Provider Orientation & Resources  

All Surgeons

 

Note: open ALL links and attachments that are applicable to your area(s) of practice.

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Correct patient, correct procedure and correct procedural site/side policy
All surgical sites involving laterality, level, and or multiples will be marked by the surgeon by placing his or her initials on the operative site such that the mark is visible after the patient is prepped and draped so that it can be reverified during the Surgical Time Out process. If it is not possible to mark the surgical site then the surgeon will mark the site on an anatomical diagram and anesthesia providers who are performing a procedure that involves laterality will mark the appropriate site with a “A” that is circled.


Safe surgery policy
Standardizes safe practices to ensure correct patient, correct procedure, and the correct procedural site/side for procedures performed in the operating room. This includes appropriate marking by surgeon’s initials at surgical site if procedure involves laterality or multiples, a formal briefing in the OR prior to starting the case with all members of the surgical team in the room, a formal Time Out lead by the surgeon and involving all members of the team (an orange Time Out towel is used as a memory trigger), a formal counting process, and formal debriefing process at the end of the case led by the surgeon.


Counts: Sponge, sharp and instrument policy
Outlines the counting procedure used to account for items such as sponges, sharps, and instruments to prevent injury to patients as a result of a retained item.


Clinical policy: Safe procedure policy – medical imaging and endoscopy
The purpose of this policy is to standardize safe practices to ensure correct patient, correct procedure, and the correct procedure site for procedures performed in Medical Imaging and Endoscopy including the process for conducting an interactive procedure time out just prior to the onset of procedure.  This policy is consistent with Safe Surgery policy and Counts policy utilized in Surgery and Labor and Delivery areas.


Surgical Care Improvement Project (SCIP)
Review of CMS core measures for patients under going a surgical procedure in inpatient and outpatient setting.


Clinical practice: Anesthesia Administration
This clinical practice applies to all inpatients and outpatients in any setting for any purpose by any route that receive anesthesia (including the use of short acting anesthetic agents for procedural sedation) in Banner Health Facilities.  All inpatients and outpatients within the Banner Health facilities receiving anesthesia will be administered anesthesia by appropriately credentialed providers based on evidenced based practice, or in its absence will practice with consensus guidelines to best serve the safety of Banner Health patients.


Clinical Policy:  Procedural sedation for therapeutic/diagnostic procedure
This clinical policy applies to both Adult and Pediatric Patients and defines the circumstances under which procedural sedation may be administered and define responsibilities and parameters for the management of the patient requiring procedural sedation for pre-intra-post, short-term diagnostic, or therapeutic procedures including monitoring requirements.  This clinical policy has been defined by not yet fully implemented.


Clinical Practice:  Management of Known Difficult Airway – Adult and Pediatrics (Excludes Neonatal)
It is an expected clinical practice that patients having a known difficult airway will receive care specific to the identified airway type that includes an electronic alert, coordination of care and airway management.  The patient will receive information and documentation related to their difficult airway and the need for notification of providers during future care.  The clinical practice design includes the creation of system-wide standards for the identification of patients with known difficult airways, EMR alerts and notifications across clinical modalities, preparation and approaches for intubation and extubation  including standardized airway carts and supplies, and the continuation of patient care planning outside the acute episode.


Clinical Practice: Sepsis And perFusion Evaluation (SAFE) for High Risk Patients-Adult
It is an expected clinical practice that all adult patients who meet criteria for an S.A.F.E. (Sepsis And perFusion Evaluation) Alert will be considered high risk for mortality and will be evaluated for severe sepsis and perfusion status.  When an SAFE alert fires on a patient, a SAFE Alert Review form will be attached and can be used to document evidence of active infection, assessment for other causes of hypoperfusion, and orders for lactic acid and NS bolus.  Patients will be reevaluated for targeted interventions as well as current diagnosis and treatment options.


Sepsis initiative
Establishes guidelines for early identification and treatment of sepsis in adult patients including Sepsis Outcomes (Mortality rate), diagnosis and treatment protocols (sepsis bundle compliance rate), timeliness of response to SAFE alert (rate), and formalized process for event investigation and documentation. Sepsis bundle includes measuring serum lactate, obtaining blood cultures prior to antibiotic administration, administering broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission, giving fluid bolus in the event of hypotension and/or serum lactate> 4 mmol/L, and placing central line in event of persistent hypotension for further tx and assessment.


