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Disaster Plan for Surgery – Surgical Services

Saint Joseph Regional Medical Center – South Bend/Mishawaka

SURGICAL SERVICES

TITLE: DISASTER PLAN FOR SURGERY POLICY: 1. Surgical Services shall have a plan of action in the event of a disaster. RESPONSIBLE ASSOCIATES: Surgical Services associates and anesthesia staff

GUIDELINES: A. During the hospital wide Disaster Phase 2 (Preparation Phase), the Director of Surgical

Services or designee shall: 1) Communicate with the chairperson of Surgical Services regarding the casualties. 2) Initiate a call plan as needed. 3) Maintain communication between the operating room and the other departments within

the facility, including other surgical services directors, managers, and supervisors. 4) Notify surgeons as necessary. 5) Designate a surgeon to categorize and triage casualties arriving in the operating room. 6) Assign staff to work phones, maintain supplies, assist in record keeping and request

dietary supplements as necessary. 7) Coordinate the disaster activities for the operating room and maintain direct contact with

triage area by telephone. B. During the hospital wide Disaster Phase 3 (Transportation of Victims), the Director of

Surgical Services or designee shall: 1) Discuss with the Chief of Surgery and Anesthesia the cancellation of elective surgeries

and notify surgeons with cases in progress that surgery should be completed as quickly as possible.

C. During the hospital wide Disaster Phase 2 (Preparation Phase), the Chairperson of Anesthesia or designee shall: 1) Communicate with the Director of Surgical Services or designee and develop a plan to

call in and assign anesthesia personnel as needed. 2) Designate a person to assign anesthesia personnel to evaluate casualties prior to surgery. 3) Coordinate activities with the laboratories and blood bank. 4) On-call anesthesiologist shall coordinate activities on off hours until chairperson is

present.

Saint Joseph Regional Medical Center Policy/Procedures Effective Date: May 2008 Disaster Plan for Surgery – continued of 2

Disaster Plan for Surgery – Surgical Services

5) Anesthesia providers at Mishawaka and Edison Lakes ambulatory center shall coordinate disaster activities for those facilities.

D. During the hospital wide Disaster Phase 2 (Preparation Phase), the Department Manager/Supervisor/ or designee shall: 1) Assume the responsibilities of the Director of Surgical Services in his/her absence. 2) Communicate with the Director of Surgical Services and Chairperson of anesthesia to

assess the need for Surgical Services personnel. 3) Initiate call plan for additional staffing as needed. 4) Make assignments as staff becomes available. Oversee staffing needs; assess need for

staffing from other SJRMC facilities. 5) Assign surgical services staff to check levels of supplies/instruments, medications, and

obtain needed items. 6) Assign surgical services staff to prepare operating rooms for anticipated surgeries. 7) Assign ancillary staff to stock supplies, obtain blood, transport patients and perform other

duties as necessary. E. During the hospital wide Disaster Phase 3 (Transportation of Victims), the Department

Manager/Supervisor/ or designee shall: 1) Assess for staffing relief as necessary. (consideration for food and rest)

F. During the hospital wide Disaster Phase 2 (Preparation Phase), the Director of ADU/PACU or designee shall: 1) Assess the need for Post Anesthesia Care Unit personnel and for intensive care unit beds,

confer with the chairperson of surgery and anesthesia regarding transfer of patients to theses areas.

G. Surgical services staff shall: 1) Remain in their work areas to be available for arriving patients. 2) Perform work duties as assigned. 3) Keep phone lines open. 4) Utilize ancillary staff to obtain needed supplies and services. 5) Remove any unnecessary clutter from the area. 6) Ensure emergency equipment is ready and available. 7) Remain calm and work as quietly and efficiently as possible. 8) Provide support to patients, families and staff.

Original Date: January 2005 Reviewed Date: Revision Date: May 2008 Effective Date: May 2008 Approved by: System Chief Nursing Officer

Fire Safety and Evacuation Plan for Surgery – Surgical Services

Saint Joseph Regional Medical Center – South Bend/Edison Lakes

SURGICAL SERVICES

TITLE: FIRE SAFETY AND EVACUATION PLAN FOR SURGERY POLICY: 1. Safe practices will be followed by all associates for the prevention of fires, the reduction of the

spread of fire, and safe evacuation of patients and staff RESPONSIBLE ASSOCIATES: Surgical Services Associates

GUIDELINES: Responsibilities of personnel during a fire in Surgery at SJRMC. A. ANYONE discovering smoke or fire will immediately notify the Manager/charge nurse and

will follow the fire response protocol R.A.C.E. 1) Rescue 2) Alarm – pull nearest fire alarm, call and report fire (Code F)

a) South Bend – 55555 b) Edison Lakes – 0555 One staff member will stay on the phone to the operator and another staff member will Call the Center Core to report the fire. The Manager/charge nurse will send a staff member from the Center Core to pull the Fire Alarm nearest to the room where the fire is located.

