Patient Care Part 2

PREPARATION OF PATIENT FOR PROCEDURES (PRE-OPERATIVE)

Patient is reassured to alleviate his/her fears and informed of diagnosis, procedure with its risks and benefits; and alternative options with risks and benefits as previously described and is advised off all DVT preventions.

1. History and physical

2. DVT assessment is done on admission

3. N.P.O. after midnight

4. Pre-medications

5. Medications that should be taken even though patient is N.P.O.

6. Antibiotics, enemas

7. IV hydration, transfusion

8. Pre-operative check of: - Consent • CBC, electrolytes, BUN • Glucose, PT, PTT • Urinalysis • Chest X-Ray, EKG • Type cross-match (when necessary)

9. Referral for medical assessment

11. Brief pre-operative note by resident/surgeon - as outlined before in Patient Care Part i.

Patients who need Swan-Ganz catheterization are admitted to the I.C.U. for the appropriate monitoring and assessment prior to going to the operating room.

Consent is obtained by the operating surgeon or member of the operating team. At the time this is obtained, the procedure is fully explained in simple terms to the patient and his family.

CBC, Electrolytes, BUN, Glucose, PT, PTT, Urinalysis results are required within 48 hours of surgery. Blood for type and cross-match is taken to Blood Bank by 1:00 p.m. on the day prior to surgery for elective cases. For an emergency case, blood can be obtained in 30 minutes. House staff takes all slips to the Blood Bank. Blood is sent to the operating room at the time the patient is placed on the table. The assigned residents for the case are in the operating room when the patient arrives, approximately 15 minutes prior to the start of the case and have reviewed the case before the operation. The O.R. Schedule commences at 8:00 a.m. on Monday through TFriday except 9:00 am on Wednesday.

TIME OUT

To avoid performing the wrong operation on the wrong patient and on the wrong side, a “Time Out” Form has been developed. These are available on the floor and in the operating room.

In the holding area in the operating room, this form has to be signed by the patient to make sure the patient agrees with the surgery and on which part of the body the operation is being performed. This must be signed by the surgeon performing the operation.

The operating room nurse will review this form in the operating room and verify that it is the correct patient by asking the patient for his name and verifying this with the patient’s wrist band and medical record number. The nurse will also verify that the patient agrees with the operation being performed and on which part of the body. The nurse, surgeon and anesthesiologist will then agree to the procedure

Once the nurse, the surgeon, the anesthesiologist and the patient are in agreement, then the patient can be given anesthesia for the procedure.

PERI-0PERATIVE ANTIBIOTICS

All patients undergoing abdominal and vascular surgery must be given appropriate antibiotics as recommended bt CMS.  This must be done within an hour before the incision.  Please make sure the Anesthesiologist notes the time the antibiotic is given on the time out sheet. If the operative procedure is more than four hours the antibiotics must be repeated at the discretion of the surgeon.  The antibiotic order must be cancelled in 24 hours. If for any reason antibiotics need to be continued after 24 hours a new order must be written and the reason for the continuation of antibiotics stated in the progress notes.  Insertion of Foley Catheter for the prodedure must be ordered and discontinued within 24 hours after the procedure.  If it needs to be continued an orde should be written and reason for continuation written in the EMR.

INTRA-OPERATIVE

Monitoring of the patient intra-operatively is the responsibility of the anesthesiologist who follows the protocol outlined by the Department of Anesthesia.

If patient needs post-operative care in the I.C.U. arrangement are made pre-operatively or prior to completion of operative procedure or after completion of the procedure were this need is recognized.

BRIEF OPERATIVE NOTE

This note should be completed within one hour of the completion of the procedure; all fields as outlined in the EMR should be accurately completed.  This is a mandatory note and is not replaceable by the operative note.

In-Patient Procedures

Post-op check:  All patients should have a post-op check done at the end of the day.  This check will be performed by the resident/PA or Np who covers the evening shifft.  This note hsould be documented in the EMR and any signifidant findings or pending information must be communicated to the following team using the SBAR method to maintian continuity of care.  Any significant finding must e escalated to the operative surgeon and/or hte director of surgery.

Transfer note:  If the patient is transferred from one service to another or from one physical location to another, a transfer note should be written and all orders rechecked for accuracy.

Progress note:  After the first 24 hours daily progress note is to be completed by the resident or PA or Np.  This note should reflect an addurate documentation of all the events for the prior 24 hours and should include an assessment of all physical findings and laboratory and radiological test results.