Clinical Practice: Central line management and Prevention of Vascular Catheter Associated Infections (VCAI)
Establishes protocols for insertion and needs assessment for central lines including central line infection outcome (infection rate), insertion protocols (central line bundle compliance rate), timeliness of central line necessity check (daily check rate), and formalized process for event investigation and documentation. Central line insertion bundle includes hand hygiene, maximal barrier precautions upone insertion (gloves, hat, mask, gown, draps), chlorhexidine skin antisepsis, optimal catheter site selection (avoidance of femoral vein for access), and daily review of line necessity.


Clinical Practice: Prevention of Catheter-associated Urinary Tract Infections
It is an expected clinical practice that all adult and pediatric patients requiring an indwelling urinary catheter will receive appropriate Catheter-associated urinary tract infection prevention (CAUTI) strategies.


Clinical practice: Surgical site infection prevention by perioperative decolonization of staphylococcal carriers
Surgical patients who are screened preoperatively and who are positive for MSSA or MRSA will be treated with internasal mypirocin and chlorhexidine body washes for decolonization of staphylococcal carriers.  Patients positive for MRSA should receive cefazolin in addition to vancomycin for preoperative antimicrobial prophylaxis.


Clinical practice: Daily chlorhexidine gluconate (CHG) for patient hygiene
It is an expected clinical practice that all adult inpatients in a critical care unit will receive daily chlorhexidine gluconate (CHG) hygiene, except where contraindicated or excluded. All patients having surgery will receive a CHG bath pre-operatively.  This clinical practice has been defined but not yet fully implemented.


Clinical Practice: Chlorhexidine gluconate (CHG) pre-operative oral rinse - adult
It is an expected clinical practice that all adult patients undergoing a surgical procedure with general anesthesia and an expected inpatient stay will receive preoperative decontamination of the oropharynx with chlorhexidine glouconate (CHG) oral rinse, except where contraindicated.


Clinical Practice: Pre-operative skin antisepsis preparation
It is an expected clinical practice that patients undergoing surgical procedures will have pre-operative skin antisepsis aimed at reducing the risk of post-operative surgical site infection by removing soil and microorganism from the skin. Except where contraindications are present, chlorhexidine with isopropyl alcohol will be the preferred agent.


Clinical Practice: Blood transfusion – adult
It is an expected clinical practice that all adult patients who are hemodynamically stable will not routinely receive packed red blood cells when the hemoglobin level is above 7.0 grams/deciliter. While the 7 g/dl red cell transfusion threshold for hemodynamically stable patients serves as a guideline for the majority of patients, there may be clinical circumstances that necessitate red cell transfusion at hgb levels higher than 7 g/dl.  Examples may include patients with signs or symptoms of anemic hypoxia and/or organ ischemia, patients with ongoing blood loss, and patients at risk of complications due to inadequate oxygenation. This clinical practice also outlines pre-operative and perioperative assessment and management regarding potential blood transfusion.


Clinical Practice: Use of Cytomegalovirus (CMV) Seronegative Blood Products (Adult and Pediatric)
It is an expected clinical practice that patients requiring red blood cell transfusions who are allogeneic stem cell transplant recipients in whom both the donor and recipient are CMV negative; or fetuses receiving intrauterine transfusion; or neonates who have received an intrauterine transfusion will receive CMV Seronegative Blood Products.


Clinical Practice: General Surgery Computer Enhanced Robotic Surgery (adult/peds)
It is an expected clinical practice that all General Surgery patients scheduled for a surgical procedure where computer enhanced robotic approach may be considered, will have their case evaluated based on procedure type, patient co-morbidity, safety, and effectiveness to govern robotic technology usage. This clinical practice has been defined but not yet fully implemented.


Clinical practice: Acute blood Loss Anemia Documentation (ABLA) in surgical patients
All surgical patients will be evaluated for acute post-operative blood loss anemia based on clinical indicators.  Accurate documentation of the clinical indicators used, the results of this assessment describing the extent of the acute blood loss anemia (ABLA), and any therapeutic treatment provided will be recorded in the medical record.  ABLA should only be documented when 1) blood loss of sufficient amount requires transfusion of blood products or 2) transfer to higher level of care (example – outpatient admitted after procedure or inpatient transferred to either a monitored bed or ICU).  ICD code assignment of ABLA will occur if documented as such by provider.


