Preoperative Patient Preparation Kaleida Health Operating Room Nurses

Hand Off of Care Include the “TICKET TO RIDE” DTKH0952. The transporter must deliver the “TICKET TO RIDE” to the Operating Room/Urology /Interventional Radiology/ GI unit staff. Consent should be signed prior to sending patient to the OR/Procedure.

Latex Allergy It is preferred that latex sensitive/allergic patients be scheduled as the first case of the day in the Operating Room. Refer to policy CL.45. Call the OR as early as possible if you discover that your patient has an allergy and is scheduled for surgery.

Informed Consent Policy LE.9 It shall be the policy of KALEIDA HEALTH, in all non-emergent situations, to obtain express consent for all operative procedures…consent should be recorded on the written patient consent form(KH00049). This express consent must be informed consent…Obtaining the informed consent is the responsibility of the physician. Once consent is obtained there needs to be a witness, the witness is ONLY verifying the patient’s signature. Any hospital employee besides the MD/resident/patient involved in the case may serve as a witness to consent.

Informed Consent Policy LE.9 Physician Partnership- Physician/Proceduralist who will perform the procedure/treatment should be the one designated on the consent form. If any partner may actually perform the procedure, the consent should read, “Dr. Henry Smith, OR Dr. John J. Doe”, corporate titles, (Example- Buffalo Niagara Western New York Surgical Group)should NOT be used. The term “AND” should only be used if they will be operating together.

Informed Consent Policy LE9 Patients Who Lack Capacity: If it is determined that the patient lacks capacity to make health care decisions, then a legally authorized individual ~ parent{minors}, health care agent{proxy}, legal guardian may consent on behalf of the patient.

Informed Consent Policy LE.9 However, if no such authorized person exists, or if such person cannot be contacted despite reasonably diligent efforts, then the consent may be obtained by a patient’s representative. The following is a listing, in the order of preference, of qualified patient’s representatives: spouse of patient adult child of patient parent of patient adult sibling of patient

Informed Consent in General Patients sign their own consent if they are able. If the patient is unable to sign, look for a Health Care Proxy or designee. Call Risk Management for assistance on a case by case basis at 859-8620 or call the operator for department personnel’s pagers.

Informed Consent: DNR/Vendor Presence Please be aware patients may need to sign the manufacturer’s rep area of the consent if they are having any devices implanted or if there is new equipment being trialed in the OR. Check orders for manufacturer rep. consent. Patients who have an existing DNR going to OR can have the DNR continued through the surgical process and should validate this by signing the DNR portion of the consent. These are the only patients who should be signing the DNR area on consent. Please check N/A for any areas on the back of the consent that do not apply.

Transfusion Consent Did you know Type and Screen along with cross matching must be done at the Kaleida site where the patient is to have the surgery/procedure? If a patient has been transfused within the last 72 hours during hospitalization a new T&S must be ordered and repeated. Any question or concerns contact the Blood Bank.

Lab Work Did you know that abnormal lab results require MD notification and follow-up documentation in the chart? The most recent results must be in the chart. Check for the most recent orders and make sure recent results are available online. Check that on the day of surgery, a finger stick has been done and charted on insulin dependent patients. Refer to grid of policy CL 46. Attached here.

Lab Work Make sure labs are drawn in a timely manner and are posted before transferring the patient to the OR. Check that a K+ has been drawn and results are charted for renal/post dialysis patients. Pending should only be used after checking for lab results immediately prior to patient going to OR and they are not yet available.  It is best for lab results be in the chart prior to patient going to OR holding area.  A true emergency would be the exception. “Pending” should be dated and timed. All female patients 9 years and older require an HCG. See policy for exceptions.

Removal of Personal Items Remember that the patient will be sedated/anesthetized and that removal of items is essential for safety and positioning. All patients should be encouraged to safeguard all personal belongings with a designee.

Removal of Personal Items Dentures/partials can compromise the patients airway when sedated/anesthetized, they must be removed prior to OR arrival. Wigs, barrettes, elastic bands and other hair ornaments can be a source of pressure points and may interfere with intubation. Jewelry can also be a pressure point, as well as, a burn hazard due to electrocautery use. Body piercing included. Policy SS_37. Rings can cause ischemia. Hearing aide may be left in, document the disposition. See preop checklist.

Universal Protocol: Verification CL.54 Prior to the start of ANY surgical/invasive procedure a verification process is to be completed. Accurately identify patient. Confirm the procedure, surgical site(s), and side. Documentation in patient medical record. Form #KH01084 Rev.01/06/2011.

Universal Protocol Record Completing this record Level 1: Must be completed prior to transfer and if incomplete the transferring nurse will be expected to complete in OR holding. The unit/floor staff will verify the patient’s identity with the patient, and or, the patient’s family/guardian and the identification band. The unit staff will verify, as appropriate, the side, right or left designation for the procedure. The nurse verifies the surgical site with the OR schedule and/or consent form. Pre-operative checklist is complete prior to patient coming to surgery. Call OR if there is a discrepancy.

Please Remember Please make sure the verification form is completed with the appropriate INITIALS and signatures. NO checkmarks…initials only. Level 1 must be completed BEFORE patient can be sent to the OR. Attestation on consent to be completed in level 2 of Universal Protocol.

Interpreter/Translator Services PT.9 The department where the patient presents is responsible to obtain interpreter services as outlined in Policy PT.9. Any department sending an LEP/hearing impaired patient to another department will notify the receiving department of the patient’s identity and the language the patient speaks. Please send Language Line phone (obtained through the hospital operator) with the patient. Please make sure interpreter comes with patient and document log in chart of each interpreter used.

Please Remember Hospital staff CAN NOT act as interpreters, unless they have been approved. Patient(s) must sign a waiver if a family member is going to interpret for the patient. The waiver can be obtained through KaleidaScope, Policy PT.9. The use of minors(under age 16) as an interpreter should be avoided unless in urgent/emergent situations, or if communication is limited to simple, non-clinical matters.

Chart Assembly/ Form Index Please refer to the SURGERY/PROCEDURAL CHART INDEX or the INDEX FOR INPATIENT GOING TO OPERATING ROOM for the format for chart assembly. Assembly of the chart/forms will facilitate documentation and patient safety.

Thanks For Your Help Thanks for your help in making sure the proper procedures and forms are completed prior to the patient coming to surgery. Please know that if you should need any help in preparing your patient for surgery the OR staff is ready to help.