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Final Perioperative Guideline For Print

The National Perioperative Guideline aims to enhance the quality and safety of surgical care in Ethiopia by providing a comprehensive framework for perioperative processes. It emphasizes teamwork and collaboration among healthcare providers to standardize care delivery and improve surgical outcomes. The guideline is part of Ethiopia's commitment to making essential surgical services accessible and affordable as part of universal health coverage.

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Fikadu Gidi
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0% found this document useful (0 votes)
940 views154 pages

Final Perioperative Guideline For Print

The National Perioperative Guideline aims to enhance the quality and safety of surgical care in Ethiopia by providing a comprehensive framework for perioperative processes. It emphasizes teamwork and collaboration among healthcare providers to standardize care delivery and improve surgical outcomes. The guideline is part of Ethiopia's commitment to making essential surgical services accessible and affordable as part of universal health coverage.

Uploaded by

Fikadu Gidi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NATIONAL PERIOPERATIVE

GUIDELINE

HEALTH SERVICE QUALITY DIRECTORATE

March, 2022
Forward
Ethiopia has been committed to ensuring that essential and emergency surgical care is accessible and
affordable to its citizens. During the first Health Sector Plan, the Ministry of Health has developed and
implemented two strategies- the National Healthcare Quality Strategy (NQS) and Saving Lives
Through Save Surgery Strategy (SaLTS) - that mainly aimed to improve the quality and safety of
surgical care. In addition, the SaLTS initiative was launched in response to the World Health Assembly
resolution-68/15 and envisioned making accessible and affordable essential and emergency surgical and
anesthesia care part of the universal health coverage.

Among the key pillars in the SaLTS strategy has been quality management. In line with quality
improvement projects, improvement of surgical care has been initiated and has shown encouraging
results. Improving the quality of surgical care will be strengthened by introducing the updated
perioperative guideline. The perioperative guideline is a guideline, which incorporates the flow of
surgical care starting from the pre-operative period, and throughout the post-operative period.

This guide, therefore, provides a detailed guide to execute surgical procedures in the process of
perioperative care. In addition, it will help to improve quality of surgical care, surgical efficiency, and
surgical safety practices among the facilities.

As improvement demands teamwork and a multidisciplinary approach, I would like to call upon all
relevant stakeholders: Ethiopian surgical society, anesthesia and anesthesiologist society, and nursing
society in addition to partner organizations, all care providers, and health managers/leaders at all level
to work hand in hand towards standardizing the perioperative care delivery system, and implementing
the guiding principles to perioperative continuum of care.

Finally, I would like to take this opportunity to extend my warm appreciation to all individuals and
organizations who have actively participated in the development of this guideline.

Dr. Hassen Mohammed Beshir (MD, MPH)

Director, Health Services Quality Directorate

2
Acknowledgment
The Ministry of Health of Ethiopia would like to express its appreciation and gratitude to those who
were involved in the preparation of this document. The Ministry of Health would also like to extend its
acknowledgment to the teams, and their institution, who exerted their knowledge and technical skills
throughout the preparation of the national perioperative guideline, as well as for contributing by
providing various technical inputs during the development of the guide.

3
Table of Contents
Background ......................................................................................................................................... 10
Introduction......................................................................................................................................... 13
1. Leadership and Management ........................................................................................................... 15
2. Teamwork and Communication ....................................................................................................... 17
2.1 Communication and relationship dynamics in the operating room .............................................. 17
2.2 Consultation Process.................................................................................................................. 18
3. Preoperative Care …………………………………………………………………………………….20
3.1 Patient Assessment .................................................................................................................... 21
3.1.1 Preoperative Surgical Assessment........................................................................ 21
3.1.2 Preoperative Anesthetic Assessment .................................................................... 25
3.2 Surgical Patient Admission ........................................................................................................ 32
3.2.1 Elective Admission Process ................................................................................. 33
3.3 Preoperative Preparation ............................................................................................................ 34
3.3.1 Pre-scheduling Checklist ..................................................................................... 34
3.3.2 Preoperative Supplies and Equipment Preparation ............................................... 37
3.3.3 Informed Consent ................................................................................................ 39
3.3.4 Pre-operative Conference .................................................................................... 41
3.3.5 Psychological Preparation of the Patient .............................................................. 44
3.3.6 Fasting Recommendations ................................................................................... 45
3.3.7 Operating Theatre Scheduling.............................................................................. 46
3.3.8 Preoperative Nursing Care ................................................................................... 49
3.3.9 Patient Transfer and Handover............................................................................. 50
3.3.10 Operating Room Readiness Checklist .................................................................. 54
4. Intraoperative Care .......................................................................................................................... 58
4.1 Intraoperative Patient Reception and Briefing ............................................................................ 59
4.1.1 Handover ............................................................................................................. 59
4.1.2 Transferring patient to OR table........................................................................... 59
4.1.3 Briefings.............................................................................................................. 59
4.1.4 WHO Safe Surgery Checklist .............................................................................. 61
4.2 Intraoperative Nursing Care ....................................................................................................... 64
4.3 Intraoperative Anesthesia Care .................................................................................................. 66
4.3.1 Preparing the anesthesia station ........................................................................... 66
4
4.3.2 Patient Positioning and Anesthesia ...................................................................... 70
4.3.3 Induction of Anesthesia ....................................................................................... 72
4.3.4 Maintenance of Anesthesia .................................................................................. 72
4.3.5 Recovery Phase ................................................................................................... 74
4.3.6 Documentation and Recording of Intraoperative Anesthesia Management ........... 75
4.4 Intraoperative Surgical Care ...................................................................................................... 76
4.5 Intraoperative Safety.................................................................................................................. 77
4.5.1 Adverse Anesthetic Events .................................................................................. 77
4.6 Managing Operating Room Efficiency ....................................................................................... 79
4.7 Intraoperative Documentation and Reporting ............................................................................. 80
5. Postoperative Care........................................................................................................................... 81
5.1 Postoperative Process Map ........................................................................................................ 81
5.2 Postoperative Transport and Transfer to PACU/ICU .................................................................. 81
5.3 Handover for Postoperative Care ............................................................................................... 82
5.4 Postoperative Surgical Care ....................................................................................................... 85
5.5 Postoperative Nursing Care ....................................................................................................... 85
5.6 Surgical Site Infection (SSI) ...................................................................................................... 88
5.7 Discharge…………. .................................................................................................................. 90
5.8 Follow up Care .......................................................................................................................... 91
6. Perioperative Critical Incident Reporting ......................................................................................... 92
6.1 What is an incident? .................................................................................................................. 92
6.2 Risk Evaluation ......................................................................................................................... 92
6.3 Incident Investigation ................................................................................................................ 94
7. Monitoring and Evaluation ............................................................................................................ 100
8. Annexes………... .......................................................................................................................... 107
Annex 1: Summary of team leadership roles and responsibilities .................................................. 107
Annex 2: Role and responsibility of team leads: OR nurses, surgeon, anesthetists/anesthesiologists
and OR managers .......................................................................................................................... 109
Annex 3: Perioperative Process Maps for Emergency Procedures .................................................. 111
Annex 4: Preoperative Surgical Checklists for Pediatric Patients ................................................... 124
Annex 5: Urgency of Admission (set criteria related to pathology of the disease) .......................... 127
Annex 6: Perioperative Briefing Templates ................................................................................... 142
Annex 7: Anesthesia Recording Template ..................................................................................... 144

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Annex 8: Operation Note Sample .................................................................................................. 145
Annex 9: Operation Registry ......................................................................................................... 147
Annex 10: Count Sheet.................................................................................................................. 148
Annex 11: Operating Theatre Table Efficiency Assessment Tool .................................................. 149
Annex 12: Discharge Form ............................................................................................................ 150
Annex 13: SSI Recording Register ................................................................................................ 152
Annex 14: Cancellation Register ................................................................................................... 153

Figures
Figure 1: Emergency surgery pre-operative process map ..................................................................... 20
Figure 2: Elective Surgery pre-operative process map ......................................................................... 21
Figure 3: OR scheduling phases .......................................................................................................... 47
Figure 4: Elective surgery intraoperative process map ......................................................................... 58
Figure 5: World Health Organization's Surgical Safety Checklist ........................................................ 63
Figure 6: Elective surgery postoperative process map .......................................................................... 81
Figure 7: WHO SSI surveillance form ................................................................................................. 89
Figure 8: Incident reporting flow chart ................................................................................................ 95
Tables

Table 1: Surgical preoperative checklist for adult patients ................................................................... 22


Table 2: Preoperative anesthesia checklist ........................................................................................... 26
Table 3: Recommended pre-operative screening test ........................................................................... 30
Table 4: Surgical risk classification ..................................................................................................... 31
Table 5: American Society of Anesthesiologists physical status classification system (ASA
classification) ...................................................................................................................................... 32
Table 6: Preoperative conference checklist .......................................................................................... 43
Table 7: Common premedication drugs and administration ................................................................. 45
Table 8: Fasting guide ......................................................................................................................... 46
Table 9: Operating schedule template .................................................................................................. 48
Table 10: Pneumonic for patient transfer- I PASS THE BATON ......................................................... 53
Table 11: Operation room readiness checklist ...................................................................................... 55
Table 12: Intraoperative nursing care checklist .................................................................................... 64
Table 13: How to prepare the anesthesia station using the SOAP ME pneumonic ................................ 68
Table 14: Anesthesia parameters to be monitored intraoperatively ....................................................... 73
Table 15: Postoperative handover checklist ......................................................................................... 84
Table 16: Risk Assessment .................................................................................................................. 93
Table 17: Incident investigation report format ..................................................................................... 96

6
Abbreviations
ALI= Acute Lung Injury
ALT= Alanine Amino Transferase
ARDS= Acute Respiratory Distress Syndrome
ASA= American Society of Anesthesiologists
AST= Aspartate Amino Transferase
BG= Blood Group
BMI= Body Mass Index
BP= Blood Pressure
Ca= Calcium
Cl= Chloride
CSD= Central Sterilizing Department
CVAT= Costo Vertebral Angle Tenderness
CVC= Central Venous Catheter
CVP= Central Venous Pressure
DHS= Demographic Health Survey
DM= Diabetes Mellitus
DOS=Day of Surgery
DVT= Deep Venous Thrombosis
ECG= Electro Cardio Gram
EFY= Ethiopian Fiscal Year
ETT= Endo Tracheal Tube
GA= General Anesthesia
GCS= Glascow Coma Scale
GI= Gastro Intestinal
HbA1C= Hemoglobin A1C
HCT= Hematocrit

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HEENT= Head, Eyes, Ear, Nose, Throat
HDU= High Dependency Unit
HGB= Hemoglobin
HMIS= Health Management Information System
HR= Heart Rate
HSDP= Health Sector Development Program
HSTP = Health Sector Transformation Plan
ICU= Intensive Care Unit
IESO= Integrated Emergency Surgical Officer
INR= International Normalized Ratio
IPC= Infection Prevention and Control
K= Potassium
KPI= Key Performance Indicator
LFT= Liver Function Test
LL= Left Lower limb
LMA= Laryngeal Mask Airway
LMIC= Low to Middle Income Countries
LNMP= Last Normal Menstrual Period
LU= Left Upper limb
MDSR= Maternal Death Surveillance Report
MET= Metabolic Equivalent Testing
Mg= Magnesium
MoH=Ministry of Health
MRN= Medical Record Number
MSS= Musculoskeletal System
Na= Sodium
NPO= Nothing Per Os
NQS= National Quality Strategy

8
OPD= Out Patient Department
OR= Operating Room
OT= Operating Theatre
PACU= Post Anesthesia Care Unit
PLT= Platelet
PONV= Post-Operative Nausea and Vomiting
PR= Pulse Rate
PT= Prothrombin Time
PTSD= Post Traumatic Stress Disorder
PTT= Partial Thromboplastin Time
RFT= Renal Function Test
RL= Right Lower limb
RR= Recovery Room
RU= Right Upper limb
SaLTS= Saving Lives Through Safe Surgery
SASD=Surgical and Anesthesia Directorate
SDG= Sustainable Development Goals
SOP= Standard Operating Procedure
SPO2= Saturation of Oxygen
SSC= Surgical Safety Checklist
T3= Triiodothyronine
T4=Thyroxine
TSH= Thyroid Stimulating Hormone
URTI= Upper Respiratory Tract Infection
VP= Ventriculoperitoneal
WBC= White Blood Count
WFSA= World Federation Society of Anesthesiologists
WHO= World Health Organization

9
List of Contributors
HASSEN MOHAMMED BESHIR (MD, MPH) --------------- ----- ------- Health Service Quality Directorate Director, MoH
EYOBED KALEB BEREDED (BSC, MPH) -------Health Service Quality Directorate, SaLTS case team officer, MoH
GETACHEW YIMAM ADEM (BSC, MPH) -------- ----Health Service Quality Directorate, SaLTS case team officer
BERHANE REDAE MESHESHA (MD, PhD) ------ --Health Service Quality Directorate, technical advisor, MoH
TADESSE SHIFERAW CHEKOL (BSC) ------------ -------Health Service Quality Directorate, SaLTS case team officer, MoH
DESALEGN BEKELE TAYE (MD) ------------------- ----------------Health Service Directorate Deputy Director, MoH
FTALEW DAGNAW GEBREEYESUS (BSC, MPH) ------- ----Health Service Quality Directorate, technical advisor
MEKUANINT AMISALU (MD, Surgeon) --------------------------------FelegeHiwot Comprehensive Specialized Hospital
AGEZEGN ASEGID MEKONEN (BSC, MSC) -------------------------------------- -Ethiopian Nursing Society
DAWIT YIFRU BETEL (MD) -----------------------------------------------------------------------JHIEPGO-Ethiopia
SEYE MESFIN (MD, Pediatrics Surgeon) ----------------------------------------------------------------JHIEPGO-Ethiopia
AMARE H/KIROS GEBREGIZI (BSC, MSC) ------------------------------------------- Ethiopian Anesthetist Association
HANAN ALI MOHAMMED (BSC, MSC) -----------------------------------------------------Ethiopian Anesthetist Association
FITSUM TAYE NEGASH (BSC, MSC ) ----------Professional Association of Emergency Surgical Officer of Ethiopia
NATNAEL GEBEYEHU (MD, Surgical Resident) -----------------------------------------St.Peter Specialized Hospital
HENOK TESHOME (MD, General Surgeon) -------------------------------------St.Paulos Millennium Medical college
FIKIREMELEKOT TEMESGEN (MD GYNACOLOGIST Surgeon)--------Ethiopian Society of Obstetrics and Gynecology
ANANYA ABATE (MD, Anesthesiologist) -------------------------------------------Ethiopian Anesthesiologist Society
BIRHANE TESFAYE (MD, Anesthesiologist) ---------------------------------------- Ethiopian Anesthesiologist Society
KIRUBEL ABEBE (MD, Surgeon) -------------------------------------------------- St.Paulos Millennium Medical College
ETSEGENET YESHITILA MINALESHEWA (BSC, MPH) --------- St. Paul Hospital Millennium Medical College

10
Background

Ethiopia is the tenth largest country in Africa, covering 1,104,300 square kilometers and is the major
constituent of the landmass known as the Horn of Africa. It is bordered on the north and northeast by
Eritrea, on the east by Djibouti and Somalia, on the south by Kenya, and on the west and southwest by
Sudan.

