Operating Room Clinical Guidelines
The following procedures are to be observed by all anesthesiology residents rotating through the Shands Operating Room. Modifications will be made as appropriate.
When possible, all residents are to see their own inpatients preoperatively every day. Sometimes, clinical duties will make it appropriate for a colleague to see inpatient preoperative patients for you.
When the preoperative evaluation and order are being written, the chart is to be checked regarding preoperative lab reports and ordering of blood. If the anesthesiologist feels that blood or additional lab tests may be needed for the procedure, he/she should contact the surgical resident to ensure that adequate blood and appropriate reports will be available. Lab reports must be received before anesthesia is induced.
All residents are to discuss all cases with their attending the evening before surgery. This call should be made in a timely fashion so the appropriate additional consultations and requests can be obtained on the patient at a reasonable hour rather than very late at night.
At the conclusion of his/her day’s schedule, the anesthetist must sign out with the clinical coordinator.
All anesthetists are to be in the operating room by 8:00 a.m., ready to anesthetize their patients. Machines are to be checked, equipment prepared, IV fluids checked, etc., before this time.
The anesthetist should meet the patient in the pre-op holding area and assist the nurse in moving the patient to the operating area so that anesthesia can be started at 8:00 a.m.
Immediately prior to inducing anesthesia, the anesthetist should recheck the patient’s chart to insure that no new information which might change the anesthetic management has become available since the preoperative visit. The anesthetist must ensure that the attending anesthesiologist signs the Anesthesia & Operative Record and initials the appropriate sections about transfers and emergence. Also on the anesthesia record, anesthesia start time, surgical start time, incision time, surgery end time and anesthesia end time must be accurately recorded to the minute. On the anesthesia record, the starting time for anesthesia begins when the anesthetist begins actively working with the patient. The starting time for surgery indicates when the patient is actively worked on for surgical purposes, e.g., positioning, placement of Foley catheter, shaving, or prepping. The incision time is indicated separately on the chart. Except in rare life or death emergencies, therefore, the "surgery start" begins well before the skin incision. The surgical ending time occurs when the dressing is in place; the anesthesia ending time, when the patient is left in the care of the nurse in the recovery room or ICU.
If not discussed the night before, the anesthetist must discuss the patient and the anesthetic management of the case with his/her attending the morning of surgery prior to taking the patient to the operating room. The anesthetist must assure that the attending is physically present in the operating room before proceeding with the induction. THE ATTENDING PHYSICIAN MUST BE PRESENT DURING INDUCTION OF ANESTHESIA AND EMERGENCE FROM ANESTHESIA. This is not optional for ANY PATIENT. In addition, the attending physician must be present at any other critical times during surgery (e.g. barbiturate coma induction and induced hypertension during cerebral aneurysm surgery or massive blood loss during any operation). The attending physician’s presence must be documented by his signing on the appropriate places in the anesthesia record.
The anesthetist should not leave the patient in the Post Anesthesia Care Unit or the ICU until satisfied with the patient’s condition, or until patient care responsibility has clearly been transferred to another member of the Department of Anesthesiology.
If there are anesthetic complications, the attending anesthesiologist should be notified immediately. Postoperative anesthesia notes should be made in the charts of all patients who are in the hospital for more than 24 hours after surgery. Subsequent follow-up notes should be written as necessary.
All decisions regarding OR scheduling should be referred to the Clinical Coordinator (CC) during the day and the team chief (1st call attending) at night (pager 3900). The team chief will notify the assigned anesthetist at once of a change in assignment. He/she will also discuss all changes with the CC in the morning before leaving.
Changes in the residents’ call schedule should be made only when absolutely necessary and then only through the chief residents with approval of the Program Director. The appropriate departments will then be notified. In the event of illness or emergency, the chief resident is responsible for assigning a replacement.
Acute Pain Management consults and nerve blocks are to be performed by the residents assigned to the Regional rotation.
The mole team residents must preoperatively evaluate any inpatients added to the OR schedule after regular hours.
Outpatient preoperative evaluations and consults will be seen by the outpatient resident and preoperative clinic staff. However, during peak times any available residents are expected to help and may be assigned to the Preoperative Clinic.
The Clinical Coordinator will be responsible for scheduling residents as available, to see emergency consults.
All complaints or concerns by residents should first be directed to the chief resident, who will attempt to solve whatever problems arise.
The responsibility for the administration of all anesthetic procedures carried out by anesthesiology housestaff rests with the attending anesthesiologist.
Preoperative Anesthesia Evaluation: It is imperative to perform an adequate preoperative evaluation of the patient. This should be done when possible by the physician who will give the anesthesia for all inpatients. The preoperative evaluation should cover the following: review of medical history and physical examination; laboratory tests, as necessary; evaluation of the patient's’ physical status; choice of anesthesia and factors influencing that choice; patient’s previous drug history; other anesthetic experience; any potential anesthetic problems; orders for pre-anesthetic medication; and patient interview and informed consent. The preceding information must be documented in the patient’s medical record on the preoperative evaluation form. The form should contain the date, time, signature and physician number. Charts will be reviewed periodically and randomly to assess how satisfactorily these requirements are being fulfilled.
Inpatients: Inpatients will be seen the evening before surgery by the resident assigned to the case or by a designated alternate when the resident assigned to the case is currently involved in patient care.
Outpatients: Anesthesiology outpatients are seen in the Pre-op Clinic, room 2285, by the outpatient resident, ARNPs, or by any available resident. Patients are seen between 8:00 a.m. and 5:00 p.m. When a patient is scheduled for surgery who will not be admitted to the hospital as an inpatient or who will be admitted the day of surgery, arrangements for an evaluation must be made by the Pre-op Clinic.
Obstetrical Patients: Although all obstetrical patients admitted to the labor and delivery area will not receive anesthesia, all must be evaluated for anesthesia. The anesthesia resident on the obstetric anesthesia service will be notified (usually, and preferably) immediately after such patients have been evaluated by the obstetric resident. The anesthesiologist should examine and discuss with the patient the various anesthesia services available, and then make a complete notation of the preoperative evaluation in the chart.
Choice of Anesthesia: The choice of anesthesia should take into account the patient’s wishes, the anesthesiologist’s expertise, and special surgical problems. Ultimately, the decision is the responsibility of the attending anesthesiologist. If the anesthesiologist and surgeon disagree irreconcilably, the former may withdraw from the case.
