Winter 2009 - Department of Anesthesiology

Compliance
Reminders
Documentation
Changes
Peripheral Line
Insertion
Transfusion
Documentation
Transfusion
Blood Product
Storage and Policy
Surgical/Block Site
Marking
Time Out Re-
Mobile Anesthesia
Carts
Sterile Procedure
Trays
Attending
Documentation in
Innovian
Points of Interest!
PALS Classes
TJC Standards for 2009
Time Out
requirements
Site Marking for
Blocks
2
2
3
4
5
6
7-8
QI Anesthesiology
Inside this issue: Compliance Update***
2 OESO Training-New Guidelines
The department has
updated the required
online training modules
in collaboration
with OESO. The new
listing will meet requirements
with both
the Department of
Anesthesiology and
the Hospital. These
modules will be introduced
in orientation
and not tied to your
job code as in past
years. The following
modules are required
annually per hospital
policy:
» Equity at Duke
» Infection Control
PALS in February
PALS will be offered
for the last night tonight.
Thanks to all
who have attended.
If there is further interest
please notify
Holly Muir.The last
class will be held in
1700 DN from 5:30-
» Fire Safety
» HEICS
» Blood Borne
Pathogens
» Environment of
Care
» Fire/Safety
» Chemical Safety
» Time Out Training-specific
to Anesthesiology
» Hand Hygiene
Modules
Modules that will be
required only once in
orientation will be:
9:30 tonight. We are
anticipating ending
early?!?!!?!
Winter 2009
» General Awareness
and Recall
for Anesthesia
» Alaris Pump
Training
______________________
Modules in development:
(required
annually)
Time Out Training
specific to Anesthesiology
Time Out
Surgical Site
Transplants
Central Line
Module

Page 2
Syringe Labeling:
• Medication
• Concentration
Date/Time
Time Required only for Propofol
Initials
**New** Pheneylephrine syringes are
good for 30days once removed from
the pharmacy refrigerator. Please remember
to label date/time when you pick
up.
Patient Identification •
Check ID Band intact and correct before
and after case
Replace ID Band if removed
Use two identifiers (patient name and
history number for inpatients)
Double-check with crossmatch and transfusion
Documentation
Note 0021:
(Updated) Patient Identified, Vital
signs, Airway, Response to medications
re-evaluated, Anesthesia Machine,
Monitors, Chart and Consent
checked and re-evaluated prior to
induction:
Transplant Notes —Abdominal Transplants Only
tx01 1st Organ verification Time Out;
If patient is on falls precautions,
assure there is a purple armband
in place.
Controlled Substances •
Keep with you or locked up at all
times
Return to pharmacy for wasting
or witness all waste and document
at point of care
Anesthesia Carts
Keep locked or under constant
surveillance
No personal belongings are to be
inside or on top of the carts.
Personal Protective Equipment
Wear appropriate Personal Protective
Equipment (PPE) including
eye wear when indicated
IV Tubing
tx02 Recipient blood type viewed in chart/browser;
(make sure to indicate whether you viewed the blood type
in the browser or in the chart) blood type must be documented
tx03 Donor blood type; blood type must be documented
Compliance Reminders
Sharps Containers
All 26 mobile anesthesia
carts will soon be fitted with
3 gal red sharps containers
within a security box similar
to the patients rooms. They
Transplant Notes-Documentation
tx04 Confirm compatible donor/recipient blood types;
tx06 UNOS ID #; N/A (for living donor) ---required UNOS ID # for
cadaveric
tx07 Final Timeout
***This is the responsibility of the Attending Anesthesiogist**-
Label with date and initials
Employee Identification
Wear Duke issued name
badge above waist, with name
readily visible
Bundle Use for Central Lines
Enter either L306 or L307
with note into Innovian
One L306 covers multiple
line placement during a single
cases
will bracket mounted onto the
carts. You will need to call the
number on the boxes to have
the container changed out. If
you feel the container will not
get you through the next day
please have the containers
changed out.
***The Attending can
delegate this
responsibility to the
provider if they are
unable to be present at
the time of verification
of organs but the
attending is ultimately
in charge of assuring
that the documentation
is completed.