According to the World Bank’s projection figures for the year 2020, the estimated total population is
114,963,583, making Ethiopia the second populous country on the African continent next to Nigeria.
Ethiopia is the home of mosaic nations, nationalities, and peoples with more than 80 different
languages. The country is among the least urbanized countries in the world with 78.3% living in rural
areas whilst only 21.7% reside in urban areas, according to the World Bank report in 2021. The largest
city in the country is Addis Ababa, the capital, with 4 million people accounting for nearly 4% of the
total population. The average size of a household is 4.7.

The Ethiopian population is currently suffering from a triple burden of communicable diseases, non-
communicable diseases and injuries affecting all age groups, with a disproportionate burden on children
and women of the reproductive age group. Analysis of the burden of disease in 2017 showed that the
major causes of premature mortality are communicable, maternal, neonatal and nutritional diseases
with neonatal disorders, diarrheal diseases, and lower respiratory tract infection constituting the top
three.

The latest figures in World Health statistics indicators (Word Health statistics 2020) show a life
expectancy of 57.5 years (58.9 years for females and 56.1 for males), infant mortality rate of 43/1000
and under-five mortality rate of 55/1000. More than 90% of child deaths are due to pneumonia,
diarrhea, malaria, neonatal problems, malnutrition, and HIV/AIDS, and often to a combination of these
conditions. These are very high levels, though there has been a gradual decline in these rates in the past
15 years. In terms of women’s health, the country’s maternal mortality rate of 412/100,000 (DHS 2016)
remains high. According to the recent national MDSR report for 2012 EFY (2019 GC), the leading
causes of maternal death were hemorrhage (37%), Hypertensive Disorders of Pregnancy (HDP) (11%),
anemia (16%), and sepsis (6%). This pattern is broadly similar to the previous years, although there is a
notable decline in HDP related deaths.

11
Currently the country is implementing the HSTP-II between 2013 and 2017 EFY- (July 2020 – June
2025 GC). The overarching objective of HSTP II is to improve the health status of the population
through realization of the following objectives: accelerate progress towards universal health
coverage; protect people from health emergencies; contribute towards transformation of households
and improve health system responsiveness.

Following the launch of the HSTP I, which identified quality and equity as cornerstones of the
transformation agenda, the National Quality Strategy (NQS) was developed to operationalize the
quality and equity agenda. In the NQS I, essential and emergency safe surgical and anesthesia care
became one of the five priority areas along with maternal, neonatal and child health, nutrition, chronic
non-communicable diseases and infectious diseases. In line with this, Saving Lives Through Safe
Surgery (SaLTS) was identified as the MoH’s flagship initiative that was designed to respond to the
World Health Assembly resolution of A68/15: making emergency and essential surgical and
anesthesia care accessible and affordable as part of universal health coverage. The SaLTS initiative
was implemented to ensure the delivery of quality, safe, essential, and emergency surgery throughout
the country thereby alleviating the national burden of diseases, disability and death that are
preventable through safe surgery.

Currently, the Ministry of Health is implementing the second national surgical and anesthesia care
strategy, SaLTS II, with a principal objective of providing high quality, safe and affordable surgical
care by improving access, efficiency, effectiveness, safety & quality of surgical care in Ethiopia. This
strategic plan will mainly focus on essential and emergency surgical services as well as few specialty
services, which are in high demand in the country and with significantly high referrals abroad.

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Introduction

The world has made a commitment to achieving the SDGs by 2030. The provision of safe and
affordable surgical care is inextricably linked to many of these goals, and is a key factor in their
successful achievement. More specifically, it has been shown that surgical, obstetric and anesthesia
care are the cornerstone for ensuring strong, resilient, and sustainable healthcare systems. Despite this
reality, over 5 billion people and more than 90% of the world’s population lack access to basic
surgical care. Moreover, the lost economic output due to poor access to safe and affordable surgical
care will cost low- and middle-income countries (LMICs) an estimated $12.3 trillion USD by the year
2030 unless access to surgical, obstetric and anesthesia care is improved.

According to data from the routine HMIS report, over 242,481 major elective surgeries have been
performed by hospitals in Ethiopia in 2013 EFY. This is far below the WHO’s estimate of 50
procedures per 1000 population. The average delay for elective surgical admission is 33 days with a
prolonged waiting time for admission. The increasing demand for surgical care and the growing
emphasis on the quality and safety of care are driving the need for the healthcare system to improve,
and so is the level and quality of surgical care.

Problems related to quality and efficiency of the peri-operative system workflow can cause surgical
delays, cancellations, adverse events/complications, unplanned return to theatre and sub-optimal care
for surgical patients. These issues affect the experience and outcomes of surgical patients, the
satisfaction of peri-operative personnel, patients, relatives and the community in general.

Perioperative care requires a considerable amount of planning, preparation, and coordination to


ensure that patients receive safe and timely surgical care. In this guideline, the first thing we did was
to enumerate and then categorize the different problems in patient flow into five major areas:
teamwork and communication, leadership, pre- operative care, intra-operative care, and post-
operative care. Subsequently, the problems were summarized and different mechanisms of averting
these problems were designed. In the perioperative care of patients, the following major problems
were identified: inefficient teamwork, poor engagement of multidisciplinary teams, poor
communication, inefficient utilization of operation rooms, unclear leadership and management

13
structure, poor surgical workforce management, poor planning and execution, shortage of surgical
supplies, prolonged surgical backlog and waiting list, inadequate patient preparation and counseling,
lack of standardized and protocoled care, surgical efficiency enhancement problems, inadequate
quality improvement implementation, poor critical incident monitoring, poor adherence and
compliance to standards and guidelines, inadequate preparation, significant resource wastage, poor
postoperative follow-up and poor interdepartmental integration for continual care.

Based on this assessment, several mechanisms were designed to overcome and alleviate these
problems. Several checklists, guiding rules and working arrangements were designed and adopted. A
perioperative guideline was developed in April 2014, and had helped to significantly improve and
standardize the national perioperative care in Ethiopia. However, the development of new scientific
thoughts on perioperative care in addition to lack of updates of concepts on safety and efficacy on the
initial guideline mandated a revision.

14
1. Leadership and Management

Health Facility level


The health facility senior management team will establish and organize the facility's surgical and
anesthesia services office. A surgeon, gynecologist, anesthesiologist, or IESO (at the health centers)
in the facility staff will lead the office. The office will in turn establish and lead the SaLTS
multidisciplinary team. The operation theater manager will serve as team secretary. Each health
facility should design activities and tasks based on the need and relevance to the institutional and
national surgical and anesthesia care plan.

The SaLTS multidisciplinary team will be represented by staff from:

❖ Heads of the different surgical specialties


❖ Obstetrics-gynecology department head
❖ Anesthesia department head
❖ Operating room manager
❖ Scrub nurse head
❖ Midwifery head
❖ Surgical ward head nurse
❖ Post-anesthesia care unit (PACU) head
❖ Pharmacy service head
❖ Laboratory service head
❖ Quality and data management unit
❖ Central sterilizing department (CSD) and infection prevention
❖ Biomedical engineering service head

The roles and responsibilities of the multi-disciplinary team and OR manager is annexed (Annex 1).

Health Centers

To cascade the leadership structure at the health center level, a SASD office shall be established
under the medical director and will be led by the surgical team leader.

15
Federal Health Facilities

Hospitals under the federal government will directly communicate with the SASD office at the MoH.
However, the structure in federal health facilities is similar to hospitals elsewhere.

University Hospitals

University hospitals shall establish a SASD office under the chief clinical director or medical service
vice-provost. The organizational structure for a national surgical and anesthesia service shall be
designed per the specialty/subspecialty surgical care provided in the hospital.

OR Manager

An operation room manager who is trained in OR management shall be assigned to oversee the
overall surgical services.

OR Manager

OR nursing team lead Anesthesia team lead Surgery team lead Biomedical and other units

Details of roles and responsibilities of each team lead are annexed (Annex 2).

16
2. Teamwork and Communication

2.1 Communication and relationship dynamics in the operating room


One of the cornerstones of effective teamwork is communication between team members to achieve
anticipated results, especially in high-risk areas such as operating theatres/rooms. Surgical team
members need not only clinical knowledge and technical skills, but also skills to engage in teamwork,
to understand the complexity of the clinical situation, to make appropriate decisions and to act
efficiently.

Principles of Teamwork in the OR

❖ All members need to be secure in their technical expertise


❖ All members must be socially capable of managing and interacting with their staffs: The team
should understand that all team members are equally significant for a procedure and should
respect each other’s tasks for better surgical outcomes.
❖ The team must avoid blaming others for different mistakes; the senior in charge should be part
of the solution when a problem or complication arises.
❖ The team should maximize the use of all surgical checklists to optimize communication and
establish a shared mental model. The team should provide feedback in the form of debriefs after
the surgical procedures
❖ All health professionals need to be open-minded to criticism
❖ Newly assigned OR staff should be mentored to ensure a smooth transition of the member to
the OR team and culture
❖ All team members should be versed in the principles and protocols of key responsibilities of
each member of the surgical work force team for clear division of tasks and to readily identify
roles for shared tasks
❖ When an intra-operative conflict, misunderstanding or communication gap among the team
members occurs, the OR team is obligated to report the incident and the team should readily
discuss the incident, to create a conducive work environment.
❖ To strengthen inter professional communication, the surgical team shall use the following
platforms:
• Regular SaLTS multi-disciplinary team meetings
17
• Monthly multidisciplinary clinical audit forum (mortality and morbidity audit, surgical
efficiency audit, audit on nursing process, SSI audit, pain management audit, general
and regional anesthesia audit, surgical cancellation audit)
• Regular meetings between the OR manager and the team lead every week
• Regular meetings between the team lead and their respective health workforce

2.2 Consultation Process


Effective inter-professional communication and collaboration leads to safer patient care and enhanced
workplace satisfaction. Communication happens in various forms throughout different departments,
the commonest type being interdepartmental consultations. Consultation is defined here as one health
provider seeking formal recommendations from another health provider regarding the care of a
patient. Listed below are the crucial components to be included during consultations for proper and
effective communication.

Consultation Components (4Cs)

Contact

❖ State your name, service, and role on the team


❖ Confirm the consultant’s name, service, and supervising attending/senior

Communicate

❖ Confirm the name, medical record number, and location of the patient/client
❖ State your suspected or confirmed diagnosis
❖ Provide a brief synopsis of the patient’s history, pertinent to the question you are asking
❖ List any pertinent physical exam and laboratory findings
❖ State any interventions you have started, including the patient’s response to these
interventions
❖ State the reason you are requesting the consultation
❖ Establish a timeframe in which you expect the consultant service to evaluate the patient

Collaborate

❖ Ask the consultant what questions and recommendations they have

18
❖ Ask the consultant if they would like any additional studies or therapies to be initiated prior to
their evaluation

Close the Loop

❖ Review the actions you will complete prior to the patient’s evaluation by the consultant
service
❖ Review the actions the consultant will complete
❖ Thank the consultant for his or her time

19
3. Preoperative Care
Preoperative care starts when a surgeon encounters a patient/client at the surgical referral clinic,
emergency/regular OPD or from the wards and extends until the patient is transferred to the
operation theatre on the day of surgery. The surgical team (surgeon, anesthesia and nurse)
evaluates, optimizes and prepares the patient, required equipment and supplies for operation
preoperatively.

The preoperative process for elective and emergency general surgery and gynecologic
procedures is illustrated below:

Figure 1: Emergency surgery pre-operative process map

20
Figure 2: Elective surgery pre-operative process map

Note: The preoperative process map for emergency and elective cesarean section procedures is
annexed (Annex 3).
3.1 Patient Assessment
3.1.1 Preoperative Surgical Assessment
The modern preparation of a patient for operation characterizes the convergence of the art and
science of surgical discipline. The context in which pre-operative preparation is conducted
ranges from the outpatient office visit to hospital inpatient consultations, or the emergency
department evaluation of a patient. The approaches to pre-operative evaluation differ
significantly, depending on the nature of the complaint and proposed surgical intervention,
patient health and assessment of risk factors, and the results of directed investigations and
interventions to optimize the patient's overall status and readiness for operation. Failure to make
a proper assessment of the patient’s condition is one of the commonest and most easily avoidable
causes of mishap associated with surgical conditions. Such an assessment must include every
aspect of the patient’s condition, and not just the pathological problem requiring surgery. As
such, a preoperative surgical checklist must be completed for all surgical patients by the
surgeon/gynecologist at the SRC/GRC when the patient comes for admission. A template of the
checklist for adults is displayed below:

21
Table 1: Surgical preoperative checklist for adult patients

Patient Name: _________ MRN: _______Age: _____Gender: ____Ward and Bed number: ______
Present Absent Not Applicable
HISTORY
1. History of respiratory tract infections in the last
two weeks (runny nose, cough, fever)
2. History of fluid loss in the last 24 hours
(vomiting, diarrhea, bleeding)
3. History of COVID-19 vaccination
4. History of recent skin rashes
5. History of any current medication (antibiotics,
anticoagulants)
6. History of any chronic medical illness
(diabetes, hypertension, thyroid disorders,
bleeding disorders, liver disease, cardiac
disease, COPD, renal disease)
7. History of previous surgery
8. History of known allergies
9. History of substance abuse
10. Last menstrual period

PHYSICAL EXAMINATION Present Absent Not Applicable


1. General appearance:
Signs of respiratory distress:
If present, specify:
Signs of cardiovascular failure:
If present, specify:
2. Vital signs:
Blood pressure 22
PR
(Regular/Irregular)
Respiratory rate
Temperature
3. BMI
4. Signs of anemia (assess conjunctiva, palm of
hand)
5. Abnormality in respiratory system
If present, specify abnormality:
6. Abnormality in cardiovascular system
If present, specify abnormality:
7. Colostomy washout adequate (determined by
nature of colostomy output)- for patients on
bowel preparation
8. Presence of new skin lesions/rashes

INVESTIGATIONS Done Not Done Not Applicable


1. CBC within normal range and updated within
the last week
2. Blood group and Rh factor
3. Fasting blood sugar
4. Pregnancy test
If done, specify result:
5. Serum electrolyte within normal range and
updated in the last one week
6. RFT within normal range and updated in the
last two weeks
7. LFT within normal range and updated in the last
two weeks
8. Echocardiography done
9. Chest X-ray done

23
TREATMENT Done Not Done Not Applicable
1. Patient/attendant counseled about the proposed
procedure and has given written consent
2. Patient/attendant counseled about keeping the
patient NPO for at least six hours before surgery
3. Required amount of cross matched whole blood
prepared
4. For Patients on bowel preparation:
- Clear fluid diets started 24 hours before day of
surgery
- Cleansing enema BID started 48 hours before day of
surgery
- Antibiotic bowel preparation initiated
5. Vitamin K administration (only for patients with
jaundice)
6. Anesthesiologists/senior anesthetist notified
about subcritical/critical patients 24 hours prior
to the day of surgery
7. ICU bed reserved for patients requiring
postoperative ICU care
Diagnosis:_____________________________________________________________________

Is the patient fit for surgery? 1. Yes 2. No

If no, specify the reason: _______________________________________________

Physician’s Name: __________________________Signature: ____________

Date (DD/MM/YY): _________________


24
Once the surgical checklist is completed and the patient is deemed fit for surgery, the patient is
sent to the anesthesia clinic for a preoperative anesthesia assessment.