Clinical practice: Preventing postoperative pulmonary complications (ADULT)
Adult surgical patients will be screened to identify risk for developing post-operative pulmonary complications (PPCs).  Patient specific interventions to reduce PPC risk will be applied.  These include pre-operative pulmonary optimization, intraoperative surgical and anesthetic modalities, post-operative pulmonary intervention through the use of pain control, patient mobilization and lung expansion maneuvers.

Clinical practice: Use of medication for the reversal of anticoagulation - adult
It is an expected clinical practice that all adult patients presenting to a Banner facility (inpatient and emergency room department) in need of anticoagulation reversal to prevent or minimize negative outcomes (e.g., bleeding events) will be assessed to determine the most appropriate reversal strategy. This will include selection of the most appropriate medication/reversal agent based on the patient’s anticoagulation therapy.



Clinical practice: Preoperative testing for elective surgeries - adults
It is an expected clinical practice that all elective surgery adult patients will receive preoperative testing based only on clinical indication. Avoid routine tests unless testing for specific indications or purpose.


Clinical Practice: Approach to major burn patients in the Emergency Department – Pediatric and Adult
It is an expected clinical practice that all patients presenting to Banner Emergency Departments with major burns (greater than 20% of total body surface area) and/or high risk burns will undergo a rapid comprehensive assessment that includes vital signs, ABC (Airway, Breathing, Circulation), mental status and associated trauma or medical condition following Acute Trauma Life Support (ATLS) and ABA Advanced Burn Life Support (ABLS) guidelines. After initial stabilization burn patients meeting criteria for transfer to a Burn Center will be transported to a Burn Center.


Clinical practice: Epoetin clinical practice - adults
It is an expected clinical practice that adult patients will receive epoetin for appropriate indications (anemia of chronic kidney disease, zidovudine-induced anemia, chemotherapy-related anemia, myelodysplastic syndrome, and Jehovah’s Witnesses with anemia) using standardized dosing and monitoring to ensure the safe and effective use in a hospital setting.


Clinical Practice: Management of asymptomatic pyuria and bacteriuria – adult
It is an expected clinical practice that adult patients with no symptoms of urinary tract infection (UTI) should not be screened for UTI with urinalysis or culture, including patients with indwelling foley or supra pubic catheter.  In the event that an asymptomatic patient is screened, a finding of pyuria and/or growth of bacteria or fungi should not lead to treatment with antibiotics based on IDSA (Infectious Disease Society of America) guidelines of 2005.  Exceptions are asymptomatic patients who are pregnant or are undergoing urologic surgery for which screening and antibiotic treatment may be indicated.

There are conflicting recommendations from expert specialty organizations regarding the treatment of asymptomatic bacteriuria in patients undergoing elective joint replacement surgery.  Therefore, physicians should weigh the risk of infection in these patients vs. the risk of antibiotic use on a case by case basis.


Clinical Practice: Gynecologic Oncology Referrals (Adult) Language
It is an expected clinical practice that all adult gynecological oncology patients with confirmed or suspected gynecologic malignancies will be referred to a gynecological oncologist or a physician trained in gynecological surgical procedures to perform debulking and/or staging.


Clinical Practice:  Excisions for Breast Cancer Margins
It is an expected clinical practice that all adult patients with pathologic stage I and II invasive breast cancer treated with breast conserving surgery and whole breast radiation, positive resection margins will be addressed with re-excision, while negative margins provide optimal outcome and re-excision is not indicated.


Clinical Practice:  Screening pregnant women for suspected appendicitis
It is an expected clinical practice that all pregnant patients presenting to the hospital who are suspected of having appendicitis will be screened using ultrasonography.  If further testing is needed, MRI will be used if resources are available.  This clinical practice has been defined but not yet fully implemented.


Addition for pediatric general surgeons

Clinical practice: Use of medical imaging for diagnosing appendicitis in pediatric patients
Outlines work-up of suspected cases of appendicitis in patients under 18 years of age including clinical exam, surgical consult, and if advanced imaging is indicated, to utilized ultrasound first (if available). Then if the ultrasound is equivocal or negative (or not available) and there is a reasonable index fo suspicion, a CT scan with IV and without oral contrast is recommended. 


Clinical Practice: Management of Appendicitis–Pediatric
It is an expected clinical practice that all Pediatric patients with a definitive diagnosis of appendicitis will receive fluid resuscitation, IV antibiotic treatment, surgical consultation and pre and postoperative management.


