Appendix D. Site Visit Comparison Process

Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

D1. Pre-Operative Steps

Process Step / Facility FeatureAcademic Hospital, Off-Site ASCCommunity Hospital, Co-Located ASCFree-Standing ASCPediatric Hospital, Off-Site ASC

Appointment is scheduled

Unsure who schedules appointment, but it is not ASC nurses, as one said "The schedulers don't always understand patient specifics so they might schedule someone at bad time for their type of procedure." The ASC doesn't have as much control over it.

Scheduled by surgeon's office and posted in ASC schedule.

Scheduled by surgeon's office and posted in ASC schedule.

Yes. (But unsure whether by surgeon or ASC).

Information (appointment, patient, history and surgery) is transferred to ASC

 

Scheduling secretary from surgical offices calls their scheduling department to reserve type of surgery and equipment and give patient's special need instructions like obesity, blindness etc, but really not get some info like diabetic until patient history taken by ASC.

  

Pre-surgery physical exam conducted

Every patient here must have a physical within 30 days of procedure.

All have to have full physical before procedure.

  

Main/only pre-op call conducted (timing)

First contact with ASC is pre-op call, try to call at least 7 days before surgery but often only a couple days before.  Hard to get a hold of people because 80% of population works, Always talk at least 2 days before.

Pre-op phone call aimed at week before. 96% get contacted in the week, but based on volume, not always.

Pre-op call as early as possible, sometimes a few days before. Aim for 3-5 days before.

A couple weeks to a week before.

Main/only pre-op call conducted: lifestyle and medical history, previous procedures, medications, conditions, infections

Discuss when having procedure, reminding to keep appointment, asking if they have a ride, questions about medical history and health and instructions on how to get to the ASC. Ask if diabetic.

Health history taken (e.g., previous surgery, medical, prescription history). This identifies testing needed for the procedure (for example people on diuretics need electrolyte test, diabetics get blood sugar).  Pre-surgical testing dept here or at private doctors office. Every once and a while this happens day of, but normally testing done in advance. Ask about co-morbidities and special needs, give basic instructions, how much medication take day of surgery, what to bring, what not to eat, when to arrive, what to expect, where to arrive.  The surgeon's office provides instructions too. Many offices have surgical coordinator that schedules the surgery and surgeon provides details of surgery then. Also ask history of MRSA (these will need to be isolation patients).

Basic questions including: allergies, background, contacts, dentures, drug use, medications, dosages. Info on when to get there, food to eat or not eat, medications to take or not take, not to wear jewelry, bring responsible adult, check doctors names and phone numbers. Follow checklist for medical information needed from doctors. Answer patient questions. Check lab work, EKG etc. and other requirements for procedure and age. Give day before and morning of instructions.

Surgery history, cardiac issues, breathing, illnesses.

 

Pre-op call information passed to anesthesiologist and/or endocrinologist

   

Yes, passed to both after call.

Special issues/process for diabetics?

Diabetic patients, on day before surgery, do half their insulin, then day of surgery they do not consume sugar free, they drink real soda. Very careful about insulin dependent cases so try and do them early and always be flexible. The schedulers don't always understand patient specifics so they might schedule someone at bad time.

An endocrinologist does not typically work on a case in advance for adults, but on day of surgery they will measure insulin etc.

 

Check glucose before and after the procedure. If a patient is known to be diabetic then additional procedure prep done and insulin needs incorporated throughout plan for surgery. Requires an endocrinologist's note for insulin dependent patients and the endocrinologists are involved during procedure day.  Before they were involved it was too difficult for the anesthesiologists to figure out accurate regimen, now they are integrated.

Case reviewed by anesthesiologist, determines eligibility

Certain protocols can cancel a case, if too high BMI (body mass index) can cancel, if medical history indicate quite a few complications- co morbidities, diabetes, dialysis, hypertension, heart irregularities, medications, clinical trials. Nurses do not make call to cancel. Patients who are scheduled for this facility are reviewed by anesthesiologist, who makes call. If canceled are forwarded to hospital.