The preoperative surgical checklist for pediatric patients is annexed (Annex 4).

3.1.2 Preoperative Anesthetic Assessment


The preoperative anesthetic assessment is the evaluation of the patients’ medical, physical and
mental status before taking the patient to the operation theater. Anesthetic drugs and techniques
have profound effects on human physiology. Hence, a focused review of all major organ systems
should be completed prior to surgery. Inadequate pre-operative planning and errors in patient
preparation are the most common causes of anesthetic complications.

A pre-anesthesia assessment shall be done by the anesthetist or anesthesiologist, ideally at the


pre-anesthesia clinic, prior to admission. Once the patient is admitted, a second assessment shall
be done a day prior to surgery. An anesthesiologist/anesthetist should follow the following when
conducting the pre-operative assessment:

1. The anesthesiologist/anesthetist shall perform the pre-anesthetic evaluation/assessment


and decide the fitness of the elective patient for anesthesia at the OPD level, before
admission.
• In case of emergency and urgent surgery, the assessment should take place as
early as possible.
2. The anesthesiologist/anesthetist should correctly identify the patient
3. The anesthesiologist/anesthetist should review the medical record
4. The anesthesiologist/anesthetist should interview and examine the patient to:
o Discuss the medical history, family history, social history, drug history, allergies,
previous anesthetic experiences and drug therapy
o Assess those aspects of the patients physical condition that might affect decisions
regarding pre-operative risk assessment and management, and classify the health
status of the patient according to the ASA physical status and surgical risk
classification system
o Perform complete physical exam, including an airway assessment by using
common airway assessment methods to determine difficulty in airway
management

25
5. Obtain and/or review tests and consultations necessary to conduct anesthesia
6. Determine the appropriate prescription of pre-operative medications as necessary to the
conduction of anesthesia
7. The anesthesiologist/anesthetist shall discuss possible plans of management with the
patient and explains any options available, to enable the patient to make an informed
choice
• The responsible anesthesiologist/anesthetists shall verify that the above has been
properly performed and documented in the patient's record
• Prior to administration of any anesthesia medication, a written informed consent
for the use of anesthesia shall be obtained and documented in the medical record
8. Decide the fasting/NPO time based on the type of ingested food (see the fasting guideline
under table 8)
9. The patient shall be reassessed immediately prior to induction of anesthesia by an
anesthesiologist or anesthetist. The plan shall be consistent with the patient assessment
and shall include the anesthesia to be used and the method of administration
• Patients with unstable conditions should be postponed for optimization prior to
induction of anesthesia

Table 2: Preoperative anesthesia checklist

Name of patient : Date:


Age(Years) : Sex : Weight (Kg): Height (Meters):
BMI:
Card number: Ward: Surgical Diagnosis:

Planned Procedure: Presentation:

Past surgical Yes No If yes, document illness:


illness
Past medical Yes No If yes, document illness:
illness

26
Current Yes No If yes, document illness:
medical
illness
Current Yes No If yes, document medications:
medications

Known Yes No If yes, document allergy:


allergy
Smoking Yes No If yes, document number of pack year
Alcohol Yes No If yes, specify how much Other substance
Previous History of air Ye No If yes document details: Functio
way/ anesthesia s nal
complications status
(MET)
Vital signs: BP(Sys/Dia)= PR= RR= SPO 2=
o
T= Pain score=
Air way MG= TMD= Mouth opening=
assessment Neck mobility= Dentations=
HE Conjunctiv Dehydratio Ye No For pediatric age <2 >2
EN a: n s group: capillary refill sec sec
T Pink
Pale
Cardio Abnormal heart Yes No If yes write :
vascular sounds heard
system Arrhythmias Yes No If yes write:
Cardiac devices Yes No If yes write:
Respiratory Abnormal/decreased/ Yes No If yes what/where?
system absent breath sounds

Abdomen Hepatomegaly/ascite Yes No If yes what/where?


s /tenderness
Genito- Catheterized Yes No If yes UOP= C YES NO
urinary V
system A
T
:
Hematuria Yes No UT Yes No For females LNMP=
I
Musculoskel DVT Ye No If yes write medication:
etal system s
Edema Yes No If yes grade and cause:
Central GCS= Pupillary response= Power: RU= RL=
nervous LU= LL=
27
system
Electr Na+= K+= Ca+2= C Mg+2=
Investigations

olytes L
-
=
CBC BG&RH= HGB= HCT= PLT= WBC= Neutrophil
%=
OFT Cr= BUN= ALT= AST= Bilirubin Albumin=
=
Endo RBS= HbA1C= TSH= T3= T4= Others=
crine
Coag INR= PT= PTT= Others=
ulatio
n
ECG if
any
Echocardiography
If any
CXR if any
CT Scan report if any
Assessment
Final

Mode of GA GA with GA with IV sedation Spi L/A


anesthesia with LMA sedation with nal
ETT mask /Epi
dur
al
Medications to Yes No If yes document details:
be hold
Anesthesia Plan

Medications to Yes No If yes document details:


be continued

Premedication Yes No If yes document details:


needed
Blood & blood Yes No If yes document details:
products needed

28
NPO
Time
Post-operative Analgesia plan
disposition
Anesthesia Signature
evaluator Name=
Preoperative Laboratory and Diagnostic Studies

The indications for testing should be based on information obtained from medical records,
patient interview, physical examination, and type and invasiveness of the planned procedure.

29
Table 3: Recommended pre-operative screening test

Test Procedure Disease of Condition

ECG CVS CVS disease, Hypertension, Diabetes

Respiratory disease, CVS disease


Chest radiograph Thoracic
Heavy smoker (relative)

CVS disease, Renal disease ,Malignancy


Hemoglobin >500ml blood loss Diabetes ,Aspirin use ,NSAID use,
Full dose anticoagulation

Use of drugs with renal excretion, Renal


Possible perioperative
Creatinine disease, CVS disease, Hypertension,
renal failure
Diabetes, NSAID use

Glucose Diabetes, Steroid use

Genitourinary Use of drugs with renal excretion, Renal


Urinalysis Orthopedic implant disease (relative), CVS disease (relative) ,
Valve replacement Hypertension(relative), Diabetes

Pregnancy …. Female in reproductive age

Coagulation Bleeding risk by history, Plan full dose,


….
studies Anticoagulation

30
Risk Assessment and Stratification
Standardized patient risk assessment and stratification should be done before any surgical
procedure. One can use the American Society of Anesthesiologists (ASA) anesthesia risk
classification system to assess the risk of perioperative morbidity and mortality. Surgical
procedures can also be classified as low, intermediate and high-risk procedures depending on the
expected perioperative cardiovascular morbidity. Accurate risk assessment and stratification is
important for patients to make an informed decision for consent. It is also useful for caregivers to
plan ahead of time in terms of human resource, equipment, supplies, drugs and any alternative
treatments.

A perioperative plan including patient optimization should be devised based on risk assessment
and stratification. One should also take in to consideration if a certain type of patient or
procedure can be cared for in a specific setup, requiring high-level professionals or special
equipment/supplies.

Table 4: Surgical risk classification

Low risk (<1%) Intermediate risk (1-5%) High risk (>5%)


• Superficial surgeries • Abdominal/ Intra- • Aortic and major vascular
o Breast peritoneal(for example, • Open lower limb
o Dental cholecystectomy) revascularization
o Thyroid • Head and neck surgeries • Thromboembolectomy
o Eye • Peripheral vascular • Duodeno-pancreatic surgery
• Reconstructive/ plastic surgeries • Liver resection, transplantation,
• Gynecologic: minor • Neurosurgery bile duct surgery
• Orthopedic: minor • Gynecologic: major • Repair of perforated bowel
• Urologic: minor • Urologic: major • Adrenal resection
• Orthopedic: major • Intra-thoracic: for example
• Renal transplant pneumonectomy,
• Intra-thoracic: non major esophagectomy, pulmonary
transplant

31
Table 5: American Society of Anesthesiologists physical status classification system (ASA
classification)

ASA Class Criteria Pooled mortality (%)


I A normal healthy patient 0-0.3 %
II A patient with mild disease that does not limit activity (e.g., 0.3 -1.4 %
controlled Hypertension, Asthma, Diabetes)
III A patient with severe systemic disease that limits activity 1.8 – 5.4 %
(e.g., angina pectoris, uncontrolled hypertension)
IV A patient with severe systemic disease that is a constant 7.8 – 25 %
threat to life (e.g. Congestive heart failure, renal failure)
V A moribund patient who is not expected to survive with or 9.4 – 57.8 %
without operation (e.g., rupture aortic aneurism)
VI A declared brain-dead patient
E Emergency case

3.2 Surgical Patient Admission


The surgical patient admission is the process whereby patients are admitted to the hospital and
have surgery/an operation. Surgical admissions should be arranged through the liaison service,
which should provide service 24 hours a day, 7 days a week and 365 days a year, including
holidays and weekends for emergency surgery. The hospital should have a written protocol for
the surgical admission of patients that includes all steps to be taken in the admission process,
including how to arrange admissions, in addition to the activities to be undertaken when the
patient arrives.

Upon arrival on the ward, the patient should be received by a nurse who will initiate the ward
admission process, provide an orientation of the available facilities (such as toilet and showers),
and provide instructions for caregivers and so forth. The receiving nurse should in addition
assess the patients/clients condition on arrival in the ward and inform the on-duty physician, as
per the nursing preoperative checklist attached below.

32
3.2.1 Elective Admission Process
The liaison officer has to book elective admissions:

❖ When a patient requires elective admission. A clinical member of the relevant case team
should send the following minimum patient information:

o Patient name, phone number and medical record number


o Summary of the clinical history and reason for admission
o Urgency of admission (set criteria related to pathology of the disease)
▪ Details of criteria to determine urgency of admission for a patient are
annexed (Annex 5)

❖ The liaison officer should book the admission date, provide an appointment card and
assign a medical record number to the patient. The officer should take the contact
information of the patient (and/or caregiver) and give his/her office contact address to the
patient so that the patient can be informed about his/her admission schedule.
o The officer will remind the patient of admission a week prior to the date of
admission
o The officer will inform the patient if there is a change in schedule
o The officer shall adjust the waiting list accordingly when there is a cancellation
for admission
❖ On the day of admission, the patient should report to the liaison officer and from there
he/she will be assisted to make any payment/free stamp and will be directed to the
relevant surgical case team/ward.
❖ On a daily basis, the liaison officer should inform the surgical ward case team of planned
admissions for the following day to ensure that the required service is available and allow
the case team to make all necessary preparation for the admission.

The following key requirements have been identified to facilitate effective elective admission
practices:

o All patients should have a treatment plan within 24 hours of admission


o Having a centralized waiting list management system
o Agreement on the parameters for scheduling operation theatre lists with the OR team

33
3.3 Preoperative Preparation
At the surgical ward, a ward nurse shall accept admitted surgical patients from the liaison office,
check identity, orient and assess the patient and confirm if the preoperative surgical and
anesthesia evaluation was done or not. If done, the nurse shall perform the initial nursing
assessment and document patients’ chart.

3.3.1 Pre-scheduling Checklist

The pre-schedule screening is to be completed by the surgical team, anesthesia team and nursing
team respectively, to assure patient, facility and staff readiness for surgery.

The ward nurse shall notify the operating surgeon and/or the assigned resident to evaluate the
patient and perform the pre-schedule screening.

The surgeon, after evaluating the patient, shall notify the anesthesia team for the pre-schedule
anesthesia screening.

Once the surgical team (surgeon, ward nurse, OR nurse and anesthesia member) confirms that all
necessary preparation is completed during the preoperative conference (see section 3.3.4), the
patient can be scheduled for surgery.

Pre-scheduling Checklist

Identification
Patient Name____________________________________________ MRN ___________

Age ____Sex _____Weight_______ Height________ BMI_______ Blood group_______

Covid test ___________Ward_______ Bed number_________

Surgical related
Date surgical evaluation is done__________________________

Surgical diagnosis______________________________________

Planned procedure_____________________________________

Alternative procedure (if applicable) _______________________

34
Estimated blood loss____________________________________

Number and type of blood products required and prepared ____________________________

Surgical instrument availability confirmed(Y/N)


_______________________________________

Surgical equipment functionality confirmed (Y/N


______________________________________

Special surgical instrument/equipment (if needed) is made available(Y/N) __________________

Surgical informed consent is taken (Y/N) _________

Patient understands about the surgical procedure including (but not limited to) amputation,
insertion of implants, temporary or permanent stoma, drainage tube, nasogastric tube,
tracheostomy (Y/N) ___________

Imaging required in the OR is ready to be sent with the patient(Y/N) _______

Prophylactic antibiotics (if applicable) is ordered (Y/N) ________

Surgical readiness complete (Y/N) ______

Name and signature of responsible surgeon __________

Anesthesia related
Date pre-anesthesia evaluation is done ________________ASA status ________________
Comorbid conditions_____________________________________________________________
Medications patient is taking _____________________________________________________
______________________________________________________________________________
Known allergy (Y/N) _____________________________

Risk stratification ________________________________

Planned type of anesthesia_________________________

Any alternative plan of anesthesia(Y/N) ___________________

Difficult air way anticipated(Y/N) ___________________

35
Preparation for difficult airway management is complete, If applicable (Y/N) __________

Risk of aspiration anticipated(Y/N) __________________

Aspiration prophylaxis ordered(Y/N) ____________

If yes, what was ordered? ______________________________

Medication that shall be continued through the perioperative period is continued(Y/N) ________
Which ones? __________________________________________________________________
Medication that shall not be continued through the perioperative period is discontinued(Y/N) ___
Which ones? ___________________________________________________________________
Substitute medications (if applicable) is given(Y/N) ___________

Which ones? ______________

Instruction on how to take medications is provided to the patient(Y/N) _________

Premedication (if applicable) is ordered(Y/N) __________

If yes, what was ordered? ________________________

Fasting time is ordered(Y/N) _____________

DVT prophylaxis (if applicable) is ordered(Y/N) ________________


Anesthesia supply availability is confirmed (Y/N) _________
Anesthesia equipment functionality is confirmed (Y/N) __________
Special equipment or supply (if needed) is made available: for example invasive line,
medications (Y/N)

If yes, which equipments/supplies were made available?