Brief note/short note:  These notes are written to document events that oddur in between progress notes.  Significant events shuld be escalated to the surgical attending as soon as possible.

Discharge summary:  Note should be completed within 6 hours of discharge of the patient and should summarize the entire hospital stay, with a plan for the post-operative care of the patient.  Patients are to be notified 24 hours prior to discharge.

OPERATIVE NOTE

After the surgery is completed the following are recorded immediately as brief operative note and the applicable report is entered in the computer.

1. Date of Procedure

2. Pre-operative diagnosis

3. Post-operative diagnosis

4. Operation

5. Surgeon

6. Residents

7. Type of Anesthesia

8. Indication for prodedure

9. Pre-operative Measures:

    a. Time-Out

    b. Prophylactic antibiotics

    c. DVT Prophylaxis

    d. Catherization

10.Specimen and results of frozen section

11. Location of drains or tubes

12. Estimated blood loss

13. Wound classification (clean, clean contaminated)

14. IV fluids given - total amount including blood/blood products

15. Intraoperative medications administered

16. Complication/unusual events

17. Description of procedure

18. Instrument and sponges count

19. Condition of patient at end of procedure

20. Post procedure Plan of Care

21. Residents stay with patients until they are admitted to the Recovery Room. Postoperative orders are written and baseline diagnostic tests as indicated obtained.

POST-OPERATIVE ORDERS

VITAL SIGNS

The usual routine is:

a. every 15 minutes first hour

b. half hour until fully awake from anesthesia

c. Every hour for 4 hours

d. Per nursing routine if patient is stable

IV FLUID

Specify composition and rate (including replacement solutions)

Pain medication → PCA Pump

DIET

• According to individual patient and operative procedure
• NPO
• Advance diet as needed

 ACTIVITY

Early ambulation

Deep breathing,

coughing Incentive

spirometer

DRAINS, TUBES, AND CATHETERS

Antibiotics

DVT PROHYLAXIS

Based on the patient’s risk assessment, the appropriate DVT prophylaxis must be ordered and must be started within 24 hours following the procedure if there is no contraindication.

Post-Operative Check for In-Patients

Ambulatory Surgery

Out-patients require a pre-op note, a brief op note and an operative note.  The discharge summary should include documentation of the patient status on disdharge.

The ASU calls the patient on the evening of surgey to check on the status of the patient.  The patient is advised to retrun to the ER if he or she has any signifidant issues that need the intervention of a physician (high fever, bleeding, fainting, sevee nausea or vomiting, etcc)

In-patient bedide procedures

A progres note is written prior to the procedure, to indicate an appropriate indication and adequate consent and preparation for the procedure.

A separate procedure note is written to document the performance of the procedure.

A post procedure check is documented within 24 hours to ensure no complications occurred and that the patient is stable.

Short note is written after the patient is deemed stable and the service has signed off on the cases, if the patient is on another service.  Instructions are included to allow for a recall or follow up of the procedure.

Attending supervision

The operting attending surgeon is ultimately responsible for the care provided by all team members in the Department of surgery.  All notes written by the residents, PA's and NP's ae to be reviewed and countersigned by the attending with the appropriate attestation that will reflect an eye to eye contact with the patient on a dily basis during week days and the approprite coverage contact during weekends and holidays.  These notes are to be signed within 24 hours of placement.  The Attending surgeon should do  dialy check o ensure that a note has been written and if not he should contact the relevant chief resident or complete a note himself.  Delinquency on behalf of the Chief resident should be reported to the PI Chairperson or the Director of Surgery.

PAIN

It is very important that patients are made as comfortable as possible after surgery. Patient’s pain status must be assessed and appropriate pain medication given. The PCA pump should be used whenever it is needed. Please use Morphine for the pump, (do not use DEMEROL). The pain management team is available for consultations.

NOTIFY RESIDENT

For the following:

• Temperature > 101
• BP < 100/60 or > 180/100
• Pulse > 120 or < 50
• Resp. > 30
• Unable to void by 8 hours post-operative
• Urine output less than 40cc/hr
• Bright red blood saturates the dressing

It is the responsibility of the intern on call at night to perform pre and post-operative checks on all patients on the services he/she is covering.

DICTATION OF OPERATION

All operations are dictated as soon as they are completed and at the same time the operating resident enters the case in the computer to get credit from the Residency Review Committee.