3) Contain – if possible, place wet towels at the base of the doors 4) Extinguish – if possible and Evacuate the Operating Room

B. Roles of the surgical team 1) The Surgeon should

a) Remove from the patient materials that may be on fire and help put out the fire; b) Control bleeding and prepare the patient for evacuation if necessary; c) Conclude the procedure as soon as possible; d) Place sterile towels or covers over the surgical site; and e) If the patient is no in immediate danger, help move the patient if necessary.

2) The anesthesia care provider should a) Shut off the flow of oxygen/nitrous oxide to the patient or field and maintain

breathing for the patient with a valve mask respirator (ie ambu bag);

Saint Joseph Regional Medical Center Policy/Procedures Effective Date: May 2008 FIRE SAFETY AND EVACUATION PLAN FOR SURGERY– continued Page 2 of 4


b) Collaborate with the circulating nurse on the need to turn off the medical gas shutoff valves;

(1) At SJRMC-SB – The surgery staff will be responsible for the medical gas valves located outside the room. They will communicate with the anesthesia care provider, surgeon and other members of the staff as necessary before shutting the valves off.

(2) At Edison Lakes – A designated staff member, in conjunction with the anesthesia care provider and surgeon, will be responsible for the medical gas shut off valves located outside each room.

c) Disconnect all electrically powered equipment on the anesthesia machine; d) Disconnect any leads, lines, or other equipment that may be anchoring the patient to

the area; e) Maintain the patient’s anesthetic state and collect the necessary medications to

continue anesthesia during transport; and f) Place additional IV fluids on the bed for transport with the patient, if time permits.

3) The scrub person should a) Remove from the patient materials that may be on fire and help put out the fire; b) Assist with the conclusion of the procedure if possible; c) Obtain sterile towels or covers for the surgical site and instruments; d) Gather a minimal number of instruments onto a tray or basin and place them with the

patient for transport; and e) Assist with patient transfer from the OR table to a stretcher/bed for transport out of

the OR. 4) The perioperative RN circulating should

a) Ensure the patient’s safety by remaining with him or her and comforting him or her; b) Activate the fire alarm system and call the fire code to alert all necessary personnel; c) Extinguish small fires or douse them with liquid if appropriate; d) Remove any burning material from the patient or sterile field, and extinguish it on the

floor; e) Prevent fire from spreading to shoes or surgical clothing by not stepping on it; f) Provide the scrub person and anesthesia care provider with needed supplies; g) Collaborate with the anesthesia care provider on the need to turn off the medical gas

shutoff valve; h) Carefully unplug all equipment if the fire is electrical; i) Be aware of the safest route for escape; j) Obtain a transport stretcher if necessary; k) Remove IV solutions from poles and place them with the patient for transporting out

of the OR;



l) Help the anesthesia care provider disconnect any leads, lines, or other equipment that may be needed for transporting the patient; and

m) Not delay leaving the OR suite. 5) The perioperative registered nurse in charge/designee should

a) Notify the safety officer, telephone operator, or designated person of a fire and its location;

b) Document the time the fire started; c) Determine how many people are in the department and account for everyone;

(1) May want to assign a staff member to check each room . d) Set up a communication point and identify a person to staff it;

(1) This person will assist with facilitating the flow of communication as people come and go through the surgery department including the Fire Department.

e) Determine the state of ongoing surgery/procedures in each area f) Consult with the anesthesia care provider in charge on how to handle each patient; g) Assign personnel to assist where needed h) Ask visitors to leave if necessary; and i) Notify PACU staff of possible evacuation of the operating rooms and evacuate

patients who may need to be moved immediately. PACU is the designated area for evacuation of patients. If PACU is blocked an alternative area will be designated.

6) Ancillary personnel should (i.e. specialty techs, SPD techs) a) Help clear corridors for evacuation; b) Secure equipment for transporting the patient as directed by the circulating nurse c) Help prepare a safe area to transfer patients to, if this is needed; d) Follow instructions for evacuating the patient if needed; and e) Assist where directed.

7) People and patients should be evacuated to a safe area through at least two fire doors. The last person through the doors shall close the door to contain the fire and lay a moistened towel across the base of the door.

8) When necessary, the surgical team will return to a safe operating room to complete the surgical procedure.

9) When there is no immediate danger, the surgical team will continue the procedure and “defend in place” awaiting further instructions. Moisten towels may be needed to place at the bottom of the doors.

