Health Care Guideline Perioperative Protocol How to Cite this Document Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Institute for Clinical Systems Improvement. Perioperative Protocol. Updated March 2014. ICSI Members, Sponsors and organizations delivering care within Minnesota borders, may use ICSI documents in the following ways: • ICSI Health Care Guidelines and related products (hereinafter “Guidelines”) may be used and distributed by ICSI Member and Sponsor organizations as well as organizations delivering care within Minnesota borders. The guidelines can be used and distributed within the organization, to employees and anyone involved in the organization’s process for developing and implementing clinical guidelines. • ICSI Sponsor organizations can distribute the Guidelines to their enrollees and those care delivery organizations a sponsor holds insurance contracts with. • Guidelines may not be distributed outside of the organization, for any other purpose, without prior written consent from ICSI. • The Guidelines may be used only for the purpose of improving the health and health care of Member’s or Sponsor’s own enrollees and/or patients. • Only ICSI Members and Sponsors may adopt or adapt the Guidelines for use within their organizations. • Consent must be obtained from ICSI to prepare derivative works based on the Guidelines. • Appropriate attribution must be given to ICSI on any and all print or electronic documents that reference the Guidelines. All other copyright rights for ICSI Health Care Guidelines are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any use, adaptations, revisions or modifications made to ICSI Health Care Guidelines by the user or others. www.icsi.org Copyright © 2014 by Institute for Clinical Systems Improvement Health Care Protocol: Perioperative Fifth Edition March 2014 Index Table 1. Preoperative Basic Health Assessment and Medication Review 1.1 Basic Health Assessment 1.2 Preoperative Testing 1.21 Electrocardiogram 1.22 Hemoglobin 1.23 Potassium 1.24 Chest X-Ray 1.25 Pregnancy Test 2. Medical Conditions 2.1 Cardiovascular Disease 2.11 Beta-Blockers 2.12 Statin Therapy 2.13 Anticoagulation and Blood Disorders 2.131 Coronary Stents 2.132 Antithrombotic Therapy 2.133 Venous Thromboembolism Prophylaxis 2.2 Sleep Apnea 2.3 Diabetes Mellitus 2.31 Glycemic Control 2.32 Oral Hypoglycemic Therapy 2.33 Newer Anti-Diabetic Medications 2.4 Chronic Medication Use 2.41 Drugs to Continue 2.42 Drugs to Stop 2.5 Nicotine Cessation Return to Table of Contents www.icsi.org Copyright © 2014 by Institute for Clinical Systems Improvement 1 Perioperative Index Table Fifth Edition/March 2014 3. Antibiotic Management 3.1 Antibiotic Selection 3.11 Multi-Drug Resistant Organisms (MDRO) 3.12 Penicillin Allergy Management 3.13 Skin Testing 3.14 Vancomycin Allergy Management 3.15 “Clean” Procedures with Higher Infection Risk 3.2 Prevention of Endocarditis 3.21 Patients with Cardiac Conditions 3.3 Procedures in Patients with Previous Total Joint Replacement 3.4 Colorectal Surgery 3.41 Bowel Preparation 3.411 Mechanical 3.412 Antibiotic 3.5 Antibiotic Administration 3.51 Preoperative 3.52 Intraoperative 3.53 Postoperative 4. Patient Education and Communication 4.1 Preoperative Showering/Shaving 4.2 Preoperative Fasting Recommendations (Nothing by Mouth) 5. Patient, Procedure and Site Verification 5.1 Pre-Procedure Planning and Preparation (Equipment, etc.) 5.2 Scheduling 6. Surgical Site Marking with Initials 6.1 Site Marking by Surgeon 7. Regional Anesthesia Techniques and Verification Process 8. Patient Transported to Intraoperative Area Using Checklist (Reverify Patient Identification) 9. Verify Site Marking/Position Patient/Skin Preparation/Clipping 9.1 Skin Preparation and Hair Removal Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 2 Perioperative Index Table Fifth Edition/March 2014 10. Prior to Incision – Active Verbal Time-Out 11. Discrepancies 12. Hard Stop 13. Reverify/Pause If Internal Laterality/Implants/Spine Level 14. Safe Site Implementation 15. Communication 15.1 Briefing 15.2 Structured Hand-Off for Any Surgical Personnel Changes 15.3 Structured Hand-Off Process 16. Never Events 16.1 Retained Foreign Objects 16.11 Baseline Count 16.12 For Appropriate Cases, Do Wound or Body Cavity Exploration and Imaging If Counts Not Reconciled: Postoperative Follow-Up If Counts Remain Unreconciled 16.13 Perform Delayed Wound Closure/Open Packing, Final Count and Retained Foreign Object Prevention Process 16.14 Patient Returns to the Operating/Procedure Room for Final Wound Closure 16.15 Hard Stop – Perform Reconciliation Process 16.16 Imaging If Counts Not Reconciled: Postoperative Follow-Up If Counts Remain Unreconciled 16.17 Close Wound 17. Environmental 17.1 Normothermia Planning and Management 17.2 Preventing Fires in the OR/Procedure Room 17.3 General Environmental Concerns 17.4 Environmental Controls: Operating/Procedure Room Survey 18. Follow-Up Appointments Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 3 Perioperative Fifth Edition/March 2014 Table of Contents Work Group Leaders Annotations ........................................................................................................................ 