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ANESTHESIA OPERATING ROOM ORIENTATION A guide to help with transition

BETH ISRAEL DEACONESS MEDICAL CENTER

DEPARTMENT OF ANESTHESIA, CRITICAL CARE AND PAIN MEDICINE

Update: 9/16

Anesthesia Operating Room Orientation

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Beth Israel Deaconess Medical Center ........................................................................................... 1

Department of Anesthesia, Critical Care and Pain Medicine ......................................................... 1

Introduction .................................................................................................................................... 4

DAILY WORK FLOW ......................................................................................................................... 4

The Day Before ............................................................................................................................ 4

The Day ........................................................................................................................................ 5

Staffing ........................................................................................................................................ 7

Leaving the OR ............................................................................................................................ 9

Turnover Times ......................................................................................................................... 10

West Campus OR .......................................................................................................................... 11

Pharmacy ................................................................................................................................... 11

Non-medication Supplies .......................................................................................................... 11

Preop holding ............................................................................................................................ 12

EAST CAMPUS OR ......................................................................................................................... 13

Pharmacy ................................................................................................................................... 13

Anesthesia Workrooms ............................................................................................................. 13

Preop holding ............................................................................................................................ 14

East PACU .................................................................................................................................. 14

Postop ICU East (FICU) .............................................................................................................. 14

REMOTE ASSIGNMENTS ................................................................................................................ 15

ECT ............................................................................................................................................. 15

MRI ............................................................................................................................................ 16

EP LAB ........................................................................................................................................ 17

West procedural center (WPC) ................................................................................................. 17

Interventional radiology CT scan ............................................................................................... 18

Interventional Neuro-radiology ................................................................................................ 18

GI ............................................................................................................................................... 18

L3 ............................................................................................................................................... 18

Other Areas and Assignments ...................................................................................................... 20

PACU .......................................................................................................................................... 20

PAIN / Acute Pain Service .......................................................................................................... 20

Pre-anesthesia testing (PAT) ..................................................................................................... 20

Call ................................................................................................................................................. 22


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Responsibilities and workflow .................................................................................................. 22

West call attending ................................................................................................................... 22

East call attending ..................................................................................................................... 23

Relief of late calls ...................................................................................................................... 24

Backup at Night & Weekends: .................................................................................................. 25

FAQs .............................................................................................................................................. 26

How to page if portal is down? ................................................................................................. 26

How to order blood products in the OR? .................................................................................. 26

Stat lab ....................................................................................................................................... 26

Massive transfusion protocol .................................................................................................... 26

Hemodynamically unstable patient in the PACU ...................................................................... 27

Anesthesia STAT or Code Blue .................................................................................................. 27

Code Team ................................................................................................................................. 28

Code Stroke ............................................................................................................................... 28


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INTRODUCTION This document outlines the daily work flow of the operating room. As all institutions differ in their operational methods this is an effort to outline some of the expectations and work rules for the benefit of new staff. This is intended to serve as a guide to facilitate an understanding the institutional culture, minimizing confusion and easing the process of transition. All new hires are invited to read this document. Items in blue are specific to attending staff (MD/DO)

DAILY WORK FLOW

The Day Before

OR schedule and assignment The schedule can be viewed online on the BIDMC portal, and is also posted in east and west campus anesthesia offices. Names of anesthesia providers are listed on the right side of the schedule. The schedule is usually final around 3pm. On rare occasion late changes are made and you should receive a notification by beeper or email.

Many patients have medical history available in the OMR (Online Medical Record – BIDMC Portal under Applications). If they have visited the Pre-Admissions Testing unit, received surgery at BIDMC previously, or have been seen as an inpatient, then a preliminary H&P will be present in their AIMS record. Previous records and PAT records can be seen in the patient’s OMR.

ALWAYS check the weekly schedule to ensure that it is accurate. The daily assignments are made from that information.

It is important to look through the entire schedule as you might be assigned to more than one location.

Check your email for anesthesia alerts. An email alert is sent out to the staff assigned to cases with complex issues such as significant comorbidities, challenging airways, chronic pain, etc.

If there is a matter that needs to be discussed with the surgeon you can page the surgeon or email them.

The residents assigned to the cases will contact you in the evening to discuss the anesthetic plan.

If the assignment is listed at the bottom of the schedule as 'Available East’ or 'Available West, you are not assigned a particular room (reserved for breaks, add-on cases or unexpected changes). Report to the floor manager on the appropriate campus at 7am and they will assign tasks as needed.

If you are missing from the schedule but expected to be working, please call 4-2675 (Molly Bennet) the day before as it could be an error. If there was no assignment, you can expect to report to the west campus OR at 7am the next day and check in with the floor manager.

Inpatient Preops Inpatient preoperative assessments are the responsibility of the resident assigned to the case. If there is an inpatient case assigned to a solo attending or a CRNA, the float resident or the call team often assist by seeing the patient the evening before surgery. In some cases the


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overwhelming number of preops or late additions to the list may result in a patient not being seen or consented. For preoperative assessments seen prior to surgery please look in OMR, under ‘Reports’ and scroll to the Anesthesia tab on the right side of the screen. Previous anesthetic records are also available here.

The Day First case start time is 7:30am (8am on Tuesday and 9:30am on Wednesday). First case start is the time of patient entry into the OR. We have large posters on each campus that detail the ideal timeline of achieving compliance with on time starts. Every effort is made by all OR and periop personnel to achieve this start time. If there is an unexpected delay please inform the floor manager.

OR set up Anesthesia circuit and tray (Laryngoscope with MAC3 blade, ETT tube sizes 7.0 & 7.5, suction cannula, oral airway) are placed in the OR by the anesthesia techs. During the day, they are also responsible for turning over the room at the end of each case. Any additional equipment, if needed, are located in the blue bell cart in the OR and the work room. Please make sure the AIMS record is working. It is a good idea to restart the system in the morning as updates may have taken place overnight. If there are problems with AIMS, the pager number is: 3-AIMS

Holding Area

Colored cards on the chart: When a patient is in the holding area, a colored plastic card will be attached to the front of their chart. This card is a very important visual aid!

