“If Your Ambulatory Surgery Unit Was an Airplane, Would You Take Off In It?”

Presented by

Sharon L Groves, BSN, MSA, ARM, ASHRM, CPHRM

Berkley Medical

Objectives

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Fire Prevention

Two common categories of fire in the OR:• External

• drapes, dressings, gauze sponges, or objects such as tubing or petroleum-based ointments, etc.

• Oropharyngeal Internal airway • the endotracheal tube

Fire prevention and response training

• Fire drills are conducted at least quarterly. • At least 50% of the required drills are

unannounced. • All fire drills are critiqued to identify

deficiencies and opportunities for improvement.

• The effectiveness of fire-response training according to the fire plan is evaluated at least annually.

Fire prevention and response training

• During fire drills, staff knowledge is evaluated, including the following: • When and how to sound fire alarms (where such

alarms are available) • When and how to transmit for off-site fire responders • Containment of smoke and fire • Transfer of patients to areas of refuge • Fire extinguishment • Specific fire-response duties (e.g., preparation for

building evacuation)

Topics

• Fire prevention

• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Prevention of Post-op Infections

• Prophylactic antibiotics should be considered and used according to the following published guidelines:• Surgical procedures for which prophylactic antibiotics

are recommended• The selection of appropriate medications• The timing of administering medications• The route of administration and• The personnel responsible for procuring, preparing

and administering the medication.

Infection Control

• OSHA manual/completing 300 log should be in use

• Exposure control plan should be up to date• Gloves / masks / eye protection readily

available• Containers for proper sharps disposal

available

Infection Control

• Sterilization procedures include sterilization of surgery instruments, running controls and keeping logs

• Weekly spore testing• Infections tracked and trended• Staff understanding of the use of OSHA

Blood Borne Pathogen Noncompliance reporting

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Falls

• Evaluate and identify risk factors for falls in the older patient before and after the procedure.

• Develop an appropriate plan of care for prevention

• Perform a comprehensive evaluation of falls that occur in the center

• Perform a post-fall revision of plan of care as appropriate.

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient,

procedure, or implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Preventing Wrong Site Surgery

• Steps• Preoperative verification process• Marking the operative site• “Time out”• Site marking must be done for any

procedure that involves laterality, multiple structures, or levels (even if the procedure takes place outside of an OR).

Preventing Wrong Site Surgery

• Things to Consider• Imaging studies are available

• Implants are available

• Blood is available.

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Emergency Transfer

• Effective policy and procedure for immediate transfer to a hospital for care beyond the capabilities of the ASC.

• Written transfer agreement if applicable• Arrangement for ambulance services• Transfer of medical information

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission

• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery,

discharge, instructions• Anesthesia informed consent• Culture of Safety

Malignant Hyperthermia

• Rare life-threatening condition that is triggered by exposure to certain drugs used for general anesthesia

• Treatment of choice: Dantrolene the only known antidote.

Malignant Hyperthermia

• Malignant Hyperthermia Cart

• Perform Mock drills on all shifts

• Note: calcium channel blockers + Dantrolene may produce life-threatening hyperkalemia and myocardial depression.

Malignant Hyperthermia Protocol 1-800-644-9737

Possible Triggers Acute Phase Treatment

• Succinylcholine• All volatile anesthesia• Potassium salts

Clinical Manifestations• 1. Elevated EtC02• 2. Muscle rigidity• 3. Tachycardia• 4. Tachypnea• 5. Hypercarbia• 6. Cardiac dysrhythmia• 7. Respiratory and or metabolic

acidosis• 8. Fever• 9. Unstable/rising blood pressure• 10. Cyanosis/mottling• 11. Myoglobinuria

Acute Phase Treatment• 1. GET HELP! GET DANTROLENE!• 2. Discontinue all possible triggers• 3. Hyperventilate with 100% 02• 4. Adm Dantrolene (2.5mg/kg)• 5. Adm NA Bicarb 1-2 meq/kg• 6. Institute cooling measures• 7. Treat dysrhythmias• 8. Adm additional Dantrolene• 9. Monitor urine output, K, Ca,

PT/PTT, ABG, EtC02• 10. Treat hyperkalemia with

regular insulin• 11. Consider Mannitol/Furosemide• 12. Consider monitoring of arterial

blood pressure, CVP, PA.

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Foreign Body

• Operative Room Protocols – additional counts are performed :

• When more sponges or sharps are added to the sterile field• Upon relief of either the scrub or circulating nurse• Before body cavity closure• Before completion of the operation.

• If count is incorrect: • Immediately halt completion of the procedure and have

anesthesia maintained until a correct count is verified• Take an intraoperative x-ray—surgeon determines which is

appropriate

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery,

discharge, instructions• Anesthesia informed consent• Culture of Safety

Patient Selection for Ambulatory Surgery

• Develop general rules and guidelines to ensure uniformity of patient selection

• American College of Surgeons recommends consideration of:• Age• Medical condition• Anesthetic risk• Complexity of operation• Anticipated degree and duration of post-op pain and

discomfort• Probability of post-op complications.

Discharge Instructions

• Recovering patients kept under direct observation

• Two individuals in PACU at all times ( 1 RN)• Established criteria for discharge followed• Process for AMA• Written discharge instructions provided

Discharge Instructions

• Patients prohibited from driving home after receiving anesthesia

• Follow-up calls to patients made,

• Process to follow when you do not reach the patient

• MD or MD Anesthesia in house until all patients discharged

Post-discharge Instructions

• Guidelines to follow if post-op problem• Instructions in their own language – Spanish etc.• Patients need to know:

• How to care for themselves at home• What signs and symptoms can be expected• Specific activities to avoid and for low long• Which symptoms need to be brought to the healthcare

professional’s attention and when• How to reach a professional who can answer other concerns

that may arise• A time, place and date for a follow-up appointment.

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Anesthesia Consent Form.

□ General Anesthesia

Expected result

Total unconscious state

Technique Drug injected into blood stream, breathed into lungs

Risks Mouth or throat hoariness, injury to mouth or teeth, awareness under anesthesia, injury to blood vessels, vomiting, aspiration, pneumonia

□ Spinal or Epidural

With sedation

Without sedation

Expected result

Temporary decreased or loss of feeling and or movement to lower part of the body

Technique Drug injected into blood stream, breathed into lungs

Risks Mouth or throat hoariness, injury to mouth or teeth, awareness under anesthesia, injury to blood vessels, vomiting, aspiration, pneumonia

Topics

• Fire prevention• Prevention of post-operative infection• Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or

implant • Emergency transfer or admission• Malignant Hyperthermia• Retained Foreign body• Patient selection for Ambulatory Surgery, discharge,

instructions• Anesthesia informed consent• Culture of Safety

Culture-Of-Safety

• Pay attention to detail.• Employees use the STAR method: stop, think, act, and review.

• Communicate clearly. • Employees read back orders, ask clarifying questions, and ensure that

they explain information clearly. • Think critically.

• Employees think critically by ensuring that information is taken from credible sources and validating the accuracy of information with their own knowledge and other resources.

• Hand off effectively. • Employees communicate the five P’s (patient or project, plan, purpose,

problems, precautions) during handoffs.• Be a good wingman.

• Employees coach their peers and check up on each other regarding safety practices. In addition, employees are encouraged to speak up when they have a question or concern and to use the chain of command.