   

Check-in pre-op call conducted (timing)

No, only original pre-op call conducted.

No, only original pre-op call conducted.

No, only original pre-op call conducted.

Yes, charge nurse does a day before call.

Check-in pre-op call conducted (content)

No, only original pre-op call conducted.

No, only original pre-op call conducted.

No, only original pre-op call conducted.

Day before remind them time to arrive and guidelines and confirm everything. Confirm everything that pediatrician sent on day of surgery. Check up to date health status.

Patient follows pre-surgery food instructions

Nothingto eat or drink after midnight for any anesthesia, since schedule might change they need to be flexible. If they were told to not eat for a 6-8 hour window then the ASC would be waiting for that period if there were schedule changes. Having all patients not eat means they can juggle the schedule. Patient can brush teeth day of surgery, no gum or mints.

The patient anesthesia guidelines for all have changed recently to not eating 8 hours before surgery instead of all night. Babies are a shorter period with 3 hours before with no clear liquid and 6 hours with no breastfeeding.

Nothing to eat or drink after midnight.

Enforcing no eating is a challenge, sometimes because non-English speaking patients and parents will need an interpreter on phone and parents can be bad about enforcing policy.

Patient follows pre-surgery medications instructions

Depends on requirements for procedure.

Depends on requirements for procedure.

Depends on requirements for procedure.

Depends on requirements for procedure.

Patient follows pre-surgery shower instructions

Nurses lament that with outpatient they cannot monitor/require this. They discuss inpatient process where they wash patients in shower in early morning or night before in chlorohexidine. They want to make it part of the pre-op instruction to make them bathe, but not part of it because Drs. assume that everyone does. They admit that nothing about surgery site prep cleaning changes between inpatient and outpatient, because nurses assume even if they do bathe, they are not good at it. But they are concerned about the level of cleanliness of the patient and their clothing when they get to the ASC, thus what they wear out of it.

 

Patient instructed to have showered with anti microbial soap night before and morning of.

 

Day of surgery, patient arrives and checks in at registration

For check in they need a picture ID. They also need you to have a ride. The ASC likes to have an estimated time it takes to get from patient's house to ASC so that if they need to call they can catch them before they leave if the schedule changes.

Come in from front door, go to registration, check in and the secretaries notify pre-op nurses who get the patient.  Each admitted individually.

Business office first place go when come here.

Guardian checks patients in.

Paperwork processed/verified: spelling of name, payment, insurance, surgeon, procedure

Yes.

Confirm identity (or guardian), first desk is insurance, identification, co-pay, etc. Verify spelling of name and birth date.

They check name spelling, paperwork (except consents, which is done later with anesthesiologist), payment etc. picture ID, and birth date.

Nurse verifies correct patient.

Check that guardian and/or ride is present and provides consent and/or contact information for patient pick-up

Yes.

Yes.

Yes, if the driver is coming later and not there at start, then they want a cell phone number, but the patient must have a ride set up.

Yes, very important because can have all kinds of issues with guardian consent. If there is a custody issue if parents separated, need guardian paperwork. Also, many times children sent with other person, like grandparent, but need parent or forms signed by parent and can't start until resolved.

Nurse admits patient to pre-op area

Yes.

Yes.

Yes.

Yes, will admit after verify guardian and that it is correct child.

Pre-op facility

Pre-op area with 6 curtained bays.  The try to keep it all private, but it is close to other people.

One big room with bays separated by walls and closed by curtains.

Pre-op bays (there are 5), different kinds of beds (trio, I, stretcher), Beds are cleaned before going into bays, fitted sheets, top sheet, blanket, pillow, pillow case.

Have three separate pre-op rooms, one family per room because of HIPPA.

Who is allowed in pre-op?

No family members allowed with them since pre-op is such a small area. Exceptions made for elderly, children, often just give instructions to person with them during post-op instead.