10) After a fire, everything should be left in place so the safety officer and the fire department can conduct a thorough investigation of the cause of the fire.

C. Fire Safety Education 1) All associates will do an annual departmental fire safety competency review, including

evacuation procedures/ 2) Periodic evacuation fire drills will be conducted in the department.



3) Healthcare Industry personnel and students shall be included in fire safety education. This shall include location of fire extinguishers and fire alarm pull downs.

REFERENCES/STANDARDS:

• 2008 Perioperative Standards and Recommended Practices, Association of periOperative Registered Nurses, Inc., Denver, CO, 2008.

Original Date: November 2004 Reviewed Date: November 2005 Revision Date: May 2008 Effective Date: May 2008 Approved by: System Chief Nursing Officer

Malignant Hyperthermia Crisis – Surgical Services

Saint Joseph Regional Medical Center – South Bend/Mishawaka/Edison Lakes

SURGICAL SERVICES

TITLE: MALIGNANT HYPERTHERMIA CRISIS POLICY: 1. Registered nurses, licensed practical nurses and the surgical technologists in the Surgical Services

Department shall be knowledgeable about malignant hyperthermia. Anesthesiologists shall manage the patient in a malignant hyperthermia crisis and the perioperative nursing team shall assist the anesthesiologist during a malignant hyperthermia crisis.

RESPONSIBLE ASSOCIATES: Surgical Associates

GUIDELINES: A. Suggested M.H.A.U.S. (Malignant Hyperthermia Association of the United States) protocol

for malignant hyperthermia management shall be available in the surgical services department. 1) This protocol may not apply to every patient and out of necessity must be altered

according to specific patient needs. B. The malignant hyperthermia hotline phone number shall be available in the departments. C. Malignant hyperthermia crisis supplies shall be available in the department.

1) Supplies shall include but not limited to: a) Drugs: Dantrium (Dantrolene) x 36 vials at SJRMC-M and SB, x 18 vials at ELMC,

Sterile water for mixing Dantrium, Sodium Bicarbonate, Furosemide, 2% Lidocaine, Heparin, Mannitol, Procainamide HCl, and Dextrose 50%.

b) Equipment: Syringes, needles, Foley catheter kit, urometer, nasogastric tubes (varied sizes, rectal tube, supplies to insert invasive lines and tubes and labels for blood studies.

2) Outdated medications and supplies shall be restocked on a routine basis by an assigned person.

3) Malignant hyperthermia crisis supplies are kept in PACU on the malignant hyperthermia cart at SJRMC-SB and on the OR crash carts at SJRMC-M and ELMC.

D. Refrigerated supplies that may be needed to bring body temperature down will be kept in the department. These supplies include but not limited to: 1) Humulin - regular 2) Normal Saline solution for irrigation and infusion.

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Malignant Hyperthermia Crisis – Surgical Services

E. A cooling mattress shall be available. F. If a patient is known to be a susceptible malignant hyperthermia patient:

1) notify the surgeon and anesthesiologist of patient’s history. 2) have malignant hyperthermia supplies readily available. 3) have the crash cart readily available. 4) using the patient’s weight, calculate initial Dantrium dose to be used if crisis occurs.

G. Employee education: 1) All department registered nurses, licensed practical nurses, surgical technologists,

specialist techs and assistive personnel shall review malignant hyperthermia literature annually.

2) The Senior Director of Surgical Services or designee shall approve appropriate literature for review.

3) Malignant hyperthermia literature for review shall include but not limited to: a) Pathophysiology b) Agents capable of triggering malignant hyperthermia c) Clinical signs of malignant hyperthermia d) Treatment H. Drug of choice

REFERENCES/STANDARDS: • 2008 Perioperative Standards and Recommended Practices, Association of periOperative Registered

Nurses, Inc., Denver, CO, 2008. Original Date: July 1996 Reviewed Date: Revision Date: April 2008 Effective Date: April 2008 Approved by: System Chief Nursing Officer

Electrosurgical Safety – Surgical Services


SURGICAL SERVICES

TITLE: ELECTROSURGICAL SAFETY POLICY: 1. Personnel working with electrosurgery equipment shall be knowledgeable about the principles of

electrosurgery, risks to patients and personnel measures to minimize these risks and corrective actions to employ in the event of a fire or injury.

2. In all procedures involving the use of electrosurgical equipment, patients and personnel must be protected from hazards associated with electrosurgery.

RESPONSIBLE ASSOCIATES: Physicians, RN’s, Scrub Person (i.e., nurses, scrub

technologists.