_______________________________________________

Number and type of blood product required and prepared _______________________________


Pertinent IX labs are ready to be sent to OR (Y/N) ______________
Difficulty for IV access anticipated(Y/N) ______

If yes, alternative plan for IV access_______________

Acute pain service required (Y/N) __________


36
Postoperative disposition planned (ICU/ Ward) ________________________

ICU bed availability (if needed) (Likely/unlikely) _____________MV availability_________


(NB: If ICU bed /or MV/ is unlikely to be available do not schedule the patient)
Anesthesia readiness complete (Y/N) ______

Name and signature of anesthesia provider_____

Administrative related

Ward __________ Bed No. __________

Patient has admission card (availability confirmed) (Y/N) ________________________

Patient has deposited the required payment or has free patient stump (Y/N) ________ (confirm
by seeing admission card)

Surgical, anesthesia and administrative readiness is complete (Y/N) ________________

Name and signature of ward nurse __________________________________________

3.3.2 Preoperative Supplies and Equipment Preparation


Pharmacy

The OR pharmacy shall notify the OR team on the available surgical and anesthesia supplies
weekly. This shall preferably be done electronically.

Blood Bank

The blood bank shall notify availability of blood products to the OR nurse before the patient is
scheduled. This shall be in a written form as a response to blood product and cross match
requests from the ward. This information shall be made available on time. Availability of cross-
matched blood products will be confirmed by a signature and stamp of the blood bank head or
delegate on a written document, which shall be attached in the patient’s chart.

Biomedical Unit

37
The biomedical unit shall be responsible to check the functionality of OR equipment daily and
report weekly to the OR coordinator. Any equipment malfunction shall be corrected as it occurs
or an alternative solution should be sought out on the spot.

38
3.3.3 Informed Consent

Informed consent is a document a patient signs to verify that he/she has engaged in a discussion
with a health care practitioner about a proposed medical treatment. Obtaining informed consent
is an opportunity to guide a patient to the right decision for themselves, and dispel any unrealistic
expectations regarding the procedure.

The patient informed consent form should include the following:


▪ Type of the surgery/anesthesia
▪ Site of operation/anesthesia including laterality or level
▪ The expected benefits
▪ Risks and adverse effects
▪ Alternate treatments available
▪ The consequences of not having the surgery
A template of an ideal consent form in the local language of Amharic can be found below:
የቀዶ ህክምና ስምምነት ቅፅ
የታካሚው ሙሉ ስም…………………….………………..……………ፆታ…….እድሜ……
አድራሻ፡ ክ/ከ/ክልል……………ወረዳ….........ቀበሌ……….የቤት/ቁ………ስልክ ቁጥር…………………
የታካሚው እድሜ ከ18 አመት በታች/እራሱን የሳተ/የአእምሮ ህመምተኛ ከሆነ ብቻ በሚመለከተው የሚሞላ
ቤተሰብ/ሞግዚት/ተወካይ ሙሉ ስም………………………….
አድራሻ፣ክ/ከ/ክልል…………………ወረዳ…................ቀበሌ……………….የቤት/ቁ……………..
የበሽታው(የህመሙ) አይነት………………..………………………………………
የታቀደወ የቀዶ ህክምና አይነት_____________________________________________
አኔ ስሜ ከዚህ በላይ የተጠቀሰው ታካሚ ስላለኝ የጤና ችግር (ከላይ የተገጸው ) እና ስላሉት የህክምና አማራጮች በቂ ገለጻ ተደርጎልኛል::
ለጠየኩዋቸው ጥያቄዎች በቂ ማብሪያሪያ ተደርጎልኛል፡፡ለበሽታዬ ቀዶ ህክምና ባይደረግ ሊያመጣ የሚችለው ችግር የተገለጸልኝ ሲሆን
በማንኛውም ቀዶ ህክምና ወቅት እርግጠኛ የሆነ ውጤት ሊኖር እንደማይችል እና በዚህ ቀዶ ህክምና ላይም እንደዚሁ እርግጠኛ ውጤት እንደሌለ
በምረዳው ቋንቋ ተነግሮኝ ተገንዝቤአለሁ፡፡በቀዶህከምናው ጊዜና ከዚያ በኁላ ሊያግጥሙ ስለሚችሉ
የሚጠበቁ ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬
¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬

ሆነ የማይጠበቁ

ተያያዥ የጤና ችግሮችም በበቂ ሁኔታ ተገልጾልኝ ተረድቻለሁ፡፡


ስለሆነም በዶ/ር ……………………. እና በስራ ባለደረቦቹ የቀዶ ህክምና እንደሚያስፈልገኝ በሚገባኝ(በምነጋገርበት) ቋንቋ በተገልጸልኝ
መሰረት በሙሉ ፈቃዴ የቀዶ ህክምናው እንዲደረግልኝ ተስማምቻለው፡፡ ዶ/ር………………………ከአቅም በላይ በሆነ ምክንያት ቀዶ
ህክምናውን ለማከናወን ባይችሉ ወይም የባለሙያ እርዳታ ቢያስፈልጋቸው ሌሎች እርሳቸው የመረጡዋቸው ባለሙያዎች ቀዶ ህክምናውን
ካለምንም መዘግየት እንዲያደርጉልኝ ፈቅጃለው፡፡ በተጨማሪም ፤ምንአልባት ቀድሞ ከታወቀው(ከተገመተው) ውጪ በቀዶህክምናው ወቀት ሌላ
ህመም ቢገኝብኝ ከታቀደው የቀዶህክምና ውጭ ሀኪሞቹ ተገቢ ነው ብለው ያመኑበትን የቀዶ ህክምና አሰቸኳይ ባይሆንም እንኳን እንዲሰሩልኝ
ተስማምቻለው ፡፡

39
በቀዶ ሕክምናው ወቅት ወይም ከቀዶ ህክምናው በኋላ ደም / የደም ተዋፅዎች ልገሳ ቢያስፈልገኝ እንዲለገሰኝ እና ደም/ የደም ተዋፅዎች ከወሰድኩ
በኋላ ሊያመጣ የሚችለውን ችግሮች ተነግረዉኝ ለመዉሰድ
ተስማምቻለሁ--------------------------------
አልተስማማሁም ------------------------------
ለህክምና ሳይንስ ትምህርት እውቀት ሽግግር እና እድገት ቀዶ ህክምናው በሚካሄድበት ወቅትና ከዚያ በኁላ ተማሪዎች እና አጥኚዎች እንዲኖሩ
እፈቅዳለው፡፡ በዚሁ ጊዜ ለሳይንስ ትምህርት የሚጠቅሙ ፎቶግራፎች እና ቪዲዮች ስሜንና ማንነቴን በማይገልፅ መልኩ እንዲነሱና
ለትምህርታዊ አገልግሎቶች እንዲውሉ ፈቅጃለው፡፡
በቀዶ ህክምናው ጊዜ ከአካሌ የሚወገዱ የሰውነት ክፍሎች ተገቢው ምርመራ እንዲደረገላቸው፤ አንደአስፈላጊነቱም በተገቢው
መንገድ(በሆስፒታሉ አሰራር መሰረት) እንዲጣሉ ተስማምቻለው፡፡
የተነገረኝ መረጃ ግልጽ ሆኖልኝ ይህንን ቅጽ ለመፈረም ወይም ላለመፈረም ምርጫ እንዳለኝ ተነግሮኝ ተስማምቼ ለመፈረም ወስኛለሁ፡፡
ታካሚ /ቤተሰብ/ተወካይ ስምና ፊርማ ----------------------------
የሀኪሙ ስምና ፊርማ --------------------------------------------

ከላይ በተገለጸው መሰረት ታካሚው ካልተስማማ ያልተስማማበት ምክንያት ከታች ይገለጽ፡፡


-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------

የታካሚው ስም-------------------------------------- ፊርማ---------------------------ቀን--------------------


የሐኪሙ ስም----------------------------------------ፊርማ---------------------------ቀን---------------------
የእማኞች ስምና ፊርማ
1. ስም----------------------------------- ፊርማ------------------
2. ስም----------------------------------- ፊርማ------------------
3. ስም----------------------------------- ፊርማ------------------

ማስታዎሻ፡-ተቋማት እንደ አስፈላጊነቱ ይዘቱን ሳይቀንሱ ሊያሻሽሉት ይችላሉ፡፡

የአንስቴዢያ ስምምነት ቅጽ
የታካሚው ሙሉ ስም…………………….………………..……………ፆታ…….እድሜ……
አድራሻ፡ ክ/ከ/ክልል……………ወረዳ….........ቀበሌ……….የቤት/ቁ………ስልክ ቁጥር…………………
የታካሚው እድሜ ከ18 አመት በታች/እራሱን የሳተ/አይምሮውን የሚያመው ከሆነ ብቻ በሚመለከተው የሚሞላ
ቤተሰብ/ሞግዚት/ተወካይ ሙሉ ስም………………………….
አድራሻ፣ክ/ከ/ክልል…………………ወረዳ…................ቀበሌ……………….የቤት/ቁ……………..
የበሽታው(የህመሙ) አይነት………………..………………………………………
የታቀደወ የቀዶ ህክምና አይነት_____________________________________________
የታቀደዉ የአነስቴዚያ አይነት
እኔ ስሜ ከላይ የተጠቀሰው ታካሚ ሊሰራልኝ ለታቀደው ለቀዶ ህክምናው ወይም ለሌላ የህክምና ምርመራ የሚያስፈልገውን የአንስቴዢያ
(የማደንዘዝ፣ ሰመመን) አይነት መርጠው ወ/ሮ/አቶ/ዶ/ር ………………………………………………………… እና የስራ ባልደረቦቻቸው
እንዲሰጡኝ ፈቅጃለሁ፡፡ ያሉትንም የአንስቴዢያ (የማደንዘዝ፣ ሰመመን) አማራጮች ጥቅማቸውና ጉዳታቸው ሊያጋጥሙ የሚችሉ፤
የሚጠበቁ

40
ያማይጠበቁ

ውጤቶች በዝርዝር በባለሞያው ተነግሮኝ ለመወሰን እድል ተሰጦኛል፡፡


የታካሚዋ/ው ስምና ፊርማ------------------------------------ ቀን----------------

የሐኪሙ ስም----------------------------------------ፊርማ---------------------------ቀን---------------------
የእማኞች ስምና ፊርማ
1. ስም----------------------------------- ፊርማ------------------
2. ስም----------------------------------- ፊርማ------------------
3. ስም----------------------------------- ፊርማ------------------

ከላይ በተገለጸው መሰረት ታካሚው ካልተስማማ ያልተስማማበት ምክንያት ከታች ይገለጽ፡፡


-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------

የታካሚው ስም-------------------------------------- ፊርማ---------------------------ቀን--------------------


የሐኪሙ ስም----------------------------------------ፊርማ---------------------------ቀን---------------------
የእማኞች ስምና ፊርማ
1. ስም----------------------------------- ፊርማ------------------
2. ስም----------------------------------- ፊርማ------------------
3. ስም----------------------------------- ፊርማ------------------

3.3.4 Pre-operative Conference

The pre-operative conference is an important surgical team forum for pre-operative discussion
and communication of surgical patients. It improves efficiency of the surgical team and
optimizes patient safety. Studies show if done right, it does not take time and causes no delays in
the operation. The World Health Organization (WHO) and other institutions have developed
guidelines for pre-operative briefings. However, it can be fully or partly adopted based on the
local need.

The following are short-thumb rules for conducting a pre-operative conference:


1. The pre-operative conference should bring the following team members together:
● The surgeon
● The anesthetist/anesthesiologist
● The OR nurse
● The ward nurse
41
● Other as necessary
2. The surgeon should be the leader of the pre-operative conference
3. The pre-operative conference time should be a day before the operation
4. The outcome of the pre-operative conference should be communicated based on the
available means to all stakeholders and most importantly to the patient
5. Operation list scheduling should take into account the inputs and outcomes of the pre-
operative conference
6. The pre-operative conference checklist is used to ensure that all team members possess
accurate and explicit information regarding the patient and the procedural plan

42
Table 6: Preoperative conference checklist

Patient Full Name: Implant (s) Remark


N/A Yes
If yes, Specifics
Patient MRN Pertinent Lab Results
Names & Roles of Team Members Risk of >500 ml Blood Loss
1. No
Yes, and adequate IV access and
2. fluids planned, and blood availability
confirmed
3.
If Yes, Screen Type &
4. Cross match

Procedure or surgical site Need for prophylactic


marked or on wristband antibiotics
Yes
N/A
Laterality/Side: DVT Prophylaxis:
Left/ Right
Yes
N/A

Known Allergy Anticipated Critical Events:


Yes Surgeon___________________
No Anesthesia_________________
N/A Nursing____________________

Anesthesia type Post-operative disposition & bed availability


Difficult Airway
Yes No
Aspiration Risk?
Yes No
If yes, equipment & assistance available_______
Safety check completed pulse oximetry_______
Instruments and special equipment Other
N/A
Yes, if yes specify

43
3.3.5 Psychological Preparation of the Patient
Good communication and creation of rapport is key to prevent anxiety of patients scheduled for
surgery. The cause of anxiety includes, but is not limited to, fear of death, pain, disability and
awaking in the middle of surgery. All health providers shall provide clear information to patients
during the preoperative visit to ease patients’ anxiety:

• Surgeons should inform the patients in detail about the procedure, the surgical
complications and ease any anxiety regarding the surgical procedure.
• The anesthesia team should inform the patients about the anesthetic medication type,
route of delivery, possible anesthesia related complications and address all anxiety
regarding anesthesia administration.
• The nursing team should inform the patients regarding general knowledge of surgery,
addressing the social aspects of the perioperative period.