Two family members. If there is a language issue or in a pediatric case, you may bring in a family member into OR until patient is asleep.

Can bring anyone they want over 18, but only one person. If they have a cough then tell them to not come, do not want small kids, people in waiting room, but only one person can come to PACU at time, do dental and pediatrics too, but no one in OR ever. Maybe 10% in pediatrics. No homeless, have home address for all.

Parents and then one parent can escort to OR, given head cover, gown, but no shoe cover. No one allowed back to OR if visibly sick.

Patient-bathroom

 

Offered but not required.

Required to empty bladder.

Required.

Depending on age/gender, patient takes pregnancy test

  

Female of child-bearing age gets pregnancy test (there are waivers for this).

 

Clothing changed

With eye surgery, since transported on stretcher, even though they go through sterile corridor, allowed half street clothes but is not considered a breach of sterility since they 'never touch anything'. This 'fast track' for eye cases is everything off from waist up, waist down keep clothes but put on shoe covers. If is OR case nothing from outside environment can be worn in, gown, hair, booties.

Paper scrubs, booties, hat, mask.

Change into patient gown, booties and hair cover. Keep only underwear and boxers, no bra because of pressure.

Change into gown before bathroom at this ASC. Hair coverings and gowns, but no shoe covers here.

Intake information collected: antibiotics taken, previous anesthesia experiences, allergies, recent events, changes in history, check surgery location

Ask last time they ate, what procedure they are doing, what part of body is having surgery.

Check allergies. Verify procedure, verify NPO (nothing by mouth) status, check paperwork (history of physical, labs, testing, etc). Deal-breakers: NPO (this may just delay a few hours if the surgeon has time)(usually doesn't apply with local anesthesia, but sometime local turns general), no ride home (with general anesthesia. Locals can take themselves home).

Ask about eating/drinking requirements, allergies (food, medicine, latex), check area of body for surgery, dentures, loose teeth, contact lenses, jewelry, metal. Which body part is having surgery, tell and show.  Ask about pain on a pain scale.

Check to see if child sick.  If in pre-call found out was sick sometimes will still have child come in so to assess situation. Postpone if pink eye or fever. Also depends on where surgery is, if have diaper rash, might cancel.

Screening for preexisting infections

The director believes that every patient is supposed to be treated with universal precautions. Staff are supposed to assume a patient could have MRSA or other infections, whether they do or not. She believes this should increase the level of precaution in all cases. Staff do not know about infections until patients handed to them and unlike assumption of director, staff assume patient not infected until they find out otherwise and feel they should know in advance to better prep.

A known infection does not change things from facility point or in process in OR, but patient can be isolated in pre and post op.

No screening in pre-op assessment questions or cheek swab culture for MRSA etc. Some instances would be beneficial to do, ligament repair patients should. Finding out about body implants is important too because of pressure areas, and stray burns if using cauterizing.

 

Vitals collected: temperature, blood pressure, pulse

Check for elevated blood pressure, heart rate, and blood sugar.

Yes.

Vital signs, blood pressure on non-surgical site, also ox monitor, and temporal scan, pulse, temperature, lungs, blood coagulation (?).

Will do test for cardeo issues and if a murmur comes up, since not all families know before about it, then depending on time of day, further tests can be done so as not to cancel surgery.  Often can just be sent upstairs to cardeo dept and checked to see if benign, if is then the patient is cleared and surgery proceeds.  Otherwise it is canceled pending cardeo tests.

Notify anesthesiologist and surgeon of any variations between pre-op call information and intake information

  

Notify anesthesia and surgeon if variation based on criteria.

 

IV inserted

Yes.

Yes.

IV—disposable packs with tourniquet, chlorohexidine, transparent dressing, etc. (does not contain lidocaine, or 20guage ___). (?)

Yes.

Antibiotics bag hung

Prophylactic antibiotics: most procedures have protocol that have antibiotics one hour before cut time.

For prophylactic antibiotics, will hang bag but not start it. Anesthesiologist will start it as enter OR because have to administer within one hour so wait until enter OR. This is in case the procedure time changes unexpectedly.

