The electronic version of this document or form is the latest and only acceptable version. You are responsible to ensure any printing of this document is identical to the e-versicn. SWEDISH MEDICAL CENTER OVERLAPPING STAFFING OF TWO ROOMS Clinical Policy and Procedure Approved: August 2017 Next Review: August 2017 Clinical Area: Perioperative Anesthesia Services; C?Section Rooms and Procedural Areas (Cardiac Cath Lab, Interventional Radiology, Electrophysiology Lab, Endoscopy) Population Covered: All patients cared for in an operating/procedure room in which overlapping operations/procedures occur Campus: Ballard, Cherry Hill, Edmonds, First Hill, lssaquah Implementation Date: August 2017 Related Procedures, Protocols, and Job Aids: Schedulingiirgical Procedures: Requirements Veri?cation of Correct Patient. Procedure, and Site/Side Informed Consent for Surgery or Other Invasive Procedural Treatment Purpose To provide guidelines on the limitations and requirements governing the participation of surgeons and proceduralists in overlapping operations and procedures. Policy Statement Swedish maintains appropriate surgical staf?ng of all operating rooms (0R3) and procedure rooms to ensure safe and high quality care for all patients in a manner compliant with all legal and regulatory requirements. The primary attending surgeon is personally responsible for the patient?s safety and welfare throughout the surgery or procedure. In some cases, a primary attending proceduralist is responsible for the care of the patient rather than a surgeon. In those instances, the primary attending proceduralist will be responsible for following the steps in this Policy that are required of a primary attending surgeon.? Overlapping operations are permissible if the following criteria are met: 1) Safety Pause. The primary attending surgeon will be present for a safety pause. If the primary attending surgeon is not available for the initial safety pause during the patient preparation phase of the surgical procedure (as defined below), an alternate quali?ed surgeon, privileged surgical fellow, or chief resident may perform the initial safety pause, provided that he/she has received the relevant information from the primary attending surgeon, and he/she will be present for and participate in the case. If the primary attending surgeon is not present at the initial safety pause, the primary attending surgeon will participate in a second safety pause prior to his/her involvement in the surgical procedure phase of the surgical operation (as defined below). Surgical operations (as defined in the Policy) are divided into three phases once the patient has entered the OR: patient preparation, surgical procedure, and closure. 2) Clinical Policy/Procedure: OVERLAPPING STAFFING OF TWO OPERATINGIPROCEDURAL ROOMS 2017 Swedish Health Services Page 1 of 5 a. The patient preparation and closure phases of surgical operations generally can be delegated to appropriately quali?ed providers as identi?ed in the safety pause and do not necessarily require the primary attending surgeon?s presence. b. Some aspects of the surgical procedure phase surgical exposure, vein harvesting, trocar placement) may be delegated to appropriately qualified practitioners as identi?ed in the safety pause and do not necessarily require the primary attending surgeon?s presence. 3) The primary attending surgeon will be present for the substantial majority of the surgical procedure phase to ensure presence during the key and critical portions of the procedure. This presence will be documented by the primary attending surgeon in the post-operative note and will also be documented in the OR log as described below. 4) Some circumstances may require the primary attending surgeon to leave the OR during the surgical procedure phase. or example, the primary attending surgeon may leave the OR to attend to procedure-related tasks, take a break during long procedures, or he/she could be called to an unexpected emergency elsewhere in the operating suite or hospital. For portions of the surgical procedure phase in which the primary attending surgeon is not present, he/she must be immediately available for return to the OR, or an alternate quali?ed surgeon identi?ed in the safety pause must be available. 5) ln multidisciplinary operations that involve more than one surgeon, either simultaneously or sequentially, for different elements of the surgical procedure phase each appropriately quali?ed surgeon must be present during the part of the operation that requires his/her surgical expertise. Each surgeon?s presence will be recorded in the OR log and each attending surgeon will document his/her presence in the post?operative note. During such operations it is necessary for each attending surgeon to be present only during the part of the operation that requires his/her surgical expertise. However, the primary attending surgeon remains personally responsible for the patient?s safety and welfare for the entire surgical procedure. 6) OR staff will document each surgeon?s OR entry and exit throughout the case through manual or automated systems. 