A Red card indicates that something is missing and the patient should not be taken to the OR.

A Green card indicates that the nurse has confirmed that all the preop paperwork is complete, the surgical site has been marked by the surgical team, any preop medications if ordered have been administered and finally the operating room equipment is available, as indicated by the “box check” on the computer (The circulating nurse in the OR checks the box when the room has all the surgical equipment that is needed for the case. The box check is not an indicator of room readiness.)

Finally call the operating the room to confirm that they are ready (The list of numbers are available next to the phone on the preop area desk).

** For the first case of the day you do not need to call the OR for readiness, but you should communicate with the room to ensure things are ok before heading back.

Premedications Premeds can be ordered in the holding area through the POE system and the nurses will administer the meds in the holding area. Suggested pathways are available for Ortho and Gyn patients are available on the Anesthesia Intranet under the ‘Clinical’ tab.

Regional anesthesia/analgesia A HARD STOP TIME OUT with the preop nurse is mandatory prior to placing a block/epidural.


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Epidurals and regional blocks are often placed in the holding area. Typically first case epidurals are expected to be placed by the OR team and the regional blocks are performed by the block team (block attending assignment is indicated on the daily call schedule). If needed the block team might be able to help with epidurals in the subsequent cases. This request is initiated by the OR team. An early “heads up” to the block team is essential to avoid delays in turn over.

Communication with the surgical team with regards to the anesthetic plan is important especially if a block or epidural is not previously indicated in the schedule. This can also be discussed with the surgeon the day prior to the surgery especially for the first case to avoid unnecessary confusion and delays. If the surgeon initiates a request for a block this will be indicated on the OR schedule – either on the printed/online schedule or written on the white board.

All consents must be completed before sedating the patient. Incomplete paperwork is usually indicated by signs on the table next to the patient, but it is wise to check for yourself. The family can be asked to wait in the waiting room for procedures. Anesthesiologists are responsible for all sedatives and narcotics for blocks and a-lines in the Preop holding.

Transport the patient to OR: A surgical team member should to be present to transport the patient to the OR but this does not preclude you from going back to the room.

Transport from ICU: If the patient is in the ICU as indicated on the OR board the anesthesia team is required to transport the patient from the ICU with a surgical team member.

Equipment needed for transport

IV bag with Anesthesia tubing (the ICU usually does not have this).

Transport monitor from the work room.

Emergency medications.

If the patient is on multiple pressors some staff find it is easier to transport them with the ICU infusion pumps instead of changing them over to the anesthesia infusion pumps. But switching to the syringe pump is also acceptable.

If the patient is ventilator dependent on high levels of PEEP the respiratory therapist will assist in the transport with an ICU vent. All other patients who do not require special vent settings are transported by the anesthesiologist.

Please inform the floor manager if additional help is required in transport.

Check the consent (most often the Preop and consent are done by the float resident or the ICU team).

Finally call the OR for readiness before leaving the ICU.

Operating room

Room Entry Check In by the circulating nurse (name, date of birth, MR number and surgical procedure is reconfirmed). A member of the surgical team needs to be present at the time of check in.


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Names of all the team members are written on the white board in every OR. The patient can be moved to the OR bed and monitors applied if a surgical team member is not present but do not induce until they are present and have confirmed the procedure.

Hard Stop Time Out A final time out is initiated by the circulating nurse just prior to incision. All personnel are required to stop what they are doing and participate in the time out.

Preparation for the following case starts during the first case. This helps to minimize turn over delays. Approximately half hour prior to end of surgery the next patient is put on call by the circulator. The expectation is to get the next patient ready as efficiently as possible. If the patient is a candidate for block, page the block team to remind them about the patient.

If an attending is working with a CRNA or resident, the attending is expected to help with the Preop preparation whenever possible. If working solo, the floor manager can assign someone to help with the prep (please notify the floor manager when the patient is in holding which will be indicated by color change from grey to blue on the dashboard).

Staffing

Attending Assignment 2 rooms with residents The residents' responsibilities are as follows:

To call or page the attending the previous evening to discuss the anesthetic plan. If for some reason they are unable to reach you can page them to discuss the cases.

OR set up in the morning.

Preop preparation.

IV, A-line, epidural placement. (The attending should be available to supervise and assist).

For subsequent cases the attending is responsible for preops and IV unless arrangements are made with the resident. Other procedures like A-lines, epidural and blocks are performed by the residents with graded supervision. If the attending is in a room the floor manager or block attending can help supervise.

Attending responsibilities: Intraop teaching is an important component of the OR work flow and is highly valued by the department.

Providing constructive feedback. The attendings are expected to save a few minutes at the end of the day to summarize the day’s events: what was done well and where there is room for improvement. An online feedback can also be filled out each day by the residents and attendings. The feedback comments are anonymous and can be viewed online.

Breaks for the residents: Short breaks (15mins) each in the morning and afternoon. Lunch break is 30mins. During resident interview season, or for special events, please try to relieve the resident at the announced time.


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The residents are relieved for lecture at 4:30 pm. If your 2 rooms will be running at 4:30, attempt to relieve one resident for lecture by seeking the assistance of the floor manager.

CRNA’s Our department has several CRNA’s who work both East and West Campus at BIDMC, and at Needham and Milton. Almost all of our CRNA's have practiced both in and outside of the New England area most with many years of experience.

