, cut injury hand etc.
- URGENT: Are cases, which are real emergency, life, threatening and if immediate intervention is not done can cause mortality e.g.: Cord prolapsed, severe trauma, ruptured aortic aneurysm.
ORGANIZATION AND MANAGEMENT
Ensures that properly trained supporting staff and anesthetists are available in the right place at the right time.
There is a designated Head of Anesthesia service that will be responsible for all activities in which the department of anesthesia is engaged. The Head of department will have managerial control of the service. Takes responsibility for all aspects of the anesthesia service and reports to the Medical Director. There is a designated Charge nurse who co-ordinates with the anesthesia head and other theatre users, for scheduling of lists, instruments, and staff availability.
SCHEDULE OF LISTS
Elective lists are booked as per theatre schedule of surgeons before 1200 hrs. the day before the scheduled days.
Any major cases or additional information’s or emergency cases should be discussed with the Head of anesthesia and charge nurse. Semi- emergency cases can be booked ONLY after discussion with the Head of anesthesia
ONLY URGENT/EMERGENCY CASES CAN BE DONE IN THE EMERGENCY THEATRE TIME.
IF THERE IS A BACKLOG OF CASES, IT CAN BE DISCUSSED WITH THE ANAESTHESIA HEAD AND
THE NECESSARY ARRANGEMENTS CAN BE DONE Surgeons are encouraged to schedule lists, in their time span, and not to over book cases on the lists.
RULES OF THE OPERATING THEATRE
- The patient shall be admitted a before 7.00 hrs.
- The patient should be brought down as per schedule, 10- 15 minutes before the start of lists.
- The anesthetist shall be in the operating room not later than 8.00am for the start of routine lists, and 10 minutes before any other scheduled lists.
- The surgeon shall be in the operating room not later than 8.00 am and12.00pm for the start of the routine morning and afternoon lists respectively, and 10 minutes before any other scheduled cases.
- The surgeons must be physically present in the operating room and dressed before the anesthetist initiates any type of anesthesia.
- Timeout procedure should be initiated by the operating team and circulating staff before the start of surgery and recorded.
- Anesthetists are responsible for the patient care, peri and postoperatively in the operating room and recovery
- Should not run two operating rooms, under general anesthesia unless one operating.
- The Anesthetist is responsible for complete, documentation of events peri, and postoperative in theatre.
- In case of a critical incident has to report the event, to the Head of Anesthesia.
ANAESTHESIA ON CALL COVER
- a) The anesthesia department provides on call cover for 24 hrs daily. With First and 2nd on call with cover.
- b) These duties are on rotational basis to provide anesthetic services for:
- a) Operating rooms
- b) Emergency room.
- c) Labour and delivery room
- d) Code blue team
- e) Anesthesia consultation as needed.
- f) Cardiac Catheterization Lab
PRE- OPERATIVE ASSESSMENT
- a) Assessment prior to anesthesia is the responsibility of the anesthetist, pre-anesthesia screening ensures that patients are prima facie fit for anesthesia and surgery, and that all likely investigations will be completed and available at the time of admission.
Reception (Holding Area)
- a) Written guidelines are required to cover the process of sending for patients and their handover at reception (holding area) to a designated member of the operating department by the ward nurse.
- b) Ward nurse should accompany the patient to the operating department. Factors such as the underlying condition, including the level of consciousness, should be taken into account in individual patients.
- c) The handover must include clear communication of the patient’s name, clinical details and medical records. The name of the patient should be confirmed verbally, and name and hospital number should be checked on the ID band, and it should be documented, and signed.
Assistance for the anesthetist
1) Trained assistance for the anesthetist must be provided wherever anesthesia is provided.
The safe administration of anesthesia cannot be carried out single-handed; competent and exclusive assistance is necessary at all times.
2) The HOD must insist on adequate resources to employ, train and develop sufficient numbers of assistants to ensure a safe anesthesia service in accordance with good practice.
3) If appropriate basic resources are not available, the HOD should limit clinical practice so that safe, quality-based patient care is ensured after reporting to the Medical Director and the theatre committee.
- There should be a minimum of two members of staff present in the room at induction, the anesthetist and a trained anesthesia assistant.
2) Additional personnel will be present to assist in transferring and positioning patients or for procedures such as urinary catheterization.
The Association of Anesthetists recommends that a trained anesthesia assistant should always be present during anesthesia. Only in extreme emergencies as judged by the anesthetist should anesthesia proceed without an assistant.
1) Assistance for the anesthetist must be provided by trained assistants (technician)
2) Learners are accepted for formal training as anesthesia assistants, but they must be supernumerary and supervised at all times by a fully trained anesthesia technicians.
3) It is usual for an individual senior nurse to be responsible for rostering the anesthesia assistants and for their ongoing training.
Qualified nurses are already registered professionals but require additional training before taking on the duties of an anesthesia assistant.
1) The responsibility of anesthetists for the care of their patients extends into the postoperative period and includes the management of postoperative pain.
2) Emergence from anesthesia is potentially hazardous and patients require close observation until recovery is complete. If the anesthetist is unable to remain with the patient during this period, care must be transferred to staff that have been specially trained in recovery procedures.
3) While patients remain in the recovery area there must always be a suitably trained anesthetist immediately available within the operating room.
4) Close collaboration between the anesthetist and the surgeon is particularly important at this time so that clear instructions are given to recovery staff.
Transfer to recovery area
1) The anesthetist should be satisfied that the recovery staff are competent to take responsibility for the patient before care is transferred.
2) No fewer than two staff should be present when there is a patient in the recovery room who does not fulfill the criteria for discharge to the ward.
3) If this level of staffing cannot be assured, the anesthetist should stay with the patient until satisfied that the patient is fit to return to the ward.
1) Continuous individual observation of each patient is required on a one-to-one basis until the patient is able to maintain their own airway. The recovery staff, therefore, must not have any other duties at this time.
2) A post anesthesia care plan should be implemented for each patient, which includes monitoring to ensure satisfactory cardio respiratory function, fluid and pain management and the administration of drugs to agreed protocols.
3) Careful records must be maintained and recovery staff must be able to interpret the information and initiate appropriate action where necessary. Staff must also be able to assess the suitability of transfer of patients to the next level of care.
All staff must be trained in basic resuscitation techniques. And preferably ACLS.
1) The patient should remain in a suitably equipped recovery area until all the criteria for discharge have been met.
2) Discharge must be based on a carefully worded protocol or on the personal instructions of the anesthetist and documented in the postoperative record.
3) High-risk patients might be needed to transfer to ICU, with written instructions of care.
The optimal management structure for the recovery area should be within the overall responsibility of the anesthesia department. There must be clear lines of communication with other relevant directorates and departments.
Training and qualifications
All staff that work in the recovery area should have received appropriate orientation and training.
POST- OPERATIVE PAIN MANAGEMENT
1) All hospitals performing major surgery should have a multi- disciplinary acute pain team with an anesthetist in overall charge.
2) And a senior nurse running the service on a day to day basis, following predefined protocol.
3) Effective collaboration between the anesthetist, surgeon and nurses.
4) A high quality postoperative pain management service should include identifying the patient’s individual requirements on admission and then ‘tracking’ the patient from the surgical ward, through recovery, critical care if appropriate and back to the ward.