Pre-Surgical Evaluation and Peri-Operative Monitoring of the Surgical Patient

Policy:
 

Patients will be monitored on a peri-operative basis in a manner appropriate to the level of anesthesia used.  There is 
also a specific protocol for each level of post-procedure monitoring, again indexed to the level of the anesthetic 
agent.   
 
Intra-operative physiologic monitoring must include continuous use of a pulse oximeter as well as blood pressure readings at frequent intervals.  EKG monitoring will be immediately available
 
All patients receiving local anesthesia administered by the surgeon will be monitored by appropriate personnel during time in the operating room or the procedure room; such monitoring shall be documented on the operative report.
 
Procedure:
 
1.  Vital signs monitoring shall be recorded prior to start of the surgical procedure and at appropriate intervals
    thereafter until transfer to recovery room or direct discharge. At the request of the surgeon, EKG monitoring shall be done throughout the procedure.
 
2.  Oxygen may be administered as needed; rate and method of administration to be documented.
 
3.  Type, dosage and times of administration of anesthesia agents shall be documented on the anesthesia/operative report.

4.  Any IV administration shall be documented on anesthesia record.
 
5.  Procedure performed, surgeon, staff assisting,and pre-operative and post-operative diagnoses shall be documented on operative report.
 
6.  Clinical personnel may monitor the patient while performing other interruptible duties in the room.
 
7.  Monitoring shall include pulse rate, blood pressure, respiratory rate, pulse oximetry, skin characteristics (color/temperature/dryness), and level of consciousness. (Level of consciousness will only be verified and documented when the anesthesia level is recorded as local anesthesia only. 
 
8.  Prior to the procedure, the anesthesia provider shall perform a pre-operative assessment of the patient including, but not limited to, the following:


    A.  A listing of medications (with dosages) taken by patient, 
    B.  Disclosure of any known allergies, 
    C.  Discussion of any significant medical problems with the requirement of consent for surgery by the patient's primary care physician if there are significant clinical diagnoses present, and 
    D.  Performance of pre-operative vital signs.

    Additional elements of the pre-operative assessment will be indexed to the level of anesthesia anticipated.
 
9.  If appropriate to the procedure scheduled, each patient shall have a patent IV prior to the administration of any
    medications.
 
10. Emergency equipment shall be available in the area.
 
11. Except in the case of patients having only local anesthesia, all patients shall be monitored for at least
    30 minutes after the last administration of any medication or until discharge criteria are met.  
 

In the case of patients having only local anesthesia, patient may be discharged directly from the procedure
room unless the attending physician, upon evaluation, requests that the patient receive additional monitoring 
before discharge.  
 
Recovery is a process not just a geographic location; a patient may participate in the recovery process without leaving the procedure room or operating room.  Any patient admitted to Recovery, will be monitored for at least 30 minutes after the last administration of any medication or until discharge criteria are met.
 
12. Due to the nature of our procedures, post procedure pain is a rare occurrence. However, this organization is cognizant of the problems attendant to management of post-procedure pain, both pre- and post-discharge.  Staff members monitoring patients in Recovery.  The patient is educated regarding acceptable levels of pain and the level at which clinical intervention is desirable in order to facilitate the recovery process. The patient, and the patient's caregiver, are
instructed means of contacting the surgeon should pain relief, or clinical intervention be in order.
 
13. At the request of the surgeon, times of anesthesia and surgery shall be documented.
 
14. The nurse monitoring the patient will sign appropriate entries on the medical record.

15. Discharge criteria is outlined in the Clinical Manual.


Approved By Governing Board
AD.4
Control #39.4
GUPTA GASTRO ASSOCIATES, INC.