Usually 2-3 CRNAs are assigned to be covered by 1 attending anesthesiologist. As a team, the MD and CRNA are expected to review the cases and anesthetic plans at the beginning of the day or as the day progresses. As presented in the solo room description above, the CRNA should arrive in the prep area around 7am after setting up the operating room, perform the patient assessment, get consent and start the IV. After the first start, H&P’s, consents and IV's should done by the attending, if available. CRNA’s are able to enter postoperative PACU orders as needed in the POE system. We believe in the team model, and this requires good communication to keep the day moving smoothly. The attending is expected to provide breaks during the day: a short (15min) break each in the morning and afternoon and a 30 min lunch break which is usually done between 11am and 2p. Communicate with the floor manager to determine who will backup your other rooms while you are giving a break. If there is time between cases and the CRNA can take their own break or lunch and should let the attending know.

The CRNA day is usually over at 5pm. On very busy days some may be able to help out by staying to finish a case; a discussion with attending or floor manager should occur if this is needed. If the case is expected to finish after 5.30 pm there should be an established plan for relief (unless the nurse agrees to stay, of course).

The CRNAs are part of the late call staffing the OR’s. A plan for their assignment is usually discussed with the on call attending and floor manager.

Chief CRNA: Beth Coolidge (pager #30974)

Nurse Practitioners The department has several nurse practitioners to help with preoperative assessments and IVs, PACU coverage, and to facilitate work flow. The NP’s are assigned to the GI units, the East campus holding areas and PACU, and the West Procedural Center or holding area. The priority of the NP’s is to assist in the patient preparation of attending’s working alone, CRNA’s covered 3:1. They also often help prepare patients for blocks. On the East campus, if you are in a room and need something with a patient in the holding area or PACU, the NP may be a helpful resource.

Anesthesia technicians Dedicated techs are available for each campus (indicated on the pager menu as anesthesia tech west, Shapiro, Feldberg, or Remote). Their primary responsibilities include room turnovers, routine cleaning, delivering supplies during a case, and basic maintenance of equipment. They are best reached by Page via the BIDMC portal.

The code for most anesthesia equipment related lock is 312


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Coverage Times

West campus Mon - Fri 6am-10pm

Weekend Saturday 7am- 3:30 pm

Sunday 3 pm- 9 pm

East Campus Mon -Friday. 6:30 am-7pm

No routine weekend coverage on the east. West tech can be called if needed.

Leaving the OR

Post-Anesthesia Care Unit (PACU) At the end of the case the circulating nurse calls the recovery room for a spot. Once the recovery room confirms a spot, the patient is transported to the PACU. The anesthesia case should, if possible, be closed at the bedside computer in the PACU. A complete sign out is given to the PACU nurse and the PACU anesthesia resident, if present, using the computer or paper printout. The PACU attending can be paged for complex issues.

One copy of the AIMS record is printed and is included in the patient’s chart. A pharmacy report can be printed to return to the pharmacy with the let over narcotics. PACU orders are entered in POE on the computer.

ICU If the patient needs ICU care post op, the circulating nurse in the OR calls the bed facilitator who then assigns an ICU room. If beds are temporarily not available the patient is transferred to the PACU with appropriate monitors (EKG, pulse ox, blood pressure). Please call as soon as you know that the patient needs an ICU bed to give the bed facilitator time to secure a bed.

ICU patient in PACU The trauma ICU attending is primarily responsible for the care of this patient while the in the PACU. A complete sign out is given to the ICU attending (daily call schedule will indicate who is on call). The POE orders are entered by the ICU team in this case.

ICU transport

If the patient has an ICU bed the patient is transported to the assigned ICU with full monitoring.

If patient requires special ventilatory support the respiratory therapist with a ventilator can be called to help with transport.

If the patient requires transport to CT, the respiratory therapist should be informed (by the circulator) to have a ventilator ready in CT scan.

If the patient requires to go to INR (interventional neuro-radiology) the anesthesia tech needs to be notified to set up the ventilator and stock the blue bell with the standard


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anesthesia drug box. Any additional medication (like pressors, etc.) are carried by the anesthesiologist.

Turnover Times Turnover is the time lag between one patient leaving the OR and next patient entering the OR. Every effort is made to minimize delays by efficient use of time and resources. The goal is to keep the turn over time close to 30 minutes if possible. If additional help is required to facilitate this process please inform the floor manager.


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WEST CAMPUS OR The locker rooms are located on the 4th floor of the of the Rosenberg Clinical Center. The operating rooms are located on the 5th Floor. The anesthesia office is located on the 5th floor. Please check the OR White board in the morning to reconfirm your assignment, as schedule changes could occur overnight. The OR staff is notified in advance but sometimes this may be missed. All staff are expected to be present in the OR by 7am, or earlier if more time is required in the Preop.

Pharmacy ***STARTING LATE 2016 OR EARLY 2017, ALL or LOCATIONS WILL HAVE AN OMNICELL MACHINE FOR MEDICATIONS***

From the pharmacy (located in the OR), get either the Standard anesthesia box, or the All-day drug box. These boxes contain non-schedule 2 medications.

Schedule 2 medications are provided in standardized kits and ala carte. Use the pharmacy requisition page to request medications. The ‘major kit’ contains medications that can be used reasonably for most cases. Take one kit at a time for each patient (this is specific to west campus). Any additional controlled substance or any drug that is not in the standard drug box can be dispensed by the pharmacist. These will be documented on the pharmacy requisition sheet (white and yellow carbon copy). The kits are returned with complete documentation and signature to the pharmacy at the end of each case. A copy of the AIMS Pharmacy report is also enclosed.

Antibiotics should be obtained for each case. The hospital guidelines are available online and in each OR.

After hours: All of the medications are retrieved from the Omnicell (located near the anesthesia workroom & opposite OR6). The Kits are returned with the required documentation to the lock box located near the double doors leading to the Trauma ICU (TICU)

Please do not leave the kit unattended at any time

Non-medication Supplies Due to space constraints, the supplies on the West campus are located in several areas.