GUIDELINES: A. Electrosurgical Unit (ESU), active electrode (hand piece) appropriate dispersive electrode

(grounding pad)and any other accessories shall be used according to the manufacturers’ written instructions. 1) The ESU shall be grounded properly. 2) The ESU shall be mounted on a movable stand or teletom that will not tip. 3) The ESU and all reusable parts are cleaned with care following use according to the

manufacturer’s written instructions. 4) The bipolar ESU shall be used with its foot switch or a hand switching forceps

according to the manufacturer’s written instructions. 5) ESU operating instructions shall be available on each ESU. 6) If two ESUs are used simultaneously during an operative procedure, they must have the

same technology (e.g., both are grounded isolated units). Place the two dispersive electrodes as close as possible to their respective surgical sites and ensure that is no possibility of the two dispersive electrodes touching each other.

B. Preoperative preparation. 1) Inspection of the electrosurgical units.

a) Must have been done by biomedical personnel prior to use. b) Inspection sticker indicating date of inspection must be attached to the

electrosurgical unit. c) Inspection of the ESU must be performed at least annually. d) Only ESUs with current inspection may be used. e) ESUs are not operated in the presence of flammable agents.

Saint Joseph Regional Medical Center Policy/Procedures Effective Date: April 2008 ELECTROSURGICAL SAFETY – continued Page 2 of 5


2) Personnel shall be instructed in the proper operation, care and handling of the ESU before use.

3) Only properly functioning electrosurgical equipment is used. An ESU that is not working properly or is damaged shall be reported to the supervisor and/or equipment tech, labeled, and removed immediately with all cords and grounding pads to be checked by the biomedical department or manufacturer representative.

4) Prior to the surgical procedure, an ESU performance check is made by the circulating nurse. a) The ESU is checked for current inspection sticker from Biomed. b) All cords are inspected for integrity. c) The alarm systems are checked and audible. d) Power settings are set as low as possible or as ordered by the surgeon and

determined in conjunction with the manufacturers’ recommendations. 5) When the ESU foot switch is used, perioperative personnel should cover it with a clear

impervious cover if recommended by the manufacturer. 6) Each ESU shall be assigned an identification or serial number. 7) Patient’s jewelry should be removed.

C. Intra Operative Safety. 1) Application of dispersive electrode (grounding pad)

a) Disposable dispersive electrodes shall be used. b) Excessive hair should be removed before applying the dispersive electrode. c) Dispersive electrode must be appropriate for patient age and weight. The dispersive

electrode should never be cut to reduce its size. (1) Two dispersive pads may be necessary to use for obese patients. An adapter

for this use by the manufacturer shall be used. d) Dispersive electrode must be placed securely on patient after patient is positioned. e) Dispersive electrode must be placed over an area of good blood supply, avoiding

(1) bony prominence, scarred/fatty areas and over areas of a metallic implant. 2) Safety precautions are taken during the procedure.

a) Dispersive electrode contact is checked when patient is repositioned or if any tension has been applied to the cord.

b) Cord connections and dispersive electrode contact are checked when higher than normal settings are requested.

c) The active electrode shall: (1) fasten directly into the ESU. If an adapter is used, it should be one that is

approved by the manufacturer (2) be inspected at the field for damage before use (3) be placed in a clean, dry, well-insulated safety holster or laid on the sterile

drapes in a safe area away from areas of unintentional activation



(4) be impervious to fluids (5) be disconnected (not cut) from the ESU if allowed to drop below the sterile

field (6) have a tip that is secure and easy to clean.

3) The active electrode tip should not be applied to instrumentation but directly to patient tissue. a) Nothing shall be placed or stored on top of the ESU to prevent damage or

inadvertent adjustments of the settings. (1) The ESU shall be protected from spills. Prep solutions or containers with

fluid should not be placed on the ESU. b) Power settings should be confirmed verbally between the circulating nurse and

surgeon before activation in conjunction with the manufacturer’s written recommendations and the patient’s size. (1) The ESU should be operated at the lowest effective power setting to achieve

the desired effect for coagulation and cutting. (2) Personnel shall check the entire ESU circuit if the operator requests a

continual increase in power because of insufficient results. c) The suction system or a specifically designed smoke evacuation system may be used

as a smoke evacuation system to remove surgical smoke. Smoke evacuation systems shall be used according to the manufacturer’s written instructions.

d) The active electrode (hand piece) shall be attached to the drapes at the foot of the patient on Cesarean Section procedures. The active electrode (hand piece) shall be placed on the mayo stand during the time of delivery of the baby on Cesarean Section procedures.