Transfusion Records-Documentation
Documentation in Part C of the
transfusion record needs to be
completed by either checking the
box for anesthesia record or
writing Innovian record over the
vital signs section of Part C in
order to be compliant with Hospital
Policy.
*Two different licensed persons
must check the products and
legibly document signatures in
Part B of the transfusion record.
**See Below Example of Part B
and C in an Actual Transfusion
Record**
Part B must be
completed in whole by
two licensed
personnel.
Part C must
designate Anesthesia
Record or write
inside vital sign
record to See
Innovian Record
Required to be
checked if
documentation
is in
Innovian
DUHS Policy States:
Part C of the record.
The only exception in transfusion
documentation is anesthesia,
in which entry of
the blood product into the
anesthesia computer database
will serve as start and
completion date/time. Upon
completion of transfusion,
the white copy of the Transfusion
Report Form is placed
Page 3
in the patient’s chart and the
pink copy returned designated
location for return to
Transfusion services.
Must have two
licensed
healthcare
providers to
**verify **
Anesth. Tech,
RN, Resident,
Fellow, or
Attending.

**Transfusion Tips:
*Proper
Storage of Blood Products
Transfusion Policy:
1. Assure there are two licensed professionals OR 1 licensed professional
and an anesthesia technician to verify all identification information at the
bedside including:
Patients name and MRN on the armband match with the Transfusion
Report Form and the Compatibility Label on the product bag.
Product name, identification numbers/letters, donor ABO blood type
and RH factor on the bag label matches the Transfusion Report Form
Expiration date and time on the product and on the Transfusion Report
Form
2. Vital sign documentation policy requires initial set of vital signs to
be documented within 10-20min following
initiation of transfusion (except in
the OR)
Red blood cells and fresh frozen plasma are the only products stored in coolers.
If more than 3 of these products requiring refrigeration are requested,
they well be sent in a cooler, and must remain in the cooler until administered.
◊ Red blood cells and fresh frozen plasma must be kept under the bag of ice
to maintain a temperature range of 0-< 6° C.
◊ Do not store platelets or cryoprecipitate in coolers. These products are destroyed
at lower temperatures and will be discarded.
◊ Coolers may be returned to Transfusion for re-icing and brought back to the
bedside if necessary. The large coolers will maintain temperature for 8 hours
and the smaller coolers for 4 hrs.

Page 5 QI Anesthesiology
Site Marking: Surgical vs Block Site
Purpose: To Identify Unambiguously
the intended site of incision
for procedures involving
right/left distinction, multiple
structures, or multiple levels.
This policy also includes
regional block site information
necessary for Anesthesia
providers administering
blocks to patients prior to
surgery:
“... Prior to the placement of a
unilateral regional block
(local anesthetic block of any
kind) outside of the O.R., a
TIME OUT must be performed
by at least 2 health
care providers including the
person placing the block to
confirm surgical site, by reviewing
site as recorded in
surgical consent and by visualizing
the site marking done
TIME OUT PROCEDURE
Correct patient identity (ID Band must be in place)
Use Two Patient Identifiers: (DOB, Name, MRN)
by the surgical staff.
If the surgeon’s site
mark is not
visible to
the attendingperforming
or
supervising the block,
the anesthesiologist
must mark the site
where the unilateral
block is intended.
This mark must be
visible during block
placement. This must
be documented in the
Innovian/ anesthesia
record at the time of
block placement. This
must be followed by a
standard TIME OUT
procedure in the O.R.
prior to surgical incision.
For procedures
where the
Correct side and site (should be marked, if necessary, as per
Site Identification Policy)
Agreement on the procedure to be done
Correct patient position
Availability of correct implants and any special equipment or
special requirement
Availability of applicable imaging studies, as appropriate
Additional confirmations specific to the procedure are encouraged
to ensure that no member of the team has doubts
about the safety of proceeding.
block is placed as
part of the surgical
procedure (such as
ophthalmology), this
can be done as the
official TIME OUT
procedure and
documented as such
in the SIS system.
The standard TIME
OUT process must be
followed, and a note
should be made in SIS
of surgical site. **If
the patient’s position
is changed prior to
block placement ( and
with each change) a
repeat surgical site
verification should be
done by the person
performing the block
and the assistant
visualization of the
surgical site mark)
The surgeon will conclude the
TIME OUT.
Time Out Procedures are performed
by all individuals involved in the
case and are performed in the following
instances:
Prior to Surgical Site marking
Prior to Surgery within the OR
Suite-(to be initiated by the scrub
nurse)
Prior to local anesthetic block of
any kind outside the OR
Prior to any Surgery/Invasive
Procedure outside the OR