Holding area The Holding area contains equipment for IV access, arterial lines, epidural placement and regional anesthesia. There are ultrasound machines dedicated to regional anesthesia located here.

OR pods Each OR pod has a central area for equipment. The supplies contained in the Blue Bell cart in the OR room are duplicated here for stocking. If you are missing something in your Blue Bell, or are turning your room over at night, this is the best place to find supplies.


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Workroom Located between OR3 and OR5. This contains the less common supplies, such as CO2 absorbent or inhalational agents, replacement parts for machines, and transport monitors. The airway equipment is located in the hallway outside of the workroom, and should be signed out when taken. And finally, several vascular access ultrasounds are kept in the area or outside the workroom.

Preop holding The patients are ready for anesthesia evaluation and procedures at 7 am. If the patient requires an A-line, epidural, block, they should be ready at 6.45 am (times adjusted for late start days). The patient bay is indicated on the white board to the left of the preop desk. IVs, fluids bags, arterial lines and epidural kits are located at the farther end of the room. Arterial lines, if needed, are placed in the holding area with sterile precautions.

Equipment for blocks, including block carts and ultrasound machines, are available in the preop holding near the double doors leading into the OR. Medications are procured from the Omnicell in the PACU.


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EAST CAMPUS OR The locker rooms are located on the 4th floor of the Feldberg building. The anesthesia office, coffee room and computer room are located there, too. The operating rooms are located on the 3rd Floor of Shapiro or Feldberg buildings and are connected by a bridge – the bridge is considered part of the OR suite areas. For the most part the patients assigned to Feldberg/Shapiro ORs are in their respective holding areas.

Pharmacy Location is in the Feldberg OR next to OR 7 for Feldberg, Shapiro and remote locations.

***STARTING LATE 2016 OR EARLY 2017, ALL LOCATIONS WILL HAVE AN OMNICELL MACHINE FOR MEDICATIONS***

All day narcotic kits are supplied. The pharmacy requisition sheet has multiple lines for patients. If you have more patients than lines, you should obtain a new sheet (don’t just cram in extra lines). Minor kits (narcotic kits for one patient) are available upon request. The kit is returned at the end of the day with the pharmacy documentation and a copy of the AIMS record of every patient. After hours the used kits are deposited in a lock box located next to the pharmacy window. Every OR has a lock box to secure narcotics between and during cases, the keys are provided by the pharmacy and should be returned with the used kit.

The anesthesia box and narcotics for afterhours cases are available in the Omnicell in the OR located adjacent to Feldberg OR 2.

Anesthesia Workrooms There are several workrooms on the East Campus: Feldberg (between Feldberg OR4 and 5(MAIN) and between OR1 and OR2 (MINOR)) and Shapiro (across from Shapiro OR 8). Both workrooms have all of the necessary supplies to stock the Blue Bell in the OR. In addition, each workroom contains:

The Feldberg Workroom:

MH cart

Epidural and spinal kits

Advanced Airway equipment*

Equipment for invasive lines

Level 1 Rapid transfuser

TEE / TTE probe (Minor)

Transport monitors (Minor)

Infusion pumps (Minor)

The Shapiro Workroom

Regional medications and equipment

Advanced Airway equipment*

Multiple types of LMA’s

*Any airway equipment taken from the work room should be written on the white board located behind the door.


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Preop holding

Feldberg The first case of the day for Feldberg OR are located in the Feldberg PACU, the subsequent cases are in the preop holding area. The IV bags and sets are located in a cart outside the Holding area and at the farther end of the PACU for the first case. The IV cannula, tape, etc. are in the blue bell in the holding area.

The epidural kits are located in the work room. Block carts are located in the far end of the PACU.

There are ultrasound machines available in the Shapiro holding area and Feldberg PACU. If any equipment is taken to the OR, or removed from the expected storage space, please notify a tech or the block team.

Shapiro The Shapiro holding contains 8 bays. For the first case starts (and sometimes later), patients will also be prepped in the Phase 2 PACU, as there may be 10 or 11 starts. The location of the patient in holding will be identified on the OR schedule at the desk.

IV and regional anesthesia equipment are kept in the alcove in the middle of the holding area.

East PACU Inpatients are transferred to Feldberg PACU and outpatients to Shapiro PACU irrespective of the OR they were operated in. All outpatient MAC and regional with sedation cases go to phase 2 Shapiro PACU. Shapiro PACU is covered by the east block team during regular hours and the on call attending after 4:30pm. The NP’s can help with care if needed.

The Feldberg PACU is covered by the floor manager during the day and the call attending after 4:30. One NP is often in charge of most Feldberg PACU care. There is no routine overnight nursing coverage for either East PACU. An unstable patient will be transferred to the FICU (4th floor) or the on-call PACU nursing team will remain.

Close communication between anesthesia attending and the surgical team is important prior to transferring the patient to the ICU or making any significant change is the treatment plan.

Postop ICU East (FICU) If the patient needs ICU care have the nurse contact the bed facilitator early. Sign out the patient to the ICU team (FICU located on the 4th floor). The flowchart for care of patients is displayed prominently in the Feldberg PACU


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REMOTE ASSIGNMENTS

ECT Location: Deaconess building 2nd floor

Work flow Omnicell in the procedural location for all medications.

Occasionally, the first patient of the day may be in the PACU if they are particularly challenging (e.g. known difficult airway, severe cardiac disease), but typically you should proceed to the ECT clinic on Deaconess 2. This can be accessed from the Farr Building; take the elevators to Farr 2, enter the patient floor on Farr 2, take a right down the hallway, and go through the double doors at the end. Follow the hallway to the left and then the right, and the entrance to the clinic will be straight ahead.