7) All patients/legal representatives will be explicitly informed in the informed consent process that the primary attending surgeon will be present for the substantial majority of the surgical procedure phase, including the key and critical portions. For the patient preparation and closure phases, the primary attending surgeon may not be present if he/she has delegated those phases to appropriately quali?ed providers. 8) Swedish will monitor compliance with this Policy as part of its quality assurance and peer review process. ROC ED RE Responsible Person Steps OPERATIONAL REQUIREMENTS AND SCHEDULING Primary 1. Perioperative Services will review and adjust case order and scheduling of block time Attending as needed to ensure compliance with this Policy, appropriately account for any Surgeon/ anticipated degree of overlap as de?ned in this Policy, and prevent the possibility of Proceduralist, concurrent or simultaneous surgeries. Perioperative 2. Overlapping operations must be scheduled and performed to ensure safe and high Anesthesia quality patient care such that the flow of each procedure is not delayed, anesthesia time Leadership is not prolonged, and OR ef?ciency is maintained. 3. Every surgical patient in the OR will have one primary attending surgeon clearly designated in the patient?s medical record. 4. Prior to a surgical procedure, the involvement of the primary attending surgeon, as well as the participation of residents or privileged surgical fellows in the surgical procedure, will be discussed with the patient/legal representative. Clinical Policy/Procedure: OVERLAPPING STAFFING OF TWO ROOMS 2017 Swedish Health Services Page 2 of 5 LII Prior to a surgical procedure, the critical portions of the surgical procedure will be identi?ed and discussed between the primary attending surgeon and the privileged surgical fellow, chief surgical resident, or alternate quali?ed surgeon (if needed). The primary attending surgeon will be present for a safety pause. if the primary attending surgeon is not available for the initial safety pause during the patient preparation phase, an alternate quali?ed surgeon, privileged surgical fellow, or chief surgical resident may perform the initial safety pause, provided that he/she has received the relevant information from the primary attending surgeon, and he/she will be present for and participating in the case. During the safety pause, the physician member of the surgical team responsible for the safety pause informs the OR team as to the surgical plan, (2) identi?es the primary attending surgeon, and the quali?ed alternate surgeon if one is needed, and (3) informs the surgical team about the critical portions of the procedure. Scheduling will re?ect that the primary attending surgeon will be present for the substantial majority of the surgical procedure phase, including all critical and key portions, with no scheduled overlap during surgical procedure phase. Primary Attending Surgeon{s)/ Proceduralists, Perioperative Anesthesia Leadership, Circulating RN DOCUMENTATION 1. The primary attending surgeon will personally document that he/she was present for the substantial majority of the surgical procedure phase and all the key and critical portions in the surgical postoperative note and attestation. An OR log documenting the entry, exit, and time in OR for each participating surgeon will be maintained and monitored. Surgical Section Chiefs, Perioperative Anesthesia Leadership LEADERSHIP REVIEW The allocation of elective blocks for surgical case scheduling purposes is at the discretion of division/department surgical chiefs and Perioperative Leadership, with consideration of patient safety and quality, compliance with this Policy, and quality and ef?ciency of OR performance. On a quarterly basis, each department will review the performance of surgeons in regard to adherence to this Policy in addition to other quality and patient safety metrics and review of adverse events. Perioperative Services and Anesthesia leadership will regularly review quality and safety metrics, adverse events, and adherence to this Policy. Adverse events and quality metrics are also reviewed by the appropriate Quality Review Committee. Definitions Alternate Quali?ed Surgeon. A board eligible or board certi?ed surgeon who has medical staff privileges at Swedish. This may be an attending surgeon or privileged surgical fellow who has been observed, proctored, and certi?ed as competent by attending surgical staff at Swedish. Concurrent or Simultaneous Operations/Procedures. Surgical operations in which the surgical procedure phases Phase 2, including the key and critical components) of two separate cases in two separate ORs, for which the primary attending surgeon is responsible, are occurring at the same time. Absent any emergency or other unforeseen circumstances, concurrent or simultaneous operations cannot be scheduled or performed at Swedish under this Policy. Fellow (Non?privileged): A physician who has completed residency training and is taking advanced training in a supervised, non?privileged role. Clinical" Policy/Procedure: OVERLAPPING STAFFING OF TWO ROOMS 20'17 Swedish Health Services Page 3 of 5 Immediate availability. The surgeon/proceduralist remains in the general area of the OR/procedure room on the same campus, is reachable through a paging system or other electronic