Anesthesia Mobile Carts
Guidelines for Anesthesia Mobile
Carts:
1. Do Not keep personal belongings
in any drawer of the mobile carts.
You all have lockers, and if you are
running late, you can hang your jackets
on hooks supplied in PACU.
2. Do Not place drinks and food on
top of the carts as this is a clean
area for drug preparation
3. Do Not leave uncapped needles on
top of the cart.
4. Label all syringes with Medication,
strength of medication, date mixed
or drawn up, and your legible initials
5. Lock the anesthesia cart when not
in use or not in actual visual field-
Sterile Procedural Trays
cannot see the cart when you
are behind the curtain
6. All multidose
vials are to be labeled with date
and time and initals when bottle
is opened. All other bottles will
be discarded
SCIP Measures:
1)Assure temperature on arrival to the PACU is performed and documented
within 15 minutes of arrival.
2) When an antibiotic is used in surgery; make sure when the name of the
antibiotic is entered into Innovian that the dosage is completed. Many
charts have been noted to have 0.0mg following the name of the antibiotic.
This will be counted as a failure on audits being conducted by hospital
administration.
1. Must be completely INTACT prior to use on
a patient
2. If the integrity of the cover for the tray is
loose from the tray or otherwise compromisedthis
automatically makes the entire tray NOT
STERILE. DO NOT USE. The blue cover inside is
NOT water resistant.
Page 6

Admission Tab
Staff tab-- E-SIG (One signature is needed if you DO NOT hand over the case. In case
of hand over, then you have to E-SIG out of the case (TIME OUT) at the time of
hand over, and the attending taking over signs in at the same time)
Pre-Op Tab
History Tab
Allergies
Plan Tab
Planned Anesthesia
Planned Disposition
ASA status
Anesthesiology Review—Add your name (E-SIG optional since you have E-SIG in the staff
summary page)
Entering a written note in the remarks section or an E-SIG note is optional –you might
consider entering a e-sig note since this can’t be altered and would not carry
over to another procedure on the same patient as in a case with the remarks
section note.
Prepare Tab
Check 01-06 as appropriate
Event Tab (top row):
‘HCFA’ Tab (Attending Notes)
ANESTHESIOLOGY FACULTY
DOCUMENTATION FOR INNOVIAN
H01 Entered automatically by Innovian when the case is opened in the OR
H02 E-SIG if you hand over the case (entered at the time of hand over, at the same time E-
SIG out of the case as indicated above)
H03-06+ E-SIG at the end of the case if you started the case (includes H02 note)
H03-6 E-SIG at the end of the case if you took over the case (does not include H02 note)
H08-27 Procedural participation:
A-line, CVP, PAC, RIC, Blocks
L306-7 Central Line 'Bundle' Documentation:
L306 indicates that the bundle was followed
‘Line’ Tab
L307 indicates that the line was inserted emergently and the bundle not followed
(indicate which items not followed)
Ultrasound Use for lines or blocks:
L308-9 Document use of U/S
Print a picture for the chart

Transplant Tab
Transplant Documentation- required to enter transplant notes:
Kidneys, Kid/Panc & Liver;
tx01 1st Organ verification Time Out;
tx02 Recipient blood type viewed in chart/browser;
(make sure to indicate whether you viewed the blood type in the browser or in the
chart) blood type must be documented)
tx03 Donor blood type; blood type must be documented)
tx04 Confirm compatible donor/recipient blood types;
tx06 UNOS ID # -required UNOS ID # for cadaveric donors but not applicable
(for living donor)
tx07 Final Timeout
QI Note (Top Row)-- E-SIG
PACU Sign Out (Event Tab- Top Row)
8091 (E-SIG)--- for patients who bypass 1 st stage recovery on their way home, patients
having MAC at the eye center, and OB patients after a labor epidural for analgesia.
8092 (E-SIG)—for any PACU patients who have no complications and meet all criteria
8093 – 8131 for patients who have anesthesia complications or do not meet all
criteria at time of discharge
_____________________________________________________________________
Billing sheet
Written Signature
Document Antibiotic & CVP Bundle Compliance
Code procedure
PACU Orders
CPOE or written
TEE Documentation
E-mail notification of completed TEE studies—sign within 24hrs
This format will be placed on the Innovian Portal Website as well as a copy being sent
out to the faculty.