One of our own RN’s, Peguy Philemon, is almost always there to assist us on ECT days. He will typically start all the IVs, bag-mask the patients, and can also enter information in the computer and assist with medications if needed. The nurses in ECT should also be very helpful to orient you in the clinic.

There are 4 patient bays and each bay has its own computer for AIMS. We start at the right-most bay and proceed through the first four patients, then come back to the first bay and repeat until all the patients have been treated. Most patients will have been previously treated, so take a look at the previous anesthetic record for medications that were given. Sometimes Dr. Bloomingdale (ECT psychiatrist) will request a lower dose of methohexital if the seizure length was not adequate during the previous treatment. For new patients, the typical starting dose is 1mg/kg of methohexital and the same for sux.

Many patients receive zofran and ketorolac pre-procedure for prophylaxis of nausea and headache/muscle aches.

Induce with methohexital and sux.

Hyperventilate with ambu bag.

Place bite block after fasciculations.

Continue to hyperventilate during stimulus and seizure - hyperventilate until 20 secs for unilateral stimulus, 10 secs for bilateral (that's what they want for minimum seizure length).

Some patients get propofol after the seizure to manage post-ictal agitation.

Some patients receive labetalol,esmolol or occasionally hydralazine for treatment of hypertension and/or tachycardia.

Manage the airway until they breathe on their own and transition to simple face mask.

Remember to fill out the post anesthesia note.

Print record to nursing station printer.

Close out Omnicell at the end of the day.

Anesthesia director: TBD


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MRI MRI is located in the West campus basement in the hallway between the Clinical Center and the Farr building. There is no MRI compatible equipment on the East campus. You can take the elevators next to the Anesthesia Fishbowl and go all the way down to the basement, turn left, then take the long hallway on the right. The MRI area will be on the left towards the end of this hallway. Enter in the patient reception area because our ID swipe cards do not work down there. The secretary will let you in. Once they let you in, they will bring you to the MRI suite where you will be working.

Setup The MRI suites are set up, so that the MRI machine is in one room with an observation room right outside. You may choose to sit inside the MRI room or inside the observation room. Most people will sit in the observation room because there is a table for you with a view of the MRI machine and there is a monitor (without sound) that is right in front of you.

We have one MRI-compatible anesthesia ventilator, a Blue Bell, and an MRI-compatible infusion pump. The anesthesia tech will set up the ventilator during the day. Off hours, the MRI compatible anesthesia machine is in a closet (the radiology tech is usually helpful) and there is a fully stocked blue bell. The anesthesia machine can go in the room, the blue bell must stay outside the room. The MRI techs will place the monitors on the patient and the monitor in the room sends the information (without sound) to the screen in the observation room.

Preparation West Campus OR Pharmacy: You will need to bring a drug box, narcotics and any other medications you may need down to MRI. If you need any special airway equipment (McGrath, Glidescope) you will need to bring it with you. If you are using non-MRI compatible equipment (McGrath/GS), you will have to intubate in the hallway and bag mask the patient until they are in the MRI room. There are LMAs stocked in the Blue Bell. There should be paper anesthesia records, but in case you can't find them, bring one down. If you are setting the room up yourself, you will need extension tubing for the circuit. You can choose to intubate the patient in the PACU if the patient has a challenging airway.

Your patient should be in the regular preop area for consent and IV placement. Once they are ready for you, you will take the patient down to the MRI suite. Just outside the room with the MRI, the patient will be transferred from the regular stretcher to the MRI compatible stretcher. The patient will be wheeled into the MRI room and placed on the MRI table. If you want to intubate, you can do that in the room on the stretcher or on the MRI table (as long as you are using MRI-compatible equipment).

Important notes:

If you're sitting in the observation room, you will not have minimal benefit of sound - SpO2 decreasing, patient screaming, etc. are on a speaker and may not be audible if the speaker is muted.

You will use a paper record (White copy stays in the chart, yellow copy goes on Laura's desk, pink copy goes to pharmacy, goldenrod copy is trash)


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EtCO2 defaults to a number that is NOT mmHg, but % - it is possible to change it, but somewhat counterintuitive. You will see a tracing whether you get a % or mmHg.

If you anticipate a difficult airway and are planning a GETA, discuss with the floor manager or nurses about possibly intubating in the PACU on the 5th floor (away from other preop patients) and bringing the patient to MRI intubated.

Be sure to leave your credit cards and anything metal in your locker prior to heading down there!

Anesthesia Director: Leo Tsay pager #38823

EP LAB Location: 4th floor Farr building west campus

Commonly performed procedures: PVIs, AFIB and VFIB ablations. Anesthetics mostly general with ETT with jet ventilation in some cases. Occasional MAC

Preop The holding area is near the procedure rooms

OR West Campus OR Pharmacy: obtain major kit and standard anesthesia box.

Anesthesia equipment available: standard OR set up with glidescope.

AIMS record is available. Paper records are available in the machine drawer as a backup.

Lead aprons available for anesthesiologist are colored Yellow

Patients receiving GA recover in the OR PACU post op, use full monitors for transport

Anesthesia Director: Qi Ott pager #39791

West procedural center (WPC) Location: Farr building first floor next to the lobby (West campus)

Cases done are primarily GI endoscopies under MAC. Other procedures are less common. If GA is needed, TIVA with propofol for maintenance (Scavenging system is not up and running).

Equipment available: Standard anesthesia equipment with glidescope

Patients are brought to the holding area in the WPC. Some days a nurse practitioner is available to assist with IVs and preop assessments.

Patients recover in the WPC unless they have received general anesthesia. In that case they recover in the PACU.

West Campus OR Pharmacy: all day narcotic kit with ketamine or dexmedetomidine, and desired, standard anesthesia box.