  

Anesthesiologist checks with patient: verify all previous information, discuss what to expect, post-op instructions, consent forms

The anesthesiologist explains what they are going to do and gives different instructions depending on type of anesthesia. Post-op instructions given, consent forms done.

Sees patient in pre-op to answer questions and sign consent. Re-verify information such as NPO, medications, etc.

All patients, except local, seen by anesthesiologist, local assessed by nurse in room. Less 5% local.  Told risk etc, then do consent.

Anesthesiologist checks with them, history and physical and medical history and confirm everything.

Surgeon and/or OR nurse checks with patient: verify all previous information, discuss what to expect, post-op instructions, consent forms

The surgeons has them do consent forms, post-op instructions and explanations of surgery. If the surgeon is unsure what they are doing in the surgery yet might wait to give instructions until after.

Sees patient in pre-op to answer questions and sign consent. Re-verify information such as NPO, medications, etc.

Yes, by surgeon.

OR nurse or surgeon ask history and discuss surgery, previous procedures. Gets informed consent and mark the site.

Surgery site is marked, potentially shaved

 

Surgeon uses one-time use marker to mark site. Not sealed, but thrown away after use. Shaving: only use electrical razor, as close to incision time as possible.

Will mark body part, patient does this by writing "yes" above site. If the patient is not able to do this, the responsible adult will do this (with initials). Surgical marking pen comes wrapped, single use, thrown away after.

Mark with sterilized pen because used to be pen in pocket, but not sterile.

Post-op pain block administered now or later in OR

(Later in the OR) Anesthesiologist checks the temp and positions them, hooks them up to monitor, then do blocks.  If podiatry case they sedate a bit before doing blocks.

 

Post op block for pain done right after surgeon sees them. Is done by anesthesiologist. Blocks of varying kinds, IV valium. When is block required? Shoulder (interscaling) makes the entire arm numb for about 18 hours. Interscaling blocks and femoral blocks and 3 others, no spine or epidural.

 

Blood pressure cuffs put onto patient

 

Give each patient their own BP cuff that follows them.

Except for localized patients, all get pressure cuffs on limbs, prevent blood clots, deep vein thrombosis.

 

Pre-op nurse hand off to OR nurse who checks all information and paperwork

Make sure they have all documents ready, consent forms, Dr. order sheet, medication forms, instructions.

Nurse checks chart and consent, questions.

 

Pre-op nurse give report to circulating nurse and circulating nurse has to make sure paperwork complete and bracelet on. If not complete, paperwork goes back until complete.

Patient settled on stretcher or prepped to walk to OR

The OR nurse comes in and takes patient out to OR and transports in whatever method needed, since the patient is awake until after they do the time out.

 

Get into transport or operative stretcher- take lower part off so not have to move patient, so depending on type of procedure get on stretcher.

 

Nurse, anesthesiologist, surgeon check patient again, especially stretcher positioning

Go to pre-op after announce patient is ready, interview them.

 

Nurse, OR nurse, surgeon etc comes out and make sure they on stretcher correct, make sure comfortable.  Patient will move onto OR bed themselves or stay on stretcher. If on belly for surgery will position themselves ahead of time, not often done other places. Other places will position them on belly after asleep, but then unknown pressure and discomfort can build up.

 

Warm blanket provided

  

Yes.

 

Transport to OR: who goes with patient and mode of transportation

Endoscopy and pain patients go into OR on stretcher, all others are walked.

Straight from pre-op into the OR on the stretcher (locals walk in). Transfer from stretcher to operating table, then the stretcher is taken down the hall.

Nurse, anesthetist, operating room nurse take the patient back. Scrub nurse would already be in the room.

Parents go with patient during transport then wait during procedure in post op, if patient asleep already the parents will be escorted to recovery room.

Proceed to Next Section

Current as of April 2013
Internet Citation: Appendix D. Site Visit Comparison Process: Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html