In case of pediatric patients, family members must be around at all times to ease the patient’s
anxiety. Use of toys and games help alleviate fear.

Administration of preparative drugs/premedication

According to the patient’s clinical condition, premedication drugs shall be administered to


patients in order to smoothen the perioperative period. Premedication shall preferably be given
via oral route.

Premedication is administered for the following purposes:

▪ Reduction of anxiety and pain: the anesthetist or anesthesiologist can provide anxiolytic
premedication whenever non-pharmacologic method are deemed ineffective
▪ Promotion of amnesia
▪ Reduction of secretions
▪ Reduction of volume and pH of gastric contents (to avoid Mendelson's syndrome)
▪ Reduction of postoperative nausea and vomiting (PONV)
▪ Enhancing the hypnotic effects of general anesthesia
▪ Reduction of vagal reflexes to intubation
▪ Specific indications – such as prevention of infective endocarditis with antibiotics

44
Table 7: Common premedication drugs and administration

Drugs Route Dose (mg/kg)


Benzodiazepines
o Diazepam Oral 0.1 – 0.5
o Midazolam Oral 0.25 -1
IM 0.1 – 0.2
IV 0.01 – 0.1
Phencyclidine
o Ketamine Oral 3-6
IM 3-6
Opioids
o Morphine Oral 0.2 – 0.5
o Meperidine Oral 1–2
Antacids
o Sodium citrate Oral 30 ml
o Ranitidine IV 50 mg
o Cimetidine IV 200 mg
o Omeprazole Oral 20 mg
Prokinetic
o Metoclopramide IV 10 mg

3.3.6 Fasting Recommendations


All patients shall fast before any procedure performed under general anesthesia, regional
anesthesia or sedation. Patients should be well informed about the reason why fasting is needed
by the anesthesia provider, as well as the duration of the fasting/NPO time. It should be noted
that caregivers must also be addressed as they may secretly feed the patient, especially pediatric
patients, without understanding the grave consequence of such actions.

45
Table 8: Fasting guide

Liquid and Food intake Minimum fasting hours


Clear liquids (water, clear tea, black coffee, 2 hours
soft drinks, fruit juice without pulp)
Breast milk 4 hours
Non-human milk (including infant formula) 6 hours
Light meal 6 hours
Regular or heavy meal 8 hours

3.3.7 Operating Theatre Scheduling


Once the preschedule screening and preoperative conference is conducted and the readiness
checklist is complete, the surgical team shall schedule the patient. The schedule shall be
disseminated to the OR, respective patient ward and blood bank before the institution’s agreed
upon deadline for OR schedule submission.

OT scheduling involves an arrangement of several operating rooms to the available surgeons in a


specified period. There are multiple variables that go into consideration, including surgeon’s
availability, the patient’s condition, availability of the operating room and the presence of the
right medical devices/ surgical instruments. If done right, it contributes to improving the
operational efficiency of the hospital and ensures timely care to patients with minimal waiting
time.

There are different types of scheduling in the context of operation theaters that are followed in
different hospitals. Each institution can select any of the scheduling methods based on their
character and situation:

Open scheduling: Open scheduling allows surgical cases to be assigned to an operating room
available at the convenience of the surgeons. This method can be used in facilities with small
number of ORs with low flow (for example, primary hospitals, health centers with OR block).

Block scheduling: Block scheduling allows the assignment of specific surgeons or groups of
surgeons to a set of time blocks, normally for some weeks or months, into which they can

46
arrange their surgical cases. This method can be use in facilities where there are adequate
number of OR’s and operating staff for the hospital’s case flow (for example, referral hospitals,
teaching hospitals).

Modified block scheduling: Here the allotted block time can be modified if the operating theatre
planning does not keep up with the demands of the surgeons. This method can be use in facilities
where there are adequate number of OR’s and operating staffs for the hospital’s case flow (for
example referral hospitals, teaching hospitals).

OR Scheduling Phases

OR scheduling consists of three major phases. The three major phases in OR scheduling are
described as follows:

Strategic Phase: The main objective of the strategic phase is to provide a “case mix plan” which
is an important tool in strategic and tactical hospital planning by allocating OR blocks to surgery
groups. The strategic phase typically has a time horizon of one year.

Tactical Phase: The main objective of the tactical phase is to provide a master surgical schedule
(MSS). The MSS determines the number, type and opening hours of operating rooms for each
surgery group. In the MSS, surgery types are clustered to surgery groups based on similar
characteristics of specialties and requirement of resources in ORs, ICUs and PACUs. The time
horizon of the tactical phase is usually one to three months.

Operational Phase: After development of the MSS, the assignment of cases to operating rooms
and start/end time of each case is determined on a daily basis. This phase specifically deals with
the daily scheduling of patients for next day surgery based on the preset MSS.

Figure 3: OR
scheduling phases

47
Table 9: Operating schedule template

Department------------------------------------------- OR Table: -----------------------Day of Surgery ---------------------------------------

No Patient Age Sex MRN Ward Covid Blood Diagnosis Procedure Type of Surgeon Assistant Anesthesiologist Scrub Circulating Chronological Order Remark
Name test Group anaesthesia Surgeon /Anesthetist Nurse Nurse of conducted surgery

48
3.3.8 Preoperative Nursing Care
Once the patient has been scheduled for surgery, the ward nurse shall identify the patient and
procedure, confirm if procedure site is marked (if applicable), attach ID band on the patient,
review patient chart, confirm if surgical and anesthesia evaluation is done and assure informed
consent is taken.

The ward nurse shall ascertain all the necessary laboratory investigations and imaging are ready
and sent to the OR with the patient on the day of surgery.

The ward nurse shall educate the patient on pre-operative preparations including personal
hygiene: preoperative showering and removal of hair at surgical site.

The ward nurse shall use the following checklist when preparing a patient for OR.

Review of medical record

Patient Name________________________________________ MRN ___________

Age ______Sex _____Weight____ Height______ Blood group______ Allergy


______________

Date and time vital sign is taken _________________

BP__________PR___________RR____________T__________SPO2__________RBS_______

Chart review

Anesthesia, nursing and surgical assessment in the chart (Y/N) _______________

Patient has signed both anesthesia and surgical consent (Y/N) _______________

Blood type and cross match (if applicable) (Y/N) ____________

If yes, how many units? ______________

List of medications patient used in the past clearly indicated in the chart (Y/N)
_________________

Preoperative order is clearly written in the chart (Y/N) _______________

49
Day of surgery

Identification of patient verbally (Y/N) ___________

Procedure and procedure site indicated in the chart (Y/N) __________

Procedure site is marked (if applicable) (Y/N) ______

Crosschecked ID band on the patient (Y/N) ______

Last vital sign taken (Date and time) _______

BP__________PR___________RR____________T__________SPO2__________RBS_______

Patient kept NPO (Y/N) ___________ If yes, at what time? ___________

Patient showered(Y/N) _____________

Pre-op medications given(Y/N) ________

Patient voided urine(Y/N) ___________

Imaging sent to OR with patient (Y/N) ____________

Lab tests sent to OR with patient (Y/N) ___________

Time to OR _______________ Transported by _________________________

Full name and signature of ward nurse _______________________________

3.3.9 Patient Transfer and Handover


On the morning of surgery, a ward nurse and porter shall bring the first surgical patient on the
schedule to the OR waiting area/gate at the facilities agreed upon time, after ensuring the patient
has completed all preoperative requirements. The ward nurse shall handover the patient to the
operating room team using the preoperative handover checklist provided below. Consecutive
patients on the schedule shall be accompanied by the ward nurse and porter to the OR gate once
notified by the OR team (surgical team).

50
At the OR gate the anesthesia and OR nursing team shall:

▪ Accept the patient and confirm the patient’s identity


▪ Confirm the patient’s NPO status
▪ Check if all pre-operative orders are executed accordingly, including the administration
of medications
▪ Check if new clinical events have developed since the last evaluation

The patient shall be made to change cloth in the way that keeps the patient’s dignity at the
designated area at the OR gate.

The patient shall be transferred to the operating room table by the runner nurse once the
anesthesia and OR nursing team members confirm readiness.

Preoperative Handover Checklist

Patient Identification

Name _______________________________________
MRN ________________________________________
Ward: Bed number______________________________
Age _________________________________________
Sex _________________________________________

Planned surgical procedure


_________________________________________________________
Site marked (Y/N)
____________________________________________________________________
Allergy (Y/N)
____________________________________________________________________
Preoperative surgical order and execution status
____________________________________________________________________
Preoperative anesthesia order and execution status
____________________________________________________________________

51
NPO status /Last meal or liquid
____________________________________________________________________
Blood product prepared (Y/N)
____________________________________________________________________
Blood consent signed (Y/N)
____________________________________________________________________
Surgical and Anesthesia Consent signed (Y/N)
____________________________________________________________________
COVID status
____________________________________________________________________
Medication given and omitted (including antibiotics and DVT prophylaxis)
Medication given Time given Given by
1
2
3
4

Pre-operative vitals
BP _________ HR __________ RR _________ SPO2 __________Temperature _______
Special concern __________________________________________________________
Any new development (ask the patient) ________________________________________
Ward nurse name and signature ______________________________________________
Anesthesia provider name and signature _______________________________________

52
Table 10: Pneumonic for patient transfer- I PASS THE BATON

Initial Stands for...

I Introduction—Introduce yourself and your role/job (include


patient)

P Patient—Name identifiers, age, sex, location

A Assessment—Present chief complaint, vital signs, symptoms,


diagnosis

S Situation—Current status/circumstances, including recent


changes and response to treatment

S Safety concerns—Critical lab results*, socioeconomic factors,


allergies

THE

B Background—Comorbidities, previous episodes, medications,


family history

A Actions—What actions were taken or are required? Provide


brief rationale

T Timing—Prioritization of actions

O Ownership—Who is the responsible caregiver and professional


for the patient?

N Next—What will happen next? Anticipated changes? Is there a


contingency plan?

Adapted from (AHRQ: Agency for Healthcare Research and Quality)


*Critical lab results: indicates laboratory results specific to the patient and the procedure to be
performed.

53
3.3.10 Operating Room Readiness Checklist

The runner OR nurse must use the following checklist before bringing the patient to the
operating room and before preparing the specific case equipment cart.

54
Table 11: Operation room readiness checklist

Cleanliness and Dust

1 Inspect floor for cleanliness and dust Clean and damp dust if Remark
YES NO required
Clean and damp dust if
2 Inspect lights for cleanliness and dust
YES NO required

Clean and damp dust if


3 Inspect furniture for cleanliness and dust YES NO required

4
Check the temperature and humidity of the room YES NO
Check the appropriate equipment and supplies are available and functional
Equipment & Supplies Lists Available Functional

1 Arm Strap X2 YES NO YES NO

2 Arm Board X2 YES NO YES NO

3 Back table
YES NO YES NO

4 Bed
YES NO YES NO

5 Bed locked
YES NO YES NO
Bed made up with draw sheet is plugged in and
6
working YES NO YES NO

7 Count board is erased


YES NO YES NO

55
8 Count sheet
YES NO YES NO

9 Electrocautery unit with foot pedal(s)


YES NO YES NO

10 Foot stools
YES NO YES NO

11 IV stand X2
YES NO YES NO

12 Kick bucket and sponge counter


YES NO YES NO

13 Linen receptacle
YES NO YES NO

14 Mayo stand
YES NO YES NO

15
Patient warming machine YES NO YES NO

16 Positioning materials YES NO YES NO

17 Prep table
YES NO YES NO

18 Ring stand (2) single and (1) double YES NO YES NO

19 Safety strap YES NO YES NO

20 Sitting stools YES NO YES NO

21 Separate suction available for anesthesia


YES NO YES NO

56
22 Suction plugged in and suction working
YES NO YES NO

23 Surgical lights YES NO YES NO

24 Time-out paperwork/ Surgical safety checklist YES NO YES NO


Trash receptacles (that is, clean and
25
biohazardous) YES NO YES NO
Insert any other basic equipment per the
facility
Name and Signature…......................................... Date..../..../..../
___________________________________

57
4. Intraoperative Care
Intraoperative care begins when the patient is transferred and handed over to the operating room
team according to the facility’s operating theatre protocol and ends when the patient is handed
over to the anesthesia care unit or transferred to the ICU.

Figure 4: Elective surgery intraoperative process map

Emergency surgery and cesarean section intraoperative process maps have been annexed (Annex
3).

58
4.1 Intraoperative Patient Reception and Briefing
4.1.1 Handover
Formal standardized hand over/hand off protocols, and clear verbal and written communication
should be used during the transfer of a patient from one health professional/team to another to
ensure continuity of care.

Once the patient has been handed over at the OR gate to the OR team, the runner nurse should
transfer the patient to the OR table, accompanied by the anesthesia team.

4.1.2 Transferring patient to OR table


• Patients shall be wheeled in or transferred using a stretcher (or wheelchair when
indicated), accompanied by OR nursing and anesthesia team at all times.
o Be sure to take note of patient’s drainage tubes and lines upon transfer.
o Make sure the patients’ body is well covered and their dignity is maintained at all
times.
o For pediatric patients, the minor should be accompanied by the family
member/care giver to the OR table to reduce anxiety. The family member/care
giver shall leave the OR room once the patient is sedated.
• Make sure the OR table legs are locked before attempting to transfer patients to avoid
falls.
• Ensure the table is fully covered with a plastic sheet to avoid skin burn.
• Lower the table to the height of the stretcher and transfer the patient on to the OR table
(provide a foot stool if transferred via wheelchair).
o Use an adequate number of team members upon transferring the patient to the OR
table to avoid injury to the patients.
o It is not uncommon to see head trauma from hanging OR light; push them away
from the table up until the patient is transferred and laying comfortably on the
table.

4.1.3 Briefings
A surgeon-led preoperative briefing or "huddle" is a 1-5 minute session conducted on the day of
surgery in the OT, before the patient enters the OT. All members of the surgical team must be
present. As a team, the schedule of the day for a specific table is discussed in depth, allowing

59
timely communication of any new developments and/or schedule rearrangements to be made.
Standardized preoperative briefings include participation of the entire OR team (surgeon,
anesthesiologist/anesthetist, circulating nurse, and scrub technician) and have the following
elements:

➢ Introducing team members and their roles

➢ Rechecking patient identity (using dual identifiers) and consent, the surgical procedure to
be performed, the site, and side of surgery

➢ Identifying the patient's medical status, recent laboratory and/or radiology results, and the
management plan for medical comorbidities such as diabetes

➢ Ensuring the teams understanding of critical steps for the procedure, as well as devised
contingency plans.