Anesthesia Director: Adam Lerner pager #32758


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Interventional radiology CT scan Location: 3rd floor of the Clinical center (west campus)

Standard anesthesia equipment and lead aprons are available

West Campus OR Pharmacy: Major kit and standard anesthesia box with phenylephrine, nitroglycerine, labetalol.

Page the anesthesia tech west to connect the anesthesia machine and start AIMS record. They can help set up additional equipment like transducer, airway carts etc., upon request.

Preop patient in the west OR holding area.

Transport patient to IR suite with personnel from IR

Majority of the patients transfer to the ICU after the procedure with full monitoring


Interventional Neuro-radiology Location: Adjacent to the IR suite in clinical center 3rd floor west campus

Procedures: Cerebral aneurysm coiling, carotid stenting

Standard anesthesia equipment, AIMS, lead aprons are available

Preparation: Page anesthesia tech west to set up the machine and any additional monitors or airway equipment you might require.

West Campus OR Pharmacy: Standard anesthesia box, major narcotic Kit (single patient), vasodilators/Vasoconstrictors, etc.

*Majority of the patients transfer to the ICU after the procedure with full monitoring

Anesthesia Director: Dustin Boone pager #39714

GI Orientation packet available prior to you starting there.

Anesthesia Director: Eswar Sundar pager #38341

L3 Location: East campus 3rd floor Gryzmish building (301)

Procedures: PTC, percutaneous nephrostomy tubes, embolization.

Standard anesthesia equipment and AIMS

During regular hours anesthesia tech (east) will set up the anesthesia machine


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After hours the anesthesia machine and blue bell is stored in a room next to the suite and has to be transported and connected to the air supply manifold in the procedure suite

Reminder the scavenger needs to be turned on

East campus OR Pharmacy: Major kit (Single patient): Standard anesthesia drug box, vasopressors as needed

Preop patient in L3 suite

Patient recovers in the PACU post procedure



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OTHER AREAS AND ASSIGNMENTS

PACU West campus PACU attending is responsible for all the patients in the PACU. This assignment is in addition to other OR duties.

Duties and expectations

Receive a PACU sign out from the anesthesia attending on call the previous night.

Round on the patients with the PACU resident at least twice a day

Didactics: Part of the responsibility is to teach the PACU resident

At 4:30pm, the PACU is signed out to the on call attending.

On the east campus the regional block attending and floor manager are responsible for the PACU during the day. There is no PACU resident on call after hours.

PAIN / Acute Pain Service APS covers all patients who have an epidural or indwelling nerve catheter. Additionally APS covers all non-OB patients who have received intrathecal narcotic for the first 24 hours after injection and all peri-operative acute pain consults for medication management.

Epidural kits are located in the holding areas as are dressing supplies. Epidurals are generally placed in the holding area before going into the OR. If you place an epidural please notify the APS resident (3-PAIN).

Epidural pumps and tubing are located in the East and West campus PACUs. Premixed epidural solution (bupivacaine 0.1% + hydromorphone or fentanyl) are located in the respective OR pharmacies.

Meghan Connolly is the dedicated nurse practitioner for the service. Feel free to contact her (pager #39772)

Orders If a patient has an epidural catheter in place all analgesic/sedative orders must originate with the APS team. If a patient has a peripheral nerve catheter in place the primary team is responsible for managing analgesia orders. APS is responsible only for the peripheral catheter infusion orders.

Anesthesia Director: Marc Shnider pager #31156

Pre-anesthesia testing (PAT) The type of preoperative testing performed at the BIDMC is dependent on the patient and the surgeon. The Preadmission Testing Clinic (PAT) clinic has been recently remodeled and is located on the first floor of the East Campus Feldberg Building.


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There is NO ‘routine’ or ‘age based’ testing – T&S is performed according to the type of surgery. All preoperative tests are either ordered by the surgeon or by the anesthesia team, as needed. Routine preoperative labs have not been shown to improve outcome of surgical patients and excess testing is discouraged.

All scheduled patients will receive a phone call from a PAT nurse who confirm surgery and date, medications, allergies and medical history with the patient. The complete nursing assessment streamlines the holding area throughput on the day of surgery. The pre-anesthesia evaluation for a patient not seen in the clinic is completed in the holding area.

There is one anesthesiologist assigned to the clinic per day – the Anesthesia MD serves as a consultant to the NPs – answering questions about further testing and readiness for surgery, the MD also reviews the waived patients. CA1 residents rotate through the clinic for 2 weeks at a time– as part of a combined PAT / PACU month. Dr. Brendan Garry is our primary ‘PAT attending’. He works only in the clinic on Wed –Fridays; he has many years of experience in anesthesiology and expertise in preoperative medicine. On Mondays, Tuesdays and when Dr Garry is on vacation there are a small number of attendings rotate through the PAT clinic.

Anesthesia Director: Eswar Sundar pager #38341


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CALL

Responsibilities and workflow Late call staff start the day at 7am, and will be relieved in order of their call number. For overnight staff (West, East, OB) the OR reporting time is 4:30pm on both campuses, and 7am on weekends/holidays). The floor manager signs out the OR, Code pager and PACU to the on call attending.

Duties include:

Managing the floor by assigning cases and staff. This is usually based on the sequence in which they were booked, and the urgency of the case. All decisions are made in conjunction with the nurse in charge. Add on cases are labelled by the urgency (A through E) and the time it was booked. The cases assigned to remote locations get equal importance in terms of personnel allocation.

Cover the on-call residents and late CRNA’s. Each attending can cover 3 CRNAs or 2 residents at a time.

Relieve the non-call attendings and residents using late attendings, late CRNA and late residents.

Provide dinner breaks to the overnight residents and late attendings (on the west the float can help provide dinner breaks when he/she arrives from the east).

Manage PACU patients.

Covering intubations and codes.

Ensure preops for the next day have been seen.