Addition for general surgeons and gastrointestinal surgeons

Major Bowel Surgery Strategic Initiative
To create a more consistent approach to the care of major bowel surgery patients (elective cases) throughout the system by establishing a comprehensive clinical pathway, standardized pre-operative teaching, early ambulation post-op, early removal of NG tube and oral intake, administration of Alvimopan when indicated, conversion from IV to oral analgesics as early as feasible, and early Case Management involvement to assure expedient discharge.

Clinical Practice: Anesthesia care for adult endoscopy
It is an expected clinical practice that all adult patients undergoing endoscopy procedures will be evaluated by the performing providers to determine the need for involvement of an anesthesia provider based on procedure type and qualifying medical condition(s). If deemed necessary, then a qualified Anesthesia provider will be consulted to evaluate the patient and provide the anesthesia care service. Applicable documentation to support medical necessity and request for consult will be completed.


Additional items for cardiovascular surgeons

Clinical practice: Blood utilization in cardiac surgery
Outlines standardized pre-operative, peri-operative, and post-operative blood management that reduces the need for and insures the appropriate use of packed red blood cell transfusions in cardiac surgery.

Clinical policy: Safe procedure policy – cardiovascular services
The purpose of this policy is to standardize safe practices to ensure correct patient, correct procedure, and the correct procedure site for procedures performed in the Invasive Cardiovascular Labs including the process for conducting an interactive procedure time out just prior to the onset of procedure.  This policy is consistent with Safe Surgery policy and Counts policy utilized in Surgery and Labor and Delivery areas.

Clinical Policy: Invasive Cardiovascular Services: Sponge, Sharps and Instrument Counts 
This Clinical Policy outlines the count procedure process to be performed in the invasive cardiovascular services procedure area. This process is consistent with the system-wide counts policy utilized in the general operating room.

Clinical practice: Adult Implantable Automatic Cardio-Defibrillators (ICDs)
Outlines screening for eligibility criteria and exclusion criteria to assure evidence-based criteria are met prior to implementation of an ICD in an adult patient.

Clinical practice: Midline sternotomy care for cardiac surgery patients - adult
All adult patients who undergo open heart surgery will be evaluated for primary, secondary, and predisposing risk factors associated with sternal wound complications and/or impact healing of sternotomy site, as well as pre-admission functional status to determine the appropriate level of activity progression.  Activity progression will begin in the inpatient setting and continue to be evaluated and adjusted in the acute rehabilitation and cardiac rehabilitation settings.

Clinical practice: Insulin drip transition post cardiac surgery - adult
All cardiovascular surgery patients receiving IV insulin will be transitioned off the insulin drip to subcutaneous (sc) insulin doses sufficient to maintain blood glucose levels below 200 mg/dL and over 70 mg/dL on post-operative day 1 and 2 (defined as blood glucose closest to 0600).

Clinical Practice: Transitioning post-operative cardiac surgery patients - Adult
It is an expected clinical practice that all adult post-operative cardiac surgical patients will receive a follow up phone call within 48 hours after discharge, be scheduled for physician follow up appointments with cardiologist, cardiothoracic surgeon, and/or primary care physician before discharge and will receive automatic referral and authorization to cardiac rehabilitation to prepare for transition to the next level of care incorporating individual outpatient resources.


Addition for neurosurgeons

Clinical practice: Surgical approaches using vertebroplasty to treat painful vertebral compression fractures - adult
Patients with painful compression fractures (pain level >7 on a Visual Analog Scale (VAS) 1-10) refractory to non-invasive pain intervention(s) applied for reasonable time periods and that interferes with basic activities of daily life (ADLS) may be considered for surgical treatment (Vertebroplasty and Kyphoplasty procedures) in an outpatient setting.  Identification of the medical necessity for the procedure based on Medicare Guidelines, signature, date, and time will be established prior to procedure and documented on a “Medical Necessity Checklist” that is initiated prior to scheduling.

Clinical practice: Using Bone Morphogenic Proteins (BMP) off-label to stimulate bone growth - adult
All adult patients presenting for orthopedic and spine surgery where off-label use of human recombinant bone morphogenic protein (BMP) to augment bone fusion is being considered will be evaluated for appropriate use.  The use of off-label BMP will be tracked at the surgeon level and when three off-label uses occur the cases will be referred for peer review.


