“If Your Ambulatory Surgery Unit Was an Airplane, Would You Take Off In It?” Presented by Sharon L Groves, BSN, MSA, AR

1. “If Your Ambulatory Surgery Unit Was an Airplane, Would You Take Off In It?”Presented bySharon L Groves, BSN, MSA, ARM, ASHRM, CPHRMBerkley Medical

2. Objectives

3. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

4. Fire Prevention Two common categories of fire in the OR: • External • drapes, dressings, gauze sponges, or objects such as tubing or petroleum-based ointments, etc. • Oropharyngeal Internal airway • the endotracheal tube

5. Fire prevention and response training • Fire drills are conducted at least quarterly. • At least 50% of the required drills are unannounced. • All fire drills are critiqued to identify deficiencies and opportunities for improvement. • The effectiveness of fire-response training according to the fire plan is evaluated at least annually.

6. Fire prevention and response training • During fire drills, staff knowledge is evaluated, including the following: • When and how to sound fire alarms (where such alarms are available) • When and how to transmit for off-site fire responders • Containment of smoke and fire • Transfer of patients to areas of refuge • Fire extinguishment • Specific fire-response duties (e.g., preparation for building evacuation)

7. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

8. Prevention of Post-op Infections • Prophylactic antibiotics should be considered and used according to the following published guidelines: • Surgical procedures for which prophylactic antibiotics are recommended • The selection of appropriate medications • The timing of administering medications • The route of administration and • The personnel responsible for procuring, preparing and administering the medication.

9. Infection Control • OSHA manual/completing 300 log should be in use • Exposure control plan should be up to date • Gloves / masks / eye protection readily available • Containers for proper sharps disposal available

10. Infection Control • Sterilization procedures include sterilization of surgery instruments, running controls and keeping logs • Weekly spore testing • Infections tracked and trended • Staff understanding of the use of OSHA Blood Borne Pathogen Noncompliance reporting

11. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

12. Falls • Evaluate and identify risk factors for falls in the older patient before and after the procedure. • Develop an appropriate plan of care for prevention • Perform a comprehensive evaluation of falls that occur in the center • Perform a post-fall revision of plan of care as appropriate.

13. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

14. Preventing Wrong Site Surgery • Steps • Preoperative verification process • Marking the operative site • “Time out” • Site marking must be done for any procedure that involves laterality, multiple structures, or levels (even if the procedure takes place outside of an OR).

15. Preventing Wrong Site Surgery • Things to Consider • Imaging studies are available • Implants are available • Blood is available.

16. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

17. Emergency Transfer • Effective policy and procedure for immediate transfer to a hospital for care beyond the capabilities of the ASC. • Written transfer agreement if applicable • Arrangement for ambulance services • Transfer of medical information

18. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

19. Malignant Hyperthermia • Rare life-threatening condition that is triggered by exposure to certain drugs used for general anesthesia • Treatment of choice: Dantrolene the only known antidote.

20. Malignant Hyperthermia • Malignant Hyperthermia Cart • Perform Mock drills on all shifts • Note: calcium channel blockers + Dantrolene may produce life-threatening hyperkalemia and myocardial depression.

21. Possible Triggers Acute Phase Treatment Succinylcholine All volatile anesthesia Potassium salts Clinical Manifestations 1. Elevated EtC02 2. Muscle rigidity 3. Tachycardia 4. Tachypnea 5. Hypercarbia 6. Cardiac dysrhythmia 7. Respiratory and or metabolic acidosis 8. Fever 9. Unstable/rising blood pressure 10. Cyanosis/mottling 11. Myoglobinuria Acute Phase Treatment 1. GET HELP! GET DANTROLENE! 2. Discontinue all possible triggers 3. Hyperventilate with 100% 02 4. Adm Dantrolene (2.5mg/kg) 5. Adm NA Bicarb 1-2 meq/kg 6. Institute cooling measures 7. Treat dysrhythmias 8. Adm additional Dantrolene 9. Monitor urine output, K, Ca, PT/PTT, ABG, EtC02 10. Treat hyperkalemia with regular insulin 11. Consider Mannitol/Furosemide 12. Consider monitoring of arterial blood pressure, CVP, PA. Malignant Hyperthermia Protocol 1-800-644-9737

22. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

23. Foreign Body • Operative Room Protocols – additional counts are performed : • When more sponges or sharps are added to the sterile field • Upon relief of either the scrub or circulating nurse • Before body cavity closure • Before completion of the operation. • If count is incorrect: • Immediately halt completion of the procedure and have anesthesia maintained until a correct count is verified • Take an intraoperative x-ray—surgeon determines which is appropriate

24. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

25. Patient Selection for Ambulatory Surgery • Develop general rules and guidelines to ensure uniformity of patient selection • American College of Surgeons recommends consideration of: • Age • Medical condition • Anesthetic risk • Complexity of operation • Anticipated degree and duration of post-op pain and discomfort • Probability of post-op complications.

26. Discharge Instructions • Recovering patients kept under direct observation • Two individuals in PACU at all times ( 1 RN) • Established criteria for discharge followed • Process for AMA • Written discharge instructions provided

27. Discharge Instructions • Patients prohibited from driving home after receiving anesthesia • Follow-up calls to patients made, • Process to follow when you do not reach the patient • MD or MD Anesthesia in house until all patients discharged

28. Post-discharge Instructions • Guidelines to follow if post-op problem • Instructions in their own language – Spanish etc. • Patients need to know: • How to care for themselves at home • What signs and symptoms can be expected • Specific activities to avoid and for low long • Which symptoms need to be brought to the healthcare professional’s attention and when • How to reach a professional who can answer other concerns that may arise • A time, place and date for a follow-up appointment.

29. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

30. Anesthesia Consent Form.

31. Topics • Fire prevention • Prevention of post-operative infection • Patient fall in the ASC • Preventing wrong site, side, patient, procedure, or implant • Emergency transfer or admission • Malignant Hyperthermia • Retained Foreign body • Patient selection for Ambulatory Surgery, discharge, instructions • Anesthesia informed consent • Culture of Safety

32. Culture-Of-Safety • Pay attention to detail. • Employees use the STAR method: stop, think, act, and review. • Communicate clearly. • Employees read back orders, ask clarifying questions, and ensure that they explain information clearly. • Think critically. • Employees think critically by ensuring that information is taken from credible sources and validating the accuracy of information with their own knowledge and other resources. • Hand off effectively. • Employees communicate the five P’s (patient or project, plan, purpose, problems, precautions) during handoffs. • Be a good wingman. • Employees coach their peers and check up on each other regarding safety practices. In addition, employees are encouraged to speak up when they have a question or concern and to use the chain of command.