West call attending PACU sign out from the PACU attending. The PACU resident stays after hours until relieved

by the float resident (usually by 8pm) or the on call team if the west OR is not busy. The PACU resident’s responsibility is to take care of post op patients in the PACU. As much as possible, they are not given any additional responsibilities which might take them away from their duties in the PACU (e.g. starting non emergent cases in the OR, or giving breaks, etc.). It is the PACU resident’s responsibility to ensure trauma room is set up for emergencies. A note is required on every patient in the PACU before sign out in the morning. ICU patients “boarders” in the PACU are covered by Trauma ICU attending

All cases that are being assigned to the East campus after hours or on the weekends should be reviewed by the West call attending. Avoid double booking cases on the East on the Weekends (e.g. simultaneous cases on GI4 and Feldberg OR) as there is only one on call staff. Patients who are in the Emergency Room should not be sent East if they are unstable or otherwise emergent.

Preops: the overnight call team is responsible for the preops for the add on cases for the next day

The float resident is relieved by the on call team when the on call attending decides that that the on call team can safely take responsibility of the PACU patients.


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The post op checks for the post op ICU patients are completed by the on call residents on the weekend.

Late 5 attending gets the following day off. The other late attendings get the next day off if they are relieved after midnight. Similarly, if the liver or heart team has been working after midnight they get the next day off. In that case it is the responsibility of the West call attending to assign coverage for the vacated location.

Coverage needs to be found for sick calls. The new assignment should be communicated to the attendings and the floor manager in the morning.

There are patients who belong to IP and orthopedic services and are admitted for overnight observation under the care of a hospitalist. The patient is however in the anesthesia attending's care as long as they are in the PACU. The POE orders are written by anesthesia team on call. An attending to attending sign out is given to the hospitalist on call prior to transferring care.

Complex chronic pain issues are referred to Acute Pain Service if the need arises (APS resident on call is paged and notified).

The floor is signed out to the floor manager at 7 am the next day except on Tuesdays (7:30am) and Wednesdays (9am). The east call attending can attend the grand rounds in the morning.

The junior resident on the west campus is relieved by the on call resident for the day at 7 AM (this is done to maintain compliance with the duty hours limit mandated by ACGME)

West call weekend

Saturday, Sunday, Holidays

24-hour call starting at 7am

There are 2 residents on call

Typically there are 2 ORs to start at 7:30am. You could run a third room or remote location by calling in the moonlighter (CA3/fellow).

Late 3 is called if there are 3 rooms running and there is an urgent case to be started, or depending on the complexity of the case and the ability of the attending to cover a third OR.

If the moonlighter and late 3 are in rooms and an emergent case needs to be started the ICU attending can be requested to help out until other back up teams are called in (heart call/liver call /APS resident).

There is no PACU resident on call on weekends.

The other duties are similar to weekday calls.

BACKUP call: Late 3

ICU attending is available in house for urgent help if needed.

East call attending Similar to west call in terms of work flow and duties with some key differences.


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There is no PACU resident on call. The PACU patients are covered by the east on call attending. The regional attending and East floor manager are responsible for the PACU during the day.

Floor manager sign out includes Feld and Shapiro OR’s, GI and any remote locations. On a given day there are 2-3 remote locations operational on the east with 4-5 anesthesia personnel. Some of them might not be late call attendings and would require relief.

The codes are covered by anesthesia and OB attending on call. Please remember to notify the OB attending if you are working solo and will not be able to cover the codes. At the end of the call return the pager to the Feldberg 4th floor office desk in anesthesia office.

On weekdays hand over the pager to the floor manager.

East call weekend

This is a beeper call (7am-7am). The west call secretary will page you if there are any cases assigned to the east campus including GI. It is a good idea to check the schedule the night before, as sometimes the desk forgets to call. They also informs the OR staff and PACU nurses. PACU nurses are called in for all OR cases and for GI cases requiring general anesthesia.

ICU patients coming from the ICU are transferred by the anesthesiologist with full monitoring to the OR and recover in the ICU post op.

There are no anesthesia techs on call on the weekends. The anesthesia attendings are responsible for setting up and turning the rooms.

Narcotic (major kit) and standard anesthesia box is available in the omnicell.

At the end of the case the major kits are returned to the lock box next to the pharmacy window. The drug box is returned to the omnicell under used AA kits.

Relief of late calls All non-call attendings, CRNA and residents should be relieved before sending any on-call staff home.

Late 1-5, late residents all get relieved in order of number, lowest to highest. Late 1 and Late 2 are Campus-dependent. If there are day (non-call) people still working on the other campus, consider sending a higher numbered call staff (e.g. Late 3-5) across the street to relieve, instead of first sending Late 1 or Late 2 home.

The on-call CRNA is listed as LATE 1.5 and is to be relieved between the late 1 and late 2 attending. There is also a 7-7 CRNA, referred to as Late CRNA. They should get relieved by 7pm.

Please be in close and immediate contact with your counterpart across the street when staff are freed so they can be properly relieved. Judgment needs to be used as it may not make sense to have a higher call cross the street to relieve a lower call whose case is finishing imminently. Also, when requested to cross the street please do so as soon as possible, without changing, or driving or eating unless previously discussed


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With the exception of the float resident, the East call residents do not cross the street to the West. Once relieved they go home and do not get called back. Every effort should be made to relieve the residents before 9pm, as the duty hour restrictions will prevent them from working the next morning. If it is expected that 2 rooms will be running after 9pm, the East call attending and another late attending should relieve residents in order to allow for sufficient resident rest between shifts. ACGME requirements state there should be at least 8 hours between shifts, ideally 10 hours. Please notify the OB team to cover codes and the PACU when East OR attending is unavailable in an OR.

On the East campus the staff should make every attempt to cover 2 late residents. When there is an extra room, one late call attending should be solo. Remember to consider the GI unit in the late call coverage.