➢ Discussing antibiotic administration (if appropriate), including antibiotic selection, initial


dosing and timing, and plans for re-dosing (if appropriate)

➢ Discussing venous thrombosis prophylaxis

➢ Evaluating fire risk and discussing mitigation strategies

➢ Verifying blood product availability (if appropriate)

➢ Determining ideal monitoring strategies and availability of equipment

➢ Verifying availability and proper functioning of all necessary surgical equipment and
instruments, and identifying any implant concerns

➢ Discussing appropriate patient positioning, padding, and skin preparation

➢ Planning postoperative disposition (for example, PACU or ICU)

➢ Inviting all team members to ask questions and to speak up regarding any concerns
throughout the procedure

A preoperative briefing template, which can be adapted per facility and specialty unit, is annexed

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(Annex 6).

4.1.4 WHO Safe Surgery Checklist


To ensure safe surgical care and patient safety, all hospitals should implement the Surgical
Safety Checklist (SSC). The surgical team should make an effort to reduce avoidable adverse
events due to poor communication, poor team work and organizational culture by using the SSC
checklist recommended by the WHO, and work toward improving safety.

The WHO SSC is a standard version that serves as a template. Modification of the original SSC
is possible by adding components that are pertinent to the facility, without removing the essential
19 items.

WHO’s Surgical Safety Checklist Structure

The SSC has three phases. In each phase, the members of the surgical team have assigned
specific responsibilities:

Sign in: Before induction of anesthesia, members of the team (at least the
nurse and an anesthesia professional) verbally confirm that:

➢ The patient verifies his or her identity, the surgical site and procedure, and that consent is
signed

➢ The surgical site is marked or site marking is not applicable

➢ The pulse-oximeter is on the patient and functioning (if not, do not proceed with the
procedure)

➢ All members of the team are aware of whether the patient has a known allergy

➢ The patient’s airway and risk of aspiration have been evaluated and appropriate equipment
and assistance are available (if not, do not proceed with the procedure)
➢ If there is a risk of blood loss of more than 500 ml (or more than 7 ml/kg of
blood weight in children), appropriate access and fluids are available (if not,
do not proceed with the procedure)

Time out: Before skin incision, the entire team (nurses, surgeon, anesthesia
professionals and any professional participating in the care of the patient) verbally:

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➢ Confirms that all team members have been introduced by name and role
➢ Reviews the anticipated critical events

➢ Surgeon reviews surgical critical concerns, operative duration, and


anticipated blood loss
➢ Anesthesia staff review anesthesia concerns specific to the patient

➢ Nursing staff review confirmation of sterility, equipment availability, and other concerns

➢ Confirms that prophylactic antibiotics have been administered < 60 min


before incision is made or that antibiotics are not indicated

➢ Confirms that all essential imaging results for the correct patient are displayed
in the operating room or not applicable

Sign out: Before the patient leaves the operating room, and while the entire team is present in the
OR, verbally confirm that:

➢ The checklist coordinator/runner nurse names the procedure as recorded

➢ The needle, sponge, instrument counts are complete

➢ Specimen is correctly labeled if applicable

➢ Any equipment problems to be addressed are discussed

➢ Key concerns for recovery and management of the patient are discussed

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Figure 5: World Health Organization's Surgical Safety Checklist

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4.2 Intraoperative Nursing Care

Nursing activities in the intraoperative period are centered on patient safety, facilitation of the
procedure and prevention of infection to achieve a satisfactory response to anesthesia and
surgery. The following checklist should be filled by the nursing team during the intraoperative
period.

Table 12: Intraoperative nursing care checklist

Circulating Nurse/ Non sterile activities Initials/Signature

Environment

Assists with the preparation of the room


Ensures that needed items are available and sterile (as
required)
Checks mechanical and electrical equipment and
environmental factors
Ensures patient safety in transferring and positioning

Positions the patient (collaboration in patient positioning)


to ensure correct alignment, exposure of surgical site, and
prevention of injury
Coordinates all activities in the room with team members
and other health related personnel and departments
Procedure

Plans and coordinates the intra-operative nursing care

Checks the chart and relates pertinent data


Reviews anatomy, physiology and surgical procedures

Practices aseptic technique in all required activities

Monitors practice of aseptic technique in self and others

Ensures that needed items are available and sterile (as


needed)
Identifies and admits the patient to OR

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Assesses the patient’s physical and emotional status

Assists with transferring the patient to the operating room


bed
Ensures patients safety in transferring and positioning

Participates in insertion and application of monitoring


devices
Assists with the induction of anesthesia

Monitors the draping procedure

Measures blood and fluid loss

Monitors urine output

Counts sponges, needles and instruments (three times)

Moves nonsterile items out of the operating room

Accompanies the patient to the anesthesia recovery area

Reports and recordings

Documents intra-operative care

Records, labels and sends tissue specimens and cultures to


proper locations
Records the counted items (sponges, needles and
instruments) correctly on registration book, white board or
computer
Reports relevant information to the care of the patient to
the recovery area nurses
Records amount of drug used during local anesthesia

Scrub Nurse/ Sterile Activity

Procedure Initial/Signature

Reviews anatomy, physiology and the surgical procedure

Assists with the preparation of the operating room

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Scrubs, gowns, gloves self and other members of the
surgical team
Assists with draping procedures

Ensures the integrity of sterile field

Ensures the correct counts of sponges, needles and


instruments
Monitors practices of aseptic techniques in self and others

Reports amount of local anesthesia and other solutions


used by surgeon
Instrument

Prepares the instrument table and organizes sterile


equipment for functional uses
Passes instruments and is attentive to the surgeon and
assistants, anticipating their needs
Proper cleaning packaging instrument after use (especially
fragile instruments)
Records incidents (for example, lost instruments, lost
gauze, packs)
Patient care

Positions the patient for proper body and site alignment

Keeps tracks of irrigation fluid and drainage tubes on table


and during transfer
Applies proper dressing of wound site

Assists in the transfer and handover of the patient to the


ICU/PACU
A sample of an intraoperative count sheet is annexed (Annex 10).
4.3 Intraoperative Anesthesia Care

4.3.1 Preparing the anesthesia station


The anesthesia provider shall make sure of the availability and functionality of equipment,
supplies and medications before bringing the patient to the OR. The WFSA-WHO minimum
anesthesia standard guideline for LMIC shall be followed.

The provision of safe anesthesia depends on careful preparation, which includes:

1. Any machine or apparatus that supplies gases, vapors, local anesthesia or intravenous
anesthetic agents to induce or maintain anesthesia

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2. Any equipment necessary for securing the airway
3. Any monitoring devices necessary for maintaining continuous evaluation of the patient
4. Medications
5. The patient himself or herself correctly identified, consensual and evaluated
preoperatively
One can use the mnemonic “SOAP ME’ in preparing the anesthesia station before the patient
enters the operating room.

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Table 13: How to prepare the anesthesia station using the SOAP ME pneumonic

S- Suction Check availability of the suction machine and make sure that it is
functional
O- Oxygen -Check for availability of oxygen and ensure the amount available is
enough to last the intended operation period
-Make sure alternative oxygen sources are readily available as a
backup for oxygen failure
-Make sure oxygen delivery devices are readily available (nasal
prong, face mask, bag mask valve, pediatric breathing system)
A–Airway equipment Check availability of appropriate size of the following:
• Laryngoscope – two different size blades
• ETT – 3 (expected size and one size below and above), check
cuff
• Oral airway/Nasal airway
• LMA
• Stylet
• Anesthesia Mask
• Ambu bag
• McGill forceps
Ensure difficult airway equipment is readily available (video
laryngoscope, combitube, bougies, intubating laryngeal mask
airway, fiber-optic bronchoscope, articulating laryngoscope,
cricothyroidotomy set )
P- Positioning Avail towels , pads or ramp to be applied under pressure areas and to
maintain optimal intubation position
M – Machine, Monitors Check the anesthesia machine is functional
and Medications Check continuous monitoring device is functional
Check anesthesia and resuscitation drugs are drawn up and labeled
E–Emergency equipment Check availability of functional defibrillator, percutaneous
and supplies tracheotomy set and emergency cognitive aids

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Anesthesia Machine
In preparing for anesthesia, the anesthetic machine should be checked by the anesthesia provider:

❖ Before each administration of anesthesia


❖ Before the start of each operating day
❖ After any repair or maintenance of the anesthetic machine
❖ When introducing a new anesthetic machine
A checklist for the anesthetic machine should be available at each operating room.

Every anesthetic machine should meet the following minimum standard requirements:

❖ Oxygen and medical air flow-meters


❖ Color-coding system compatible with international standards
❖ Visual labeling of gauges and meters
❖ Anti-hypoxic device
❖ Oxygen-flush button and an oxygen failure system (visual/audible)
❖ A back-bar that can fit two vaporizers
❖ A separate built-in oxygen flow-meter
❖ A breathing system that can also accommodate pediatric patients
❖ A scavenging system
The anesthetist should be aware of the checklist and follow them exactly. There should always
be an alternative oxygen supply. An alternative method of ventilating the patient must always be
available (that is, a self-inflating resuscitation bag). All failure alarms functionality should be
checked before proceeding. There should be an oxygen analyzer present on the anesthetic
machine. No anesthesia should commence until every machine defect, if found, is fixed.

Anesthesia providers shall make sure a cognitive aid and algorithm for the management of very
common and rare emergencies, such as hypoxemia, cardiac dysrhythmia, malignant
hyperthermia, anaphylaxis or others are readily available inside the operating theater before
starting the procedure.

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Once the patient is on the OR table, make sure that IV line(s) are patent or open a new one.
Apply monitors and check the initial vital signs. Continuously communicate all procedures and
interventions applied to the patient; this will help alleviate their anxiety.

In all cases, pre-oxygenate patients before induction of anesthesia. This can be done by
administering 5-10 L/min of oxygen via a tight fitting anesthesia mask for 3-5 minutes. In case
of emergency procedures, 4-5 deep breaths will suffice.

Before induction of anesthesia, one can use the WHO anesthesia checklist to re-confirm
everything is ready.

4.3.2 Patient Positioning and Anesthesia


Proper positioning requires the cooperation of anesthesiologists, surgeons, and nurses to ensure
patient well-being and safety while providing surgical exposure. During anesthesia care,
whenever possible, patients should be placed in a position that they would tolerate when awake.
All jewelry and hair ornaments must be removed. Padded surfaces, lumbar support, and natural
joint positioning are optimal. The head should remain in the midline position without substantial
extension or flexion whenever possible. At no time should pressure on the eyes occur. Because
surgeons wish to have optimal exposure, and positions may be maintained for long periods,
prevention of complications often requires compromise and judgment. The duration of more
extreme positions, if such are necessary, should be limited as much as possible. Tilting of the
operating room table during surgery should be anticipated before draping, and the patient should
be secured accordingly. Use of safety straps and prevention of a fall are fundamental.

Airway Management
Airway management during anesthesia management of surgical patients is a crucial component
of anesthesia service in the operation theater. It needs to be practiced in accordance with updated
national and international airway management guidelines. This will be accompanied by a well-
prepared basic and advanced airway management cart/trolley. Maintenance of oxygenation must
take priority over all other issues. Pre-oxygenation should be performed before induction of
anesthesia. Mask ventilation should be used between attempts at tracheal intubation. Trauma
must be prevented at all times. The first attempt at tracheal intubation should be performed under
optimal conditions, including patient position, pre-oxygenation, and equipment preparation. The

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number of attempts with blind techniques should ideally be zero and certainly not more than
four.

The anesthesia provider should have a sequence of backup plans in place before starting the
primary technique. They should have the skills and the equipment needed to execute these plans.
When unanticipated difficulty occurs in non-lifesaving surgery, the safest plan is to terminate
attempts at tracheal intubation, awaken the patient, and postpone surgery. The anesthesia
provider should seek the best help available (“call for help”) as soon as difficulty with tracheal
intubation is experienced.

Regional Anesthesia
Different regional anesthesia techniques need to be selected on an individual basis, taking in to
consideration the patient’s preference as well.

The conduct of regional anesthesia should be performed with prior preparation for general
anesthesia, and according to the institutionally agreed upon protocol. The protocol need to
address the utilization of different regional anesthesia techniques for different purposes including
intraoperative anesthesia management, pain control and postoperative pain management
modalities.

Single-use regional anesthesia should be practiced with prepared spinal and epidural sets
respectively.

Peripheral Nerve Block


Peripheral nerve blocks, including trunk, upper and lower extremity blocks, must be practiced
with full prior pre-anesthetic evaluation of patients, and clear documentation of consent after
explanation is given to patients on advantage and shortcomings of this procedure. All peripheral
blocks should be guided by the institutional protocol. A plan for failed or deteriorating peripheral
nerve blocks, like general anesthesia or monitored anesthesia care, should be prepared according
to national and international recommendations. These blocks can be performed using the
landmark based, peripheral nerve stimulator guided or ultrasound-guided approach.

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4.3.3 Induction of Anesthesia
Make sure you have a trained assistant before administering your anesthetic medication. Perform
the WHO SSC sign in before induction of anesthesia in the presence of all surgical team
members. Inform the patient that you are anesthetizing him/her and the feelings he/she may
develop such as dizziness, sleepiness, passing out, or burning sensation at the IV administration
site. You need to inform what is expected from the patient when awakening from anesthesia such
as following instruction like ‘protrude your tongue’, or ‘open your eyes’. Induction technique
and choice of induction agent will be based on the patient’s clinical condition. In case of
emergency procedures where the patient has a full stomach or bowel obstruction, use rapid
sequence induction to reduce risk of aspiration. In case of general anesthesia, secure the airway
and maintain oxygenation and ventilation. The specific airway device to be used and ventilation
strategy depends on the patient’s clinical condition and should be individualized. One needs to
confirm the airway device is appropriately placed and patient is well-ventilated and getting
adequate oxygen.

4.3.4 Maintenance of Anesthesia


Anesthesia shall be maintained by further continuous administration of inhalation or intravenous
agents. This shall depend on the individual patients’ condition and availability of resources.
After making sure that the anesthesia state is well maintained, surgery can be started. Perform
the WHO SSC time out just before skin incision.