4) Patients with pacemakers. a) Should have continuous electrocardiogram monitoring when ESU is being used. b) The bipolar unit may be used with these patients. c) The distance between the active and dispersive electrodes should be made as short

as possible and both should be placed as far from the pacemaker as possible. d) The current path from the surgical site to the dispersive electrode must not pass

through the vicinity of the heart. e) All ESU cords and cables must be kept away from the pacemakers and the leads. f) A defibrillator should be available. g) The pacemaker’s manufacturer and the patient’s cardiologist could be checked with

regarding its function during use of ESUs. h) A magnet or a control unit should be available. i) The pacemaker should be evaluated postoperatively for proper function.

5) A patient with an automatic implantable cardioverter/defibrillator (AICD) should: a) have the ACID device deactivated before the ESU is activated b) have a defibrillator immediately available



c) have continuous ECG monitoring. 6) When using the ESU with an operating laparoscope, personnel shall:

a) examine all electrodes for impaired insulation before use b) ensure proper connection of equipment

7) Active electrode monitoring with laproscopic surgery is available for surgeon use. 8) Argon Beam Coagulation

a) The Argon Beam Coagulation shall be used according to the manufacturers’ written instructions.

WARNING: The Argon gas flow must be turned down to 4L (or as low as possible) for laparoscopy! IT MUST NEVER BE USED IN THE UTERUS.

b) Properly trained personnel will:

(1) observe all safety measures for the ESU. (2) avoid placing the active electrode in direct contact with tissue. (3) move the hand piece away from the patient’s tissue after each activation. (4) activate the argon gas flow and the ESU simultaneously. (5) limit the argon gas flow to the lowest level possible. (6) purge the argon gas line of air before each procedure. (7) flush air out of the argon gas line by activating the system after moderate

delays between activations. 9) Postoperative Safety

a) The dispersive electrode is removed gently and the skin under the electrode is I inspected for integrity.

b) Power cords are unplugged and secured. c) Active and dispersive electrodes are disposed of in appropriate receptacles.

10) Documentation a) The following information is documented on the intraoperative records:

(1) identification/serial number of ESU (2) site of dispersive electrode placement

(a) Identification of the person performing pad placement may be documented.

(3) shave of dispersive electrode placement site when applicable (a) identification of person performing shave

(4) condition of skin prior to dispersive electrode placement and following removal.



REFERENCES: • 2008 Perioperative Standards and Recommended Practices, Association of perioperative Registered

Nurses, Inc., Denver, CO 2008 Original Date: August 1992 Reviewed Date: Revision Date: April 2008 Effective Date: April 2008 Approved by: System Chief Nursing Officer

Site Verification, Time Out and Management of Wrong Site Surgery/Procedure – Nursing Services


SURGICAL SERVICES

TITLE: SITE VERIFICATION, TIME OUT AND MANAGEMENT OF WRONG SITE SURGERY/PROCEDURE POLICY: 1. All patients having surgical intervention or a procedure will be verified using multiple methods

prior to the surgical intervention or procedure.

RESPONSIBLE ASSOCIATES: Physicians, Nursing Staff, Surgery and Procedure Team Members

GUIDELINES: A. The “universal protocol” for preventing wrong site, wrong procedure and wrong person

surgery/procedure will be followed, including: 1) the pre-operative verification process; gathering and confirmation of all relevant

documentation and studies. 2) marking of operative site. 3) physician may delegate site marking to the resident, RNFA employed by the physician,

or Physician Assistant. If delegated the surgeon-of-record must confirm site during time out. i) physician or designee performing procedure must do the site marking:

(1) with patient involved, awake and aware, if possible, or the patient’s parent if the patient is a minor, or patient’s legal guardian.

(2) before patient leaves the preoperative area or enters procedure/surgical room. ii) At SJRMC-SB: For Tenchkoff insertion, registered nurses in Admission/ Discharge

Unit will mark the placement site. iii) For ostomy-related cases, enterostomal therapist when available, consulted per a

physician’s order, will mark a patient’s planned ostomy site. The physician who will be performing the surgery/procedure will confirm site marking.

iv) The mark should be unambiguous (e.g. use initials of the person making the mark, or “yes”, or a line representing proposed incision). An “X” should not be used as it is considered ambiguous. (1) Ophthalmology procedures will be marked with an obvious dot above correct

eye.

Saint Joseph Regional Medical Center Policy/Procedures Effective Date: September 2006 SITE VERIFICATION, TIME OUT AND MANAGEMENT OF WRONG SITE SURGERY/PROCEDURE – continued Page 2 of 4

Site Verification, Time Out and Management of Wrong Site Surgery/Procedure – Surgical Services

(2) The mark should be made using a marker that is sufficiently permanent to remain visible after completion of skin prep. Surgical towels should not cover the mark.