means, and is able to return to the OR/procedure room in a timely manner. The primary attending surgeon may be considered immediately available if he/she is engaged in one other OR (patient preparation, but not overlapping surgical procedure phase), performing rounds, checking on patients in recovery, reviewing charts, or performing other tasks outside of the OR that are brief and interruptible. The primary attending surgeon may not schedule patients for outpatient clinic visits during a time period when he/she is scheduled to be in the OR. Multidisciplinary Operations. Multidisciplinary operations are de?ned to include those surgeries involving multiple procedures by different surgical specialists. However, the primary attending surgeon remains personally responsible for the patient?s safety and welfare for the entire surgical procedure. Multidisciplinary operations require each surgeon to obtain separate informed consent from the patient/legal representative for that surgeon?s procedure(s), and to be present only during the portion of the surgical procedure he/she is performing that requires his/her surgical expertise. Overlapping Operations. Overlapping operations occur when the primary attending surgeon initiates and participates in a second surgical procedure after he/she has completed a ?rst surgical procedure, but before the closure phase has been completed for that ?rst case by an appropriately delegated practitioner. By de?nition, in overlapping operations the key and critical portions of the surgical procedure phases of two cases are occurring at different times. Practitioner. A member of the Medical Staff or Allied Health Staff who has appropriate privileges for the procedure. Privileged (Surgical) Fellow. A privileged surgeon who has completed his/her surgical residency training, is board eligible, and has elected to obtain additional specialized training at Swedish through a formal surgical fellowship. A privileged surgical fellow was once called a medical staff fellow. This role is distinct from a fellow (non-privileged) and resident. Provider. All practitioners, fellows, and residents. Resident. An individual who participates in an Accreditation Council for Graduate Medical Education (ACGME) approved graduate medical education (GME) program, including programs in osteopathy, dentistry, and podiatry. Residents do not have independent privileges. For the purpose of federal Medicare reimbursement rules, ?resident? also includes interns and physicians who are not in an approved GME program, but who are authorized to practice only in a hDSpital setting physicians with temporary or restricted licenses or unlicensed graduates of foreign medical schools). Surgical Operation (case de?nition). Surgeries generally can be divided into three phases once the patient has entered the OR: 1) Patient Preparation. The patient preparation phase includes the induction of anesthesia, positioning of the patient, placement of monitors and lines, other ancillary procedures, and the safety pause. 2) Surgical Procedure. The surgical procedure phase begins from ?rst incision and ends with the initiation of closure. 3) Closure. The closure phase is the period following completion of the surgical procedure, involving closure of surgical incision(s) and preparation of the patient for transfer from the OR to the post? operative recovery area. Forms Consent for Surgery or Other Invasive Procedural Treatment Safety Pause Checklist Clinical Policy/Procedure: OVERLAPPING STAFFING OF TWO ROOMS 2017 Swedish Health Services Page 4 of 5 Supplemental Information None. Regulatory Requirement Centers for Medicare Medicaid Services (CMS), 482.51(b) - Surgical Services. CMS, 42 C.F.R. Section 415.172 Physician fee schedule payment for services of teaching physicians CMS, Medicare Claims Processing Manual (CMS Pub. 100?04), Chapter 12, Sections 100, e; seq. Teaching Physician Services Det Norske Veritas (DNV). Patient Rights; SS.1 Surgical Services Washington State Department of Health. WAC 246-320-236 Surgical Services References (See Johns Hopkins Nursing Evidence Based Practice (JHNEBP) Evidence Rating Scales.) American College of Surgeons. (2016). Statements on Principles: Section IID, Concurrent surgery. Retrieved from State of Washington, Department of Health. Medical Quality Assurance Commission. (2016). Guidelines: Simultaneous and Overlapping Elective Surgeries. Retrieved from Documents/3 16- 0] STAKEHOLDERS Author/Contact Marc Horton, Executive Director of Advanced Surgical Services, Perioperative Administration Charles Watts, MD, Chief Medical Officer, Swedish Health Services Ian Wright, MD, Vice President, Perioperative Services, Swedish Health Services Expert Consultants Kat Porath, BSN, JD, Senior Risk Manager, Risk Management Marianne Klaas, MN, RN, CHSP, HACP, Administrative Director of Accreditation, Safety, Injury Management, and Clinical Quality Investigations Operating Room Executive Leadership (July 27, 2017) Robin Turner, Senior Corporate Counsel, Providence St. Joseph Health Sponsor Charles Watts, MD, Chief Medical Of?cer, Swedish Health Services 06091601 Clinical Policy/Procedure: OVERLAPPING STAFFING OF TWO OPERATINGIPROCEDURAL ROOMS 2017 Swedish Health Services Page 5 of 5