BLOOD WORK

On surgical floors, orders for routine blood work are entered in the computer. Blood is drawn by a phlebotomist and sent to the lab. Blood for type and cross-match is drawn only by the resident and the tube must be signed by the resident. Blood gases are drawn by the house staff. They are taken to the 8th floor for analysis and results are entered into the computer. Results of all blood tests can be obtained from the computer.

EKG

There is a technician available for routine EKGs from 8:00 a.m. - 4:00 p.m. after which time the EKGs are performed by the resident. There is an EKG machine on the ward. Requisition for EKG is done through the computer.

RADIOLOGY

Routine x-rays, CT Scan/MRI are ordered through the computer indicating the diagnosis and results are obtained through the computer. Specialized radiographic test (interventional radiography, angiogram, etc) are discussed with the radiology resident so that appropriate arrangements can be made. Appropriate laboratory data must be available before ordering any of these tests.  

CHARTS

All paper charts are kept in the nursing stations.  Charts are now on line.  Intern, Resident, Attending and Physician assistant notes  are all documented in the EMR.  There must be a post-op check by the resident or the physician assistant.  Progress notes are written daily on line. All procedures are recorded on line.  

DRESSING AND MINOR WARD PROCEDURES

All dressing changes and minor procedures are done in a sterile manner. Dressing changes are the responsibility of the junior house staff and the physician assistants but may be delegated, under supervision, to medical students, physician assistant, physician assistant students or surgical technicians on the ward.  HAND

WASHING BETWEEN PATENTS IS REQUIRED.

All house staff members must be certified to perform a procedure before doing so independently. If not certified, the procedure must be performed under supervision.

SPECIAL PROCEDURES

Subclavian catheterization can be performed by residents who have been certified after performing (2) defined cases under supervision.

There is a Hyperalimentation Unit. All requisitions are sent to the Unit for review.

Endoscopic procedures, such as gastroscopy and colonoscopy are arranged with the  Endoscopy Unit.  Elective bronchoscopy is done by Pulmonary Medicine. Patients in the Burn ICU or SICU are bronchoscoped by surgeons.

ROUNDS

Morning work rounds are started at 6:30 a.m. Transition of Care Form must be updated before and after rounds.  The residents go over all the patients on the service with the Chief Resident.

It is important to stress that patients on the service are the responsibility of all members of the surgical team on the service and daily notes can be written by any member of the team.  Post-op check note must be written by the operating resident within 24 hours regardless of other notes by the team.

Teaching/work rounds are made in the afternoon and must be completed before 6:30 p.m.  If for any reason the chief resident is delayed in the operating room, the next available senior resident conducts the rounds and signs out to the team on call.

Grand Rounds are held once a week (Wednesdays) to discuss the cases for the week including operations, morbidity and mortalities.

Teaching Ward Rounds by attendings are held at designated times on the services once a week. Integrated plan of care

rounds are conducted once a week under the supervision of the Chief of Service and includes representatives 

from house staff, nursing, social worker, etc.

CLINIC REFERRALS

Upon discharge, patients are referred to the appropriate clinic for follow-up; the ward clerks make these appointments

Discharge slips state the diagnosis, type of operation, medications, and the responsible attending.  All general surgery patients are referred to the follow-up clinic of the responsible attending and given written (post-operative or post-discharge) instructions, with a copy placed on the chart.

DISCHARGES

The attending, resident, nursing, social workers etc are involved in the discharge planning for a patient to ensure proper out of hospital care and follow-up.  Discharge Planning Rounds are held every Wednesday.

It is important for proper continuum of care that all involved, including the patient and family are given a 24 hour notice before a patient is discharged. This must be documented in the chart and order placed in the computer. The discharge notice is also signed by the patient.  Patient must sign that they agree to avoid 24 hour notice if decision is made to allow patient to go home before then

OTHERS

Advance directives, in particular is provided to the patient on admission.  The interdisciplinary care form is completed by the admitting resident. It permits prioritization and ensures an interdisciplinary approach to problems identified.  If new problems are found they are added to the interdisciplinary care form.  When a problem is resolved it must be noted in the problem list on the computer.

CARDIAC ARREST (777) RESPONSIBILITIES

The resident on vascular access is the designated person who responds to the emergency code '777 during his/her tour of duty. The team responsible for the patient also responds to arrest calls.

EMERGENCY ROOM

It is the responsibility of the emergency room attending on duty to make all decisions as to the need for emer­gency admission and to personally notify the resident on duty on the specific service of the name, diagnosis, condition of the patient and of the decision to admit the patient.