The anesthesia providers are expected to perform the following tasks while the operation is in
progress:

1. Monitor patient vital signs: Patient’s blood pressure, heart rate and rhythm, oxygen
saturation, temperature and expired carbon dioxide level should be monitored. This shall
be documented on the intra-operative anesthesia recording sheet at 10 minute intervals (a
template of an anesthesia recording sheet has been annexed- Annex 7).

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Table 14: Anesthesia parameters to be monitored intraoperatively

Parameter to be monitored Recommended minimum interval of monitoring


Blood Pressure (BP) Every 5 minutes or continuously using invasive
arterial line in selected high risk patients
Heart rate and rhythm (HR) Continuously using ECG
Oxygen saturation (SPO2) Continuously using pulse-oximeter
Temperature Continuously using patient monitor temperature
probe or every 30 minute using a digital
thermometer
End tidal CO2 (ETCO2) – expired carbon Continuously using capnometer
dioxide level
2. Monitoring depth of anesthesia: The anesthesia provider should clinically follow the patient
to assess whether the level of anesthesia meets the surgical stress or not and accordingly increase
or lower the amount of anesthesia administered.

3. Monitor the surgical field and blood loss: The anesthesia provider shall inspect the surgical
field to follow the course of surgery, follow critical steps and tailor anesthesia accordingly. The
anesthesia provider should also estimate blood loss by measuring blood inside the suction tube,
counting number of blood soaked gauze and taking into consideration blood pouring over the
drapes, surgeons’ hand, operation table and the floor.

4. Administer fluid: The anesthesia provider shall administer intraoperative fluid according to the
patient’s individualized fluid requirement. The fluid administration should take in to
consideration deficit, maintenance requirement and ongoing losses. Extra caution should be
taken when administering fluid to patients who are prone to develop fluid over load such as
patients with cardiac and renal failure.

5. Monitor input output strictly: In case of longer surgeries or when significant fluid shift is
expected, urinary catheters need to be inserted to monitor urine output. Urine output shall be
checked and documented by the anesthesia provider every one hour in catheterized patients.

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6. Prevent patient fall, injury and bedsore: Apply physical restraints, cushion pads and towels
under pressure areas (occiput, shoulders, sacrum, elbows, and heels) and take extra care when
transferring the patient to avoid injury.

7. Monitoring tubes: Monitor oxygen, anesthesia machine, patient monitor, breathing circuits,
tubes, IV lines and other ancillary equipment to assure proper functioning and safe delivery of
anesthesia.

8. Continuous patient monitoring and communication: The anesthesia provider shall be present
in the room throughout the administration of any kind of anesthesia be it general, regional or
monitored anesthesia care. The anesthesia provider should be vigilant and always stand by to
provide life support measures such as cardiopulmonary resuscitation. It is prudent to have
professional and continuous communication with the surgeons and other professionals as needed
throughout the surgical procedure.

9. Cautionary measures: The anesthesia provider shall maintain standards to protect patients and
staff from all hazards including cross-infection, and the safe disposal of sharps.

10. Thorough documentation: The anesthesia provider shall record all the intra operative events
throughout the procedure.

4.3.5 Recovery Phase


The anesthesia provider shall prepare for the recovery phase as the surgery is approaching the
end, as per the recovery plan set during the preoperative evaluation.

The recovery preparation may include:

• Reducing the anesthesia administered.


o Avoid totally discontinuing anesthesia before completion of surgery. This is one
of the commonly encountered mistakes made by the anesthesia provider.
• Preparing extubation equipment: functional suction machine, suction tip, anesthesia
mask, syringe, equipment for re-intubation, oxygen delivery devices
• Drawing and labeling reversal medication
• Informing the PACU/ICU to prepare to receive the patient

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When the operation ends, perform the WHO SSC sign out. Extubate the patient when the patient
becomes conscious and is able to protect his/her airway and breathe adequately, unless deep
extubation is required due to patient related factors.

The patient shall be transferred to the PACU/ICU after confirming that the effect of anesthesia is
proficiently reversed and the patient is in stable condition to be transferred. The anesthesia
provider shall remain by the patient’s side until the patient is transferred out of OR and handed
over to the PACU team. In case of aggressive or delirious patients, physical restraint and/or
sedative agents shall be used. The transfer and handover should follow institutional or national
protocols.

4.3.6 Documentation and Recording of Intraoperative Anesthesia Management


The primary purpose of anesthesia documentation is to capture accurate and comprehensive
information to communicate a patient’s anesthetic experience. The following intraoperative
anesthesia related activities should be documented on a preformed anesthesia recording sheet
[The anesthesia recording template is annexed (Annex 7)]:

• Patient identification and major preoperative findings such as ASA classification,


anticipated difficult airway, presence of allergy
• Induction technique
• Laryngoscopy grading for intubated patients
• Airway equipment used
• Medication used including dose and route
• IV access (number and size of cannula)
• Monitoring tool utilized
• Intraoperative vital signs, blood loss and urine output
• Total fluid administered, type and amount of blood product given
• Anesthesia and surgery start/end times
• Any adverse anesthetic event or complication
• Providers name and signature

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4.4 Intraoperative Surgical Care
Since every surgical procedure entails a set of operative risks, the operating team should be ready
to prevent avoidable risks and respond to complications accordingly. The operating team should
carry out the following activities during the intraoperative period:

• Check and ensure the right patient receives the right operation before each operation by
using all the appropriate checklists (for example, the WHO surgical checklist)
• Ensure thermoregulation and patient dignity are maintained (that is, patient centered care-
patient’s should be seen as human beings and not as ‘a case’)
• Ensure that the procedural technique used is the one with minimal blood loss and/or
prepare blood for major blood loss procedures
• Ensure the appropriate incision type is used and blunt suturing mechanism is applied
• Ensure the right anesthesia type is used for the specific procedure
• Ensure a sterile operation theater environment is maintained:
o Human traffic control must be implemented during the procedure
o Ensure appropriate hand washing technique is followed: washing with soap and
water followed by use of antiseptic
o Conduct appropriate skin preparation by allowing the applied antiseptic agent to
air dry
o Use dry and sterile drapes (avoid wet drape usage)
• Use measures to minimize injuries from sharp edged materials during surgery such as:
✓ Use small Mayo forceps (not fingers) when applying or removing surgical blades
from the blade holder or when loading the needle holder. (Alternatively, use
disposable scalpels with a permanent blade that cannot be removed)
✓ Always use tissue forceps, not fingers, to hold tissue when using a scalpel or
suturing.
✓ Use the hands-free technique to pass or transfer sharps (scalpel, needles and sharp-
tipped scissors) by establishing a safe or neutral zone in the operative field
✓ Always remove sharpened materials from the field immediately after use
✓ Make sure that containers for sharp material are replaced when they are only three-
quarters full and place containers as close to where sharp materials are being used
(that is, within arm’s reach)

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4.5 Intraoperative Safety
To ensure safety of the OR environment, every operating room must have proper lighting, good
ventilation, proper equipment for procedures, equipment to monitor patients as needed for the
procedure and drugs as well as other consumables required for routine and emergency use.

The staff, novice and old, must follow the national safety guide and hazardous waste
management policy. Various important components of the protocols include, but are not limited
to, the following:

▪ Applying the concept of aseptic technique (for example, respect the OR’s defined
restricted area)
▪ Demonstrating the national infection prevention and control (IPC) bundle protocol (for
example, appropriate surgical attire)
▪ Preventing and responding to various hazards in the surgical setting, as well as
identifying the role of each operating room member when facing safety threats
o Hazards such as electric burns, fire, blood splashes and falls.
▪ Customizing hazardous waste management policies
▪ Minimizing action-based, decision-based, technical and communication-based human
errors to increase patient safety

4.5.1 Adverse Anesthetic Events


An adverse anesthetic event refers to an actual injury to the patient that is associated with
administration of anesthesia. It includes unexpected or undesirable response(s) to administered
anesthesia medication or intervention.

Documentation of these events on the anesthesia record sheet and OR registry by the managing
anesthesia team is necessary, as it shall be reported to the surgical data management unit. It is
also desirable if the surgical team documents the event on the OR note as a remark.

The following tool will be filled by the anesthesia team upon discharge of the patient from the
OR and at the ward at the 72-hour mark/before discharge from the hospital.

Step 1: Was there one or more adverse event(s) associated with this anesthesia encounter?
o No, this form is now complete
o Yes, fill out reminder of form below

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Step 2: Please describe the adverse event(s). Check all that apply.

Airway Respiratory Cardiovascular Neurology

o Difficult intubation oAspiration oHypotension oIntraoperative


awareness
oDifficult ventilation oSustained requiring vasopressor
hypoxemia support oSeizure
oAirway obstruction oPeripheral nerve
oPremature oArrhythmia
compression/injury
oLaryngospasm extubation oPulmonary embolism oParesis or paralysis
oAirway trauma oPneumothorax oMyocardial oStroke
oBronchospasm infarction oHigh / total spinal
oEsophageal or Endo-
oHypoventilation o Heart failure oLocal anesthetic
bronchial intubation oALI/ARDS oPulmonary edema toxicity
oNegative pressure oHypertensive oBlindness
Renal
oDelayed awakening
pulmonary edema emergency/ crisis
oAcute kidney injury/ oRespiratory failure
failure Gastrointestinal Neuromuscular/MSK Drug error
oFluid overload
oPulmonary edema oHepatitis / hepatic oFracture oWrong drug
injury oSoft tissue injury oWrong dose
Miscellaneous
oHepatic failure oResidual Neuro- oSyringe swap
oDeath oPersistent PONV, muscular block oAmpoule swap
oCardiac arrest
Hiccup oCorneal abrasion oAllergic drug
oMalignant
hyperthermia oStress ulcer/ upper reaction
oPsychosis/ delirium GI bleeding
oPTSD Others (please
oUnplanned ICU specify)
admission

Step 3: Please note the interventions performed to treat the adverse event event(s).
______________________________________________________________
______________________________________________________________
______________________________________________________________
Step 4: Please note the outcome of the adverse event (s). Check all that apply.
Minimal risk outcome
o No adverse outcome

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Moderate risk outcome
o Unplanned ICU admission or escalation of care
Sentinel outcome
o Death
o Permanent neurologic deficit
o Organ failure
Other, specify below
_______________________________________________________________________

Step 5: Assign a severity rating to the adverse event(s) associated with this anesthesia encounter
If there are any options checked in sentinel outcome, then this is severe adverse event
If the most serious option checked above is moderate risk, then this is a moderate adverse event
If the most serious option checked above is minimal risk, then this is minor adverse event
________________________________________________________________________
The tool should remain attached in the patients chart and a copy of the tool shall be kept with the
OR anesthesia coordinator or over all OR coordinator/manager.
4.6 Managing Operating Room Efficiency
Operating theater efficiency is defined as treating the right patient, and providing the right care
within the clinically recommended timeframe, with the optimal use of the resources required to
deliver safe quality care at or below an efficient price for the service.

In order to assure the efficiency of the facilities OR table:

• The OR tables should have their own identifying code: every hospital tables should have
their own identifying code. This therefore would help to measure table efficiency and other
efficiency related measures

• Critical times: the incision time, wheels in time, wheels out time, and surgical end time
should be recorded; these are critical times where unnecessary resources are wasted. In order
to monitor and follow the status of resources, the hospital OR team should record every
‘critical time’ per OR table

• Surgical cancellation: any cancelled case and the reason for cancellation must be recorded.
Cancellation register is annexed (Annex 14)

• Surgical procedure SOP and checklist: each institution must have an SOP for all surgical
procedures and should be followed when surgeries are performed

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• Anesthesia procedure SOP and checklist: each institution must have an SOP for all
anesthesia procedures and should be followed when surgeries are performed

• Intraoperative nursing SOP and checklist: each institution must have a nursing SOP for
all surgical procedures and should be followed when surgeries are preformed

• Standard operating procedure and checklist for surgical supplies: hospitals must prepare
an SOP and checklist for supplies for each surgical procedure

A sample of an operation theatre/room efficiency assessment tool is annexed (Annex 11).

4.7 Intraoperative Documentation and Reporting


Operating room records that should be attached to the patient chart include complete: operation
note, order sheet, anesthesia record sheet, WHO surgical safety checklist, decision note and intra
operative nursing checklist.

All procedures performed must be documented in the surgeon OR book registry, anesthesia OR
book registry and nursing registry.

✓ Operation Note- After each procedure, the surgeon/assistant must complete the operation
note for the patient and should include: patient identity (name, age, sex, card number), time,
indication, procedure type, surgeon name, assistant name, scrub nurse name, runner name,
anesthetist/ anesthesiologist name, type of anesthesia provided, intra operative finding, intra
operative complications and post-operative diagnosis. A sample of an operation note is
annexed (Annex 8).

✓ Order Sheet- After each procedure, the surgeon should record the finding-based order sheet,
which includes: patient name, age, sex, date and time, diagnosis, NPO time, postoperative
antibiotics, postoperative analgesics, wound care, patient positioning, tube management and
physician signature.

✓ OR Registry Book- All surgical procedures, upon completion, must be recorded on the
provided OR registry book- in paper form or digitally. The OR registry book should include:
name, age and sex of the patient, type of procedure/ surgery, indication, name of surgeon/
assistant surgeon/scrubs/runner, name of anesthetists/anesthesiologists, type of anesthesia,
outcomes and remarks. A sample of an OR registry is annexed (Annex 9).

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5. Postoperative Care
5.1 Postoperative Process Map

Figure 6: Elective surgery postoperative process map

Postoperative process maps for emergency general surgeries and cesarean sections are annexed
(Annex 3).
5.2 Postoperative Transport and Transfer to PACU/ICU
Postoperative transport and transfer of patients requires involvement of all surgical team
members in-line with the national surgical safety guideline. The patient is moved carefully off
the operation table using a roller plate. A minimum of four persons are required to safely transfer
the patient on to the shifting trolley or the recovery bed. The wheels of the trolley or recovery
bed should be locked while moving the patient. The team should give careful attention to the
patient’s indwelling catheters, tubes and lines.

All team members will then wheel out the patient from the theater to the recovery room for close
observation. The patient should remain in the PACU/ICU for immediate postoperative care until

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the discharge criteria, according to the institutions protocol, is fulfilled. Once the patient is
stabilized, the patient’s relatives should be informed regarding the status of the patient by the
operating team.

5.3 Handover for Postoperative Care


Effective handover plays a key role in ensuring the continuity, quality and safety of patient care.
Hence, standardization of the handover process can improve patient care and the staff should
comply with the local standardized processes for patient handover. Handovers should be in both
verbal and written form.

Handover Procedure:

a. Hand over from OR to PACU/ICU

A dedicated nurse should be present in the PACU/ICU to receive the patient. Upon arrival to the
PACU, monitoring of patient’s vital signs, level of consciousness and airway patency should be
initiated.