B. At a minimum, all cases involving left/right distinction, multiple structures (fingers, toes, lesions) or multiple levels (spine) shall be marked. NOTE: In addition to preoperative skin marking of the general spinal region, special intraoperative radiographic techniques are used for identifying exact vertebral level.

C. Exemptions: 1) Single organ cases (e.g. Cesarean section, cardiac surgery). 2) Interventional cases for which the catheter/instrument insertion site is not predetermined

(e.g. cardiac catheterization). 3) Procedures done through or immediately adjacent to a natural body orifice (e.g. GI

endoscopy, tonsillectomy, hemorrhoidectomy or procedures on the genitalia) or other situations in which marking the site would be impossible or technically impractical.

4) Certain routine “minor” procedures such as venipuncture, peripheral IV line placement, insertion of NG tube or Foley catheter insertion.

5) Teeth – BUT, indicate operative tooth name(s) in documentation or mark the operative tooth (teeth) on the dental radiographs or dental diagram.

6) Premature infants for whom the mark may cause a permanent tattoo. 7) Traumatic injury where the operation or procedure site is blatantly obvious. 8) Any radiological procedure due to prior imaging before a procedure is started, the breast

will not be marked until the image is done. Then the radiologist doing procedure will mark the breast and a timeout will occur prior to any invasive aspect of procedure.

9) For “bedside” procedures, if the practitioner performing procedure remains with patient continuously from time the decision is made to do procedure and consent is obtained from the patient up to time of procedure itself, then site marking is not required.

D. A final verification, “time out,” shall be completed with the surgeon/physician, anesthesia and Surgical/ Procedural Team prior to the procedure and documented in medical record by the nurse.

E. If a patient refuses site marking, a “Refusal of Care” form is to be completed and reason for refusal documented in the medical record.

PROCEDURE 1. Preparation prior to the surgery/procedure will include:

A. presence of History and Physical/Emergency Assessment. B. consent signed by patient or guardian C. diagnostic studies (i.e. chest x-ray, labs, etc.). D. relevant images, properly labeled and displayed. E. any required implants and special equipment. F. operative/procedural site marked by physician or designee



2. Prior to start of the surgery/procedure, the entire operative/procedural team conducts a “time out” to verbally verify: A. correct patient. B. correct side and site. C. agreement on the surgery/procedure to be done. D. correct patient positioning, availability of correct implants and any special equipment or special

requirements. 3. Completion of the “time out” will be documented on operative/procedure record. 4. If any member of the surgical/procedural team has any questions or concerns regarding the

correct patient, side and site, surgery/procedure to be done, positioning, availability of correct implants, or procedure record, special equipment or requirements, the procedure is not started until all questions and concerns are resolved.

MANAGEMENT OF WRONG SITE SURGERY/PROCEDURE 1. If during course of the surgery/procedure or, after surgery/procedure has been completed, it is

determined that the surgery/procedure is being performed or has been performed on wrong site, the physician will: A. act in accord with the patient’s best interests to promote patient’s well being. B. take necessary/appropriate steps to return patient, as nearly as possible, to patient’s pre-

operative/pre-procedure condition. C. perform planned surgery/procedure on correct site unless there are medical reasons not to

proceed at that time. D. advise patient or the patient’s representative/family:

1) of what occurred, 2) of the likely consequences, if any, of the wrong site surgery/procedure, 3) of any recommendations to the patient/family of what, in the physician’s best judgment, is

the appropriate course for the patient to follow under the circumstances, and 4) answer the patient/family’s questions to the best of their knowledge and judgment.

E. if appropriate/necessary, the physician will proceed with immediate patient care interventions as consented to by the patient/family.

F. record the events in the patient’s medical record. G. provide necessary/appropriate information to the RN who, in turn, will immediately complete

an occurrence report and notify Risk Management of event. REFERENCES: • 2006 National Patient Safety Goals, JCAHO • 2008 Perioperative Standards and Recommended Practices, Association of periOperative Registered

Nurses, Inc., Denver, CO - 2006



• “7” Absolutes – A VHA Surgical Site Verification Program,” Surgical Services Management, February 2003, Volume 9, Number 1

• “JCAHO Summit Results in Revisions to Site Marking Guidelines,” AORN Connections, June 2003 • “Home Study Program – Ensuring Correct Site Surgery,” AORN Journal, November 2002, Volume

76, NO 5 • “The National Patient Safety Goals and Their Implications for periOperative Nurses,” AORN

Journal, June 2003, Volume 77, NO 6 • “Statement on ensuring correct patient, correct site, and correct procedure surgery,” Bulletin of the

American College of Surgeons, Vol. 87, No. 12, December 2002 • “AAOS launches 2003 public service ad campaign, “AAOS Bulletin, February 2003, American