Addition for orthopedic surgeons

Clinical practice:  Elective total knee replacement - adult
As part of the Reduce Variation in Orthopedic Care Initiative this clinical practice for adult inpatients receiving elective total knee replacement procedures outlines post op care processes that decrease length of stay and decrease complication rate including early ambulation on the day of surgery (patient out of bed into chair at least one time) and without Foley catheter usage during the hospital stay with few exceptions.

Clinical practice: Use of Continuous Passive Motion (CPM) following total knee arthroplasty
All Banner patients undergoing primary total knee replacement will receive appropriate intervention treatment which will not include the use of CPM (Continuous Passive Motion).  The goal for patients recovering from TKA (total knee arthroplasty) is to regain motion and function during early rehabilitation following a total knee replacement which can be achieved equally as effectively without the use of CPM when a program of active motion, early mobilization and aggressive physical therapy are implemented.  As such it is expected that CPM not be routinely used in any phase of the immediate post-operative period following a total knee replacement.

Clinical practice: Using Bone Morphogenic Proteins (BMP) off-label to stimulate bone growth - adult
All adult patients presenting for orthopedic and spine surgery where off-label use of human recombinant bone morphogenic protein (BMP) to augment bone fusion is being considered will be evaluated for appropriate use.  The use of off-label BMP will be tracked at the surgeon level and when three off-label uses occur the cases will be referred for peer review.

Clinical practice: Use of continuous flow Cold Therapy Units (Cryotherapy Units)
Adult patients who are undergoing Total Knee Arthroplasty (TKA) may receive cryotherapy if requested by their physician; ice packs or ice packs held in place with wrap may be used.  The use of continuous flow Cold Therapy Units (Cryotherapy Units) will not be used.

Clinical practice: Discontinuation of autologous blood use in elective total joint replacement surgery - adult
It is an expected clinical practice that adult patients undergoing elective total joint replacement surgery will not receive pre-operative autologous blood donation in routine elective total joint replacement surgery. It also outlines the expected practice is to optimize hemoglobin pre-operatively with erythropoietin and iron therapy as clinically indicated prior to elective surgery to raise pre-operative hemoglobin levels and minimize the risk for blood transfusions. The expected practice is to use red blood cell saving techniques where appropriate during elective total joint replacement surgical operations to conserve red blood cell volume.

Clinical practice: Surgical indications for major joint replacement - adults
It is an expected clinical practice that all adult patients with hip and/or knee arthosis should initially be managed with non or minimal evasive therapies prior to surgical consideration. Patient treatment plan must support the decision to proceed with total joint replacement (TJR) as appropriate. This clinical practice has been defined but not yet fully implemented.

Clinical practice: Surgical approaches using vertebroplasty to treat painful vertebral compression fractures - adult
Patients with painful compression fractures (pain level >7 on a Visual Analog Scale (VAS) 1-10) refractory to non-invasive pain intervention(s) applied for reasonable time periods and that interferes with basic activities of daily life (ADLS) may be considered for surgical treatment (Vertebroplasty and Kyphoplasty procedures) in an outpatient setting.  Identification of the medical necessity for the procedure based on Medicare Guidelines, signature, date, and time will be established prior to procedure and documented on a “Medical Necessity Checklist” that is initiated prior to scheduling.

Clinical Practice: Management of fragility hip fracture in adults
It is an expected clinical practice that all adults presenting with low energy hip fractures will be medically assessed and complex medical issues addressed to facilitate surgery within 24 hours for non-critical patients. This clinical practice describes a multidisciplinary approach to management of these patients starting in the Emergency Department through post-operative care.


Addition for gynecological surgeons

Clinical practice: Gynecology computer-enhanced robotic surgery
It is an expected clinical practice that all gynecology patients scheduled for a surgical procedure where computer-enhanced robotic approach may be considered, will have their case evaluated based on procedure type, patient co-morbidity, safety, and effectiveness to govern robotic technology usage. This clinical practice has been defined but not yet fully implemented.


Addition for urologic surgeons

Clinical Practice: Urology computer-enhanced robotic surgery 
It is an expected clinical practice that all Urology patients scheduled for a surgical procedure where computer enhanced robotic approach may be considered, will have their case evaluated based on procedure type, patient co-morbidity, safety, and effectiveness to govern robotic technology usage.  This clinical practice has been defined but not yet fully implemented. 


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