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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 drapped 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.
- Provider role in surgical site marking (loaded 10/11)
- Correct patient, correct procedure and correct procedural site/side policy #12705 (loaded 07/12)
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.
- Provider role in safe surgery process (loaded 10/11)
- Safe surgery policy #9542 (loaded 07/12)
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.
- Counts: Sponge, sharp and instrument policy #12688 (loaded 07/12)
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.
- SCIP core measures (loaded 01/13)
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 sepsis 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 hrs of ED admission and within 1 hr 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.
- Sepsis Simple Inpatient Flow (loaded 02/12)
- Severe Sepsis Clinical Practice (loaded 02/12)
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: Central Line Management and Prevention of Vascular Catheter Associated Infections (VCAI) (loaded 02/12)
Clinical practice: Surgical site infection prevention by perioperative decolonization of staphylococcal carriers
- Clinical practice: Surgical site infection prevention by perioperative decolonization of staphylococcal carriers (loaded 03/12)
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: Epoetin clinical practice - adults
- Clinical practice: Epoetin clinical practice - adults (loaded 04/13)
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: Use of medical imaging for diagnosing appendicitis in pediatric patients (loaded 02/12)
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.
- Major bowel surgery strategic initiative executive summary (loaded 10/11)
- Clinical practice: Small/large bowel accelerated surgical care (loaded 02/12)
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 practice: Blood utilization in cardiac surgery (loaded 02/12)
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 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: Adult Implantable Automatic Cardio-Defibrillators (ICDs) (loaded 10/11)
- Clinical practice: ICD - Summary of DOJ NCD false claims investigation (loaded 10/12)
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).
Addition for neurosurgeons
Clinical practice: Surgical approaches using vertebroplasty to treat painful vertebral compression fractures - adult
- Clinical practice: Surgical approaches using vertebroplasty to treat painful vertebral compression fractures - adult (loaded 07/12)
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: Using Bone Morphogenic Proteins (BMP) off-label to stimulate bone growth - adult (loaded 01/13)
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: Elective total knee replacement - adult (loaded 02/12)
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: Use of Continuous Passive Motion (CPM) following total knee arthroplasty (loaded 10/12)
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: Using Bone Morphogenic Proteins (BMP) off-label to stimulate bone growth - adult (loaded 01/13)
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: Discontinuation of autologous blood use in elective total joint replacement surgery - adult (loaded 03/13)
Clinical practice: Blood transfusion in elective total joint replacement surgery - adult
It is an expected clinical practice that adult patients undergoing elective joint replacement surgery who are hemodynamically stable will not routinely receive packed red blood cells when the hemoglobin level is above 7.0 grams/deciliter with few exceptions. It also outlines pre-operative and perioperative assessment and management regarding potential blood transfusion.
- Clinical practice: Blood transfusion in elective total joint replacement surgery - adult (loaded 03/13)
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: Surgical approaches using vertebroplasty to treat painful vertebral compression fractures - adult (loaded 07/12)
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.