Academy of Orthopaedic Surgeons” “Sign Your Site” initiative • Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, JCAHO

2005 National Patient Safety Goals

riginal Date: November 2000 O

eviewed Date: April 2008 R

evision Date: September 2006 R Approved by: Chief Nursing Officer

Code Blue – Nursing Services

Policy & Procedure

Policy Origin Date: July 1992 Review Date: January 2010 Revised Date: December 2009 Effective Date: December 2009

Owner: Code Blue Committee Reviewed/Recommended By: Code Blue Committee; VP Clinical Services

Function: POC Department(s): All Approved By: VP Chief Nursing Officer

Responsible Associates:

Patient Care Services Nursing and Support staff, Pharmacists, Distribution staff, Supply, Processing & Distribution (SPD) staff, Communications staff, Laboratory, Center for Spiritual Care staff, Respiratory Therapy Staff, and Medical Staff members.

Approval Date: March 5, 2010

Saint Joseph Regional Medical Center

TITLE: “CODE BLUE” RESUSCITATION PLAN POLICY: 1. Every effort will be made to resuscitate a patient when a Code Blue is called, in the absence of a written

“Do Not Resuscitate” (DNR) order in the patient’s medical record. 2. Code blue resuscitation efforts will continue unless terminated by a physician. 3. DNR orders will be rescinded when patients receive general anesthesia. The primary physician or

anesthesiologist will discuss this with the patient or patient representative and document on the Physician Order Sheet.

4. The Code Blue Team will respond to Code Blue calls within the main Medical Center and all SJRMC owned areas within the Medical Office Building (MOB). 24 hours/day, 7-days/week.

5. SJRMC Rehabilitation Institute on Elm Road for all Code Blue start BLS (Basic Life Support) and call 911.

6. Code Blue Team RNs will have Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), or Neonatal Resuscitation Provider (NRP) certification.

7. ED RN and pediatric/ neonatal RN will respond to Pediatric/ Neonatal Code Blues. The pediatric/neonatal RN will assume the role of code leader. A. The ED RN will bring the Broselow cart to pediatric codes occuring in units other than PACU, ED,

and pediatrics. 8. Intubation to be performed by a physician, respiratory therapist, or paramedic tech (in the ED) validated to

do so during a Code Blue. 9. An anesthesiologist will respond upon request as available.

PROCEDURE/GUIDELINES: Standardized Crash Carts

A. SPD will stock supplies.

Saint Joseph Regional Medical Center Policy/Procedures Effective Date: January 2010 Code Blue-Resuscitation Plan – continued Page 2 of 5


B. Pharmacy will stock medications and supply cart locking devices. 1) A tag listing the name and date of the medication that expires the earliest will be affixed to the

sealed medication tray.

Daily Maintenance of Crash Carts A. Units are responsible for daily maintenance of crash carts on their unit B. Daily maintenance includes verifying the information below using the Emergency Equipment

Checklist: 1) Presence of intact, numbered lock

a) If lock is missing, nurse returns medication tray to pharmacy and obtains replacement cart from SPD

b) Complete on-line Occurrence Report 2) Presence of medication tag. Verify expiration date. 3) Presence of defibrillator/pacing cable and pads (adult & pediatric) 4) Presence of ECG cable and electrodes 5) Verify monitor is plugged in 6) Test defibrillator per manufacturer guidelines

a) Unplug the monitor/defibrillator and test for charge b) Plug the monitor/defibrillator back in and verify that the BATT CHRG and AC POWER

lights are on. c) Repeat test if initial test is not successful

(1) Contact biomedical engineering if repeat test is not successful (2) Complete on-line Occurrence Report.

7) Presence of Broselow crash carts in ED, Surgery, Pediatrics, and PACU 8) Neonatal crash cart maintained by NICU staff. Neonatal Code Blue equipment maintained by

NICU staff

Code Blue documentation A. “Cardiopulmonary Resuscitation Record” is part of the permanent medical record.

1. Information recorded on this record replaces physician orders during the code blue resuscitation period.

2. Must be signed by the charge physician, charge nurse and recorder. B. Copy of resuscitation record sent to chair of code blue committee.

Code Blue for the patient in Isolation: A. Crash cart is handled only by the medication nurse/pharmacist, who will avoid direct patient care to

prevent contamination of the equipment.