Float resident Float resident is assigned for a week at a time, running from noon to 8 to 10pm. Float reports to the east campus floor manager where they are assigned (usually to help with lunch breaks). Float is relieved as the late first resident on the East and goes to the West. Float is responsible for preops of in-house and add-on cases for the next day. Other duties are giving dinner breaks to west campus overnight personnel and relieving the PACU resident. The float is relieved to go home when the West PACU is stable or when the OR is able to cover, at the discretion of the West call attending. Float should very, very rarely be kept beyond 10pm.

Backup at Night & Weekends:

Backup West On weekdays the late 5 attending is the backup for any cases or issues that arise after everyone is relieved. The late 5 attending has the next day off to ensure this minimally disrupts everyone. While late 5 is still in an OR, late 3 is backup. On weekends and holidays it is the Late 3 attending who serves as a backup for both campuses. The ICU attending in-house may be an anesthesiologist, and can help in short-term emergent situations.

Backup East Late 3 attending can be called in if there is an urgent case that needs to start soon while you are in the OR with another case. OB team might be available if a second pair of hands is needed urgently depending on the acuity of the cases on the OB floor.


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FAQS

How to page if portal is down? 123-pager number-call back number

Updated paging list is available at all anesthesia locations.

From outside the hospital, call 617-632-7243, followed by the pager number.

How to order blood products in the OR? If the patient has a type and cross, the circulator will call the blood bank to send the required products. The front desk sends a personnel to the blood bank with a cooler. If products are required urgently, blood bank can send it via the pneumatic tube.

Phone:

43300 west campus

74480 east campus

Type and screen: Blood sample with a green requisition slip. It is absolutely essential to sign the date and time the sample, requisition slip and the label. Two samples and paper slips are needed for type and cross for patients. If there is a historical T&S from a previous admission, only one new sample is needed. For patients who are new to the system, two samples with two slips are required. The standard cases requirements for a type and screen or cross match it is indicated in the OR schedule.

Stat lab Phone:

West 4-3230

East 7-5228

Draw the sample and fill out the pink sheet housed in the top shelf of the blue bell. The sheet and sample should have the patients label with signature date and time. The OR call back number should be included in the sheet. The circulating nurse can send the sample to the stat lab.

*The laboratory requisition sheet is required for coags and other labs.

For the Preop holding the orders are entered in the POE.

Massive transfusion protocol We have a standardized Massive Transfusion Protocol (MTP) that should be used for large volume transfusions. This should be triggered when there is significant intraop bleeding or there is expectation of significant blood loss in a very short period of time (e.g. a trauma or


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ruptured AAA coming up from the ED). The blood bank notifies the STAT lab, and begins automatic preparation of coolers for blood products. The blood bank will automatically send blood products to the OR until the transfusion protocol is cancelled. YOU MUST CANCEL THE MTP ASAP WHEN NOT NEEDED. Anyone, including you, the circulating nurse or the secretary at the front desk call the blood bank and request to initiate or cancel the massive transfusion protocol. The current ratio of products is 4 rbc in the initial cooler, followed by a 8:4:1 ratio of rbc:ffp:plt. Cryoprecipitate will also be sent at intervals when available.

The blood bank has requested that communication during a MTP be limited to essential calls only, as extra phone conversations and requests for extra products obstruct their work and slow the process of delivery. All MTP cases are reviewed by the director of the blood bank and the OR.

Hemodynamically unstable patient in the PACU Inform the PACU attending /floor manager

After hours ICU attending can be consulted on the west campus.

On the east campus OB attending is in house and can provide assistance. Vice versa, the east campus attending on call can be summoned to help in OB.

If TEE/TTE is required, Cardiac anesthesiologists are available on the West campus during regular hours. Cardiology is called on the East campus for consult.

STEMI protocol can be viewed in the portal.

Anesthesia STAT or Code Blue When there is an emergency and help is required:

Ask the circulator to call anesthesia stat overhead

The anesthesia phone has a button for anesthesia stat

In the rare occasion when a code is to be called, the number is 21212 or tell the nurse to call a code blue. The hospital code team will arrive. The team leader in this situation can be the attending anesthesiologist or the medicine resident as is normally the case with all non-OR codes. This is left to the discussion between the attending anesthesiologist and the responders.

WEST: A red code button is located in each OR which can be used as well (This is a very unlikely event as ample help is available during the day and ICU attending is available as back up after hours).

East: Two phone numbers are required to reach all locations – one covers the OR locations and the second covers the holding and PACU areas. Codes during the day will go out as an overhead AND on the code pager (2-1212) as ANESTHESIA STAT to the location. After hours, codes are called via the code pager (2-1212) and the whole code team will respond.


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GI/WPC: Both codes and Anesthesia STAT should be called over the code pager (2-1212)

Code Team When a code is called the pagers specify the location. The floor manager during regular hours and anesthesia attending on call after 4:30 pm responds to all code blue and anesthesia STAT pages. All anesthesia personnel on overnight call are expected to carry the code pagers and respond to codes.

Anesthesia STAT pages are initiated throughout the hospital when a patient requires urgent or emergent intubation. The ICU team might page the attending on call directly for urgent intubations. The OR attending can also be consulted on airway related issues in the ICU. The ED takes care of their intubations but can call for help if they have a difficult airway or need help with airway management.

Glidescopes and airway carts are present in most ICUs but PLEASE CONFIRM their availability prior to challenging intubation.

Back up: ICU attending on the west campus (sometimes the ICU attending on call is not an anesthesiologist) and the OB attending on the east.

If the patient requires a surgical airway the ACS trauma attending is via the STAT line (2-1212)

Code Stroke This indicates that a stroke patient is en route to the ED and the anesthesia attending’s responsibility is to ensure that the INR suite is ready and there are personnel available to start the case if the need arises.

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