1-65 Randall Card, MD Index Table ....................................................................................................................... 1-3 Family Medicine, Cuyuna Evidence Grading ............................................................................................................. 5-6 Regional Medical Center Recommendations Table ................................................................................................ 7-11 Mark Sawyer, MD Trauma and Emergency Foreword Surgery, Mayo Clinic Introduction ...................................................................................................................12 Work Group Members Scope and Target Population .........................................................................................13 Fairview Health Services Aims ..............................................................................................................................13 William Sypura, MD Clinical Highlights .................................................................................................. 13-14 Family Medicine Implementation Recommendation Highlights ........................................................ 14-15 Gillette Children's Choosing Wisely® ..........................................................................................................16 Specialty Healthcare Related ICSI Scientific Documents ..............................................................................16 Mary Matteson, RN, BA Definitions ............................................................................................................... 16-21 Surgery Annotations .................................................................................................................. 22-65 Gwen E. Schuller-Bebus, RN, MA Quality Improvement Support .................................................................................. 66-90 Surgery Aims and Measures ...................................................................................................... 67-70 Cheryl Swanson Measurement Specifications ................................................................................... 71-85 Patient Safety and Quality Implementation Recommendations .............................................................................. 86-87 HealthPartners Medical Implementation Tools and Resources .................................................................................88 Group and Regions Implementation Tools and Resources Table ................................................................. 89-90 Hospital Jerry Stultz, MD Supporting Evidence................................................................................................... 91-116 Pediatrics References .................................................................................................................... 92-98 Park Nicollet Health Appendices ................................................................................................................. 99-116 Services Appendix A – Patient Preoperative Guide ............................................................ 99-100 Rebekah Roemer, PharmD, Appendix B – Preoperative Questionnaire – Adult.....................................................101 BCPS Appendix C – Preoperative Questionnaire – Pediatric ...............................................102 Pharmacy Appendix D – Drugs to Stop/Drugs to Continue ................................................ 103-104 University of Minnesota Appendix E – Antibiotic Selection Table ....................................................................105 Kathleen Harder, PhD Appendix F – Antibiotic Dosing Table .......................................................................106 Human Factors Content Appendix G – Overview of Topical Antiseptics Used for Consultant Preoperative Skin Preparation................................................................................107 Carrie Terrell, MD Appendix H – Veterans Administration Methodical Wound OB/GYN Exploration Process ...............................................................................................108