B. All equipment coming into contact with the patient in isolation will be disinfected upon leaving the room per infection control policy

Initiating Code Blue: A. The person discovering the code blue situation will:

1. Push the automatic Code Blue call button and dial 5-5555. If Code Blue button not available call 5-5555. Provide the exact location of the arrest and indicate if the patient is pediatric or neonatal. a) Pediatric: children under the age of twelve b) Neonatal: infants under the age of 28 days

2. Begin BCLS interventions

Telephone Operator Response:

A. Initiate Code Blue tones over the public address system, followed by the announcement repeated 3 times: 1. “Code Blue, location (location (lakeside or garden side) not to includeing room numbers)” (state

pediatric/ neonatal as indicated), B. Page:

1. Page Resident 472-2329 (Enter call back number 335-5000 and/or text Code Blue: Room “#” and location (lakeside or garden side)

2. Page Chaplin on call 472-2766 (Alpha pager) (Enter call back number 335-5000 and/or text Code Blue: Room “#” and location (lakeside or garden side)

C. Send a Group Page/Text, “Code Blue: Room # and location (lakeside or garden side) through the Call system to: 1. Critical Care 2. Intensive Care 3. Surgical Intensive Care Unit (SICU) 4. Respiratory Therapists 5. Laboratory 6. Nursing Supervisor 7. IV Therapy

D. If unable to send Group Page/ Text call: 1. Critical Care 5-3125 2. Intensive Care 5-7107 3. Surgical Intensive Care Unit 5-2140 4. Respiratory Therapist Shift Leader 5-7108 5. Laboratory 5-6230 6. Emergency Department 5-1110 (for Code Blue in all non-patient areas) 7. Respiratory ED Therapist 5-6230



8. Nursing Supervisor 5-2430 (desk) or 5-7000 (portable phone) 9. IV Therapy 5-6115

Following Code Blue Announcement:

A. Units with crash carts are responsible to bring crash cart to code blues on their unit. B. Distribution will deliver a back-up crash cart and two IV pumps to the Code Blue location. C. Response to a Code Blue in a non-clinical area within the main Medical Center structure.

1. ED staff are responsible to bring stretcher to codes in non-clinical areas. 2. Physician and Charge Nurse will accompany the patient to the Emergency Department or the

appropriate Critical Care Unit (only if primary care physician unavailable to admit patient) 3. Crash cart will be delivered from the appropriate area. For the MOB the code cart will be stored

3rd floor South Bend Medical Foundation LAB

Code Blue Team Personnel and Roles:

CORE PERSONNEL Remain at the bedside

SUPPORT PERSONNEL Remain outside the room

1. ICU nurse: Charge Nurse • Bring RSI box • Assign team member roles • Clear room of extra personnel • Sign Resuscitation record at end

of code • Send copy of record & code

evaluation form to code blue chair• Assign nurse to return med tray to

pharmacy at the end of the code

1. Administrative Supervisor/Manager on call • Clear room of extra personnel • Remind team to send copy of

record & code evaluation sent to code blue chair

• Notify anesthesia as required o Days x7310 Major

surgery o Evenings and nights

x6855 FBP o If unavailable, x7264 ED

• Facilitate transfer to critical care 2. Patient’s Primary Nurse: Assist as

needed • Bring chart & MAR to room • Remain in room during the code • Assist in transfer of patient, return

equipment to floor, call for crash cart replacement

2. Chaplain • Notify and support patient’s

family • Facilitate communication

between family and team members

3. Pharmacist: • Medications • Respond with crash cart to codes

on first floor

3. Laboratory Technician

4. Physician/Resident: Code Leader 4. Unit Secretary when available



• Sign Resuscitation record at end of code

• Attach patient identification to code cart for charges

5. Critical Care – Progressive Nurse: documentation • Sign Resuscitation record • Submit completed resuscitation

record and code evaluation to charge nurse

5. IV Therapist when available

6. Intensive Care nurse: monitor/ defibrillator

6. Distribution Staff Member • Take replacement crash cart to

code area 7. Respiratory Therapist: Airway/

ventilation

8. Pediatric or NICU nurse as applicable

Documentation: A. Nurse’s Notes: document initiation of resuscitation and outcome.

B. Cardiopulmonary Resuscitation Record:

1. Attach rhythm strips to the Cardiopulmonary Resuscitation Record. These may be obtained through the code summary on the defibrillator monitor.

a) Initial cardiac rhythm

b) Cardiac rhythm following successful cardioversion/ defibrillation/pacing

c) Cardiac rhythm upon completion of resuscitation efforts

2. Use second Cardiopulmonary Resuscitation Record if additional space is required.

3. Code Blue Evaluation Form:

a) Complete and return to chair of code blue committee following each code.

SPD Role Following Each Code Blue:

A. Clean the crash cart and equipment.

B. Complete Crash Cart Inventory form and forward to Distribution for charging and replacement.

C. Test monitor/defibrillator.

D. Restock crash cart and document on Crash Cart Inventory form.

E. Deliver clean, restocked crash cart to Pharmacy to insert medication tray and lock cart.

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