Patient handover from runner nurse to the PACU/ICU practitioner should include patient’s name,
allergy status, details of operation performed, details of any items left in situ (for example packs,
drains, catheter), skin closure technique, type of dressing used, any local anesthetic given during
or after the operation, and any specimen taken during the procedure.

The anesthetist provider should inform the PACU/ICU practitioner about the type of anesthesia
administered, specific intraoperative anesthesia events and/or complications, as well as details of
the parenteral drugs infused.

The surgeon/assistant should inform the PACU/ICU practitioner regarding the nature of the
surgery performed, postoperative orders and surgical complications to watch for.

b. Handover from PACU/ICU to Ward

The PACU team handovers the patient to the ward team based on the postoperative handover
checklist.

Based on the institution’s set criteria, the patient’s readiness for discharge must be met before
discharge. The parameters used for discharging a patient from the PACU/ICU are the following:

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1. Uncompromised cardiopulmonary status
2. Stable vital signs
3. Pulse oximetry readings of adequate oxygen saturation
4. Adequate urine output – at least 30 ml/ hour
5. No signs of fluid volume imbalance
6. Orientation to time, person and place
7. Tolerable or minimized pain
8. Absence or controlled nausea and vomiting

c. Handover from OR/PACU to ICU/HDU (High Dependency Unit)

The PACU nurse following the same hand over protocol can transfer patients not on any
ventilator support to ICU/HDU. Patients on ventilator support should be escorted to the
ICU/HDU directly by the operating team, bypassing the PACU.

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Table 15: Postoperative handover checklist

Patient
Patient identification
Duration of surgery
Allergies
Surgical procedure and reason for surgery
Type of anesthesia (GA, regional, sedation)
Surgical or anesthetic complications
Past medical history
Preoperative cognitive function
Preoperative activity level (METs)
Limb restriction
Preoperative vitals
Procedure
Primary post-operative concern
Positioning of patient
Intubation conditions (grade of view, airway,
quality of bag mask ventilation)
Lines/catheters (IVs, a-lines, CVCs, foley
catheters, chest tubes, surgical drains,
ventriculoperitoneal-VP- shunt)
Fluid Management (Fluids given, blood loss, urine
output, transfusions)
Medications
Analgesia plan - during case, postoperative orders
Antiemetic administered
Antibiotic medications administered
Other intraoperative medications (steroids,
antihypertensive)

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5.4 Postoperative Surgical Care
The physicians should clearly prescribe and document different immediate, early and late
postoperative follow-up related care. This includes orders related to NPO time, ambulation,
venous-thromboembolism prevention strategies, pain management modalities, antibiotic
administration, postoperative care of tubes and catheters, fluid management, frequency of
follow-up, continuation of care, discharge plan and any other concern specific to the patient’s
condition.

Feeding

The decision to start feeding in the postoperative period will depend on individualized patient
factors.

Antibiotic Administration

The administration of intravenous antibiotics should be practiced based on the national rational
drug use formulary.

Venous Thrombo-embolism Prevention Strategies

Postoperative ambulation should be initiated as soon as possible. Patients should ambulate 8-12
hours following the surgery unless indicated otherwise.

For patients who are at high risk for development of DVT, preventive strategies include
intraoperative stockings, sequential pressure cuff use, and medications.

5.5 Postoperative Nursing Care


Airway

❖ Keep airway in place until the patient is fully awake and tries to eject it. Return of pharyngeal
reflex, noted when the patient regains consciousness, may cause the patient to gag and vomit
if the airway is not removed.
❖ Suck out secretions as needed.
Breathing

Use the pneumonic BREATH:

❖ B – Bilateral lung auscultation frequently

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❖ R – Rest and place the patient in a lateral position with the neck extended, and the arms
supported with a pillow, if not contraindicated
❖ E – Encourage the patient to take deep breaths
❖ A – Assess and periodically evaluate the patient’s orientation to person, place and time
❖ T – Turn the patient every 1 to 2 hours to facilitate breathing and ventilation
❖ H – Humidified oxygen administration
Circulation

❖ Obtain patient’s vital signs as ordered and report any abnormalities


❖ Monitor input and output closely
❖ Recognize early symptoms of shock or hemorrhage such as cold extremities, decreased urine
output, slow capillary refill, dropping blood pressure and narrowing pulse pressure and
tachycardia
Thermoregulation

❖ Monitor temperature to detect hypothermia or hyperthermia; report temperature


abnormalities to the physician
❖ Monitor the patient for post-anesthesia shivering
❖ Provide a therapeutic environment with proper temperature and humidity using warm
blankets, warm IV fluids, and/or room heaters.
Fluid Volume

❖ Assess and evaluate patient’s skin turgor


❖ Recognize signs of fluid imbalances:
o Hypovolemia: decreased blood pressure, decreased urine output, increased pulse
rate, increased respiration rate, and decreased central venous pressure (CVP).
o Hypervolemia: increased blood pressure and CVP, chest findings
Safety of Patients

❖ Avoid nerve damage and muscle strain by properly supporting and padding pressure areas
❖ Frequent dressing/surgical site examination for possible tightening, bleeding or discharge
❖ Raise the side rails of the bed to prevent the patient from falling
❖ Protect the extremity where IV fluids are inserted to prevent possible needle dislodgement

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❖ Make sure that bed wheels are locked
❖ Provide symptomatic therapy, including antiemetic medications for nausea and vomiting
❖ Administer phenothiazine medications as prescribed for severe, persistent hiccups
❖ Assist patient to return to normal dietary intake (liquids first, then soft foods)
Patient Comfort

❖ Observe and assess behavioral and physiologic manifestations of pain


❖ Administer medications for pain and document its efficacy
❖ Assist the patient to a comfortable position
Drainage

❖ Maintain patency and monitor drainage of tubes


Wound Care

❖ Perform hand washing before and after contact with the patient
❖ Regularly inspect dressings and reinforce them if necessary
❖ Proper wound care as needed
❖ Record the amount and type of wound drainage
❖ Re-position the patient every 2 hours. Pad pressure areas
Assessing and Managing Voluntary Voiding in Non-Catheterized Patients

❖ Assess for bladder distention and encourage patients to void upon arrival and frequently
thereafter (patient should void within 8 hours of surgery)
❖ Initiate methods to encourage the patient to void (for example, letting water run, applying
heat to perineum)
❖ Warm the bedpan to reduce discomfort and automatic tightening of muscles and urethral
sphincter
❖ Obtain order for catheterization before the end of the 8-hour time limit and if the patient
has an urge to void but cannot, or if the bladder is distended
o Continue intermittent catheterization every 4 to 6 hours until patient can void
spontaneously
Encouraging Activity

❖ Encourage surgical patients to ambulate as soon as possible, unless contraindicated

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❖ Advice patients regarding the importance of early mobility to prevent complications
❖ Anticipate and avoid orthostatic hypotension:
o When the patient gets out of bed, remain at patient’s side. Sit the patient on the
edge of bed for a few minutes initially and advance to ambulation as tolerated
o Assess patient’s feelings of dizziness and his or her blood pressure (in supine,
sitting and standing positions)
o Assist patient to change position gradually. If patient becomes dizzy, return to
supine position and delay getting out of bed for several hours
❖ Initiate and encourage patient to perform bed exercises

Gerontology Considerations
Elderly patients continue to be at increased risk for postoperative complications.

❖ Avoid restraint in geriatric patients, if possible, because it can worsen confusion. Family or
staff members may sit with the patient instead.
❖ Assist the older postoperative patient in early and progressive ambulation to prevent the
development of problems such as pneumonia, altered bowel function, DVT, weakness, and
functional decline
❖ Avoid prolonged sitting positions that promote venous stasis in the lower extremities
❖ Provide assistance to keep patient from bumping into objects and falling
❖ Encourage voiding to prevent urinary incontinence

5.6 Surgical Site Infection (SSI)


Surgical site infection is defined as an infection that occurs within 30 days after the operation
and involves the skin and subcutaneous tissue (superficial), and/or fascia/ muscle (deep), and/or
organs or spaces other than the incision that was opened.

Use the following WHO surgical site infection surveillance postoperative data collection form to
classify, diagnose and report surgical site infections. The form should be attached to each
patient’s chart.

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Figure 7: WHO SSI surveillance form

A template of an SSI registry/logbook for tracking and determining SSI rate in the wards or
postoperative departments is annexed (Annex 13).

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5.7 Discharge
The practice of discharging surgical patients from the hospital is dependent on many factors such
as the hospital norms, type and duration of surgery, coexisting medical illness and need of
postoperative care.

• Include the patient and family as full partners in the discharge planning process. Identify
which family or friends will provide care at home and include them in the conversation:
o Describe what life at home will be like
o Review medication administration
o Highlight warning signs and problems
o Explain test results
o Make follow-up appointments
• At the time of the discharge, provide patients with the brief summary of the procedure
• Advise the patient to avoid strenuous physical activities such as exercise and lifting of
heavy weights, for minimum period of 4–6 weeks following surgery
• Appoint the patient for a follow-up checkup within a week
• Upon discharge, the patient should be advised on warning signs and problems
• Prior to discharging patients from hospital, a discharge summary should be completed.
Ideally, one copy is kept in the patient’s files and another copy is given to the patient.

Thumb rules for discharge summary


1. Provide patient name, chart number, date of admission and admitting diagnosis. Avoid
lengthy descriptions.
2. Write the summary of patient’s initial presentation.
3. List test results and findings, state surgical procedures performed, including dates and
findings.
4. Write a brief summary of the hospital care. Include treatments pertinent to the diagnosis,
along with information regarding any complications.
5. Describe the condition of the patient at the time of discharge.
6. State the disposition. The disposition refers to where the patient is going upon discharge.
7. State recommendations for the patient’s continued care. Include detailed instructions
regarding diet, wound care when applicable, symptoms requiring medical attention, and

90
outpatient appointments.
8. List discharge medications. Include dosage and instructions regarding frequency and
time of day the medication should be taken.
9. Write the date of the discharge and provide the name of the person who prepared the
report.
A sample of an ideal discharge form is annexed (Annex 12).
5.8 Follow up Care
After discharge, patients should be appointed to the outpatient department. During their visit, the
care provider should:

• Ask the condition of the patient and check for presence of complications
• Examine the patient: document findings regarding the surgical site
• Assess the adherence of the patient to the given medications
• Update investigations, if indicated
• Give follow up appointment, as needed
• Address the concern of the patient and the family
• Advice on warning signs and complications

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6. Perioperative Critical Incident Reporting
6.1 What is an incident?
An incident is an event that gives rise to or has the potential to produce unexpected or unwanted
effects, which could be detrimental to the safety of service users, other persons, staff or the
organization.
6.2 Risk Evaluation
The three main categories of incident reporting are harmful incidents (serious incidents), a major
incident and a near miss.
Evaluation of risk is a key component of incident reporting. All incidents should be assessed to
determine the type of action to be taken to reduce or eliminate any risk.
All staff members have a responsibility to identify and (within their level of authority) respond to
the risk to promote its effective mitigation.
When an incident occurs the staff member who reports it should take action to manage any
immediate safety concerns, and/or escalating the incident to their line manager (or relevant other
individual as determined by the nature of the incident) immediately.
The OR manager and quality assurance manager are responsible for checking that all necessary
steps have been taken to manage the incident and its aftermath, and to ensure the risk grading is
accurate.

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Table 16: Risk Assessment

Risk Assessment Serious Major


Incident Incident
Unnatural death (procedure related) X
Procedure related events
Surgery on the wrong body part X
Surgery on the wrong patient X
Wrong surgical procedure performed on patient X
Unplanned return to operating room on this admission X
Transfer from general care unit to a higher level (for example, HDU or
X
ICU)
Length of stay greater than 10 days X
Unplanned re-presentation to department within 48 hours for the same X
condition
Return to emergency department or outpatients department for
complication related to the last hospital admission X

Disability associated with labor related event or procedure X

Incorrect blood administered (Blood to wrong patient) X


Hospital incurred patient incident, such as fall X
Development of pressure sores X
Infant discharged to wrong person or missing infant X
Health care provider/Patient with needle stick injury X
Equipment and supplies related incidents X

Lack of Electricity/ backup generator X

OR table/ Anesthesia machine malfunction X


Lack of drape/water X
Lack of oxygen X

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6.3 Incident Investigation
All incidents must be investigated and the responsibility for undertaking the initial investigation
rests with the investigation manager.
The incident investigation should be completed by the appointed investigator (usually the service
manager).
Incident Reporting Format and Procedures
1. For major and serious incidents, the health care provider should notify the facility OR
manager/ SaLTS focal person within one hour of occurrence by completing the incident
reporting format.
2. Facility manager should be notified immediately for major incidents affecting OR
functionalities such as light, water, instruments and supplies for immediate action.
3. The SaLTS focal should investigate the incident using the checklist and debrief the
reporting facility provider.
4. The SaLTS focal, with the OR manager, shall compile the investigation result report
within 12 hours for the facility management team.
5. The management team should discuss about the specific incident and design a plan of
action.
• The plan of action should be have a short term and long-term plan developed,
with responsible bodies assigned
6. The chief executive director should discuss and arrange a reporting format with the
communication board for public announcements, when there are serious incidents
creating rumors in the facility.

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Major/ serious
Incident
incident No
happened

Yes

Surgical team
leader Within 1 hour

Inform OR Inform facility


Inform

Manager/ SaLTS manager


focal person

Within 12 hours
Investigate
Incident Design an action
plan
OR manager
/Salt focal person

Figure 8: Incident reporting flow chart

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Table 17: Incident investigation report format

A. Identification of incident
1.Full name 2.Incident 3.Gender 4.Age 5.Injured person
registration o Patient
serial o Staff
number

6.Region 7.Wereda or Kefle ketema 8.Kebelle 9.House 10.Mobile or Line Phone number
number
B. Place of incident
OR (Operation Room) WARD C. Nature of incident

Male Ward Female Ward o Staff exposure (needle stick


injury)
o Anesthesia related adverse
incident
o Problems with OR instruments
o Wrong patient
o Wrong Procedure
o Wrong Medication
o Retain Instruments
o Count discrepancy
o Adverse and transfusion
reaction
o No apparent injury
o Other(specify)

PACU ICU Others (specify)

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D. Type of incident
1. Anesthesia related adverse events 2. Blood 3. Wrong Surgical
transfusion Intervention
o Airway- difficult intubation/laryngeal intubation
o Drug unavailability consideration after one
administration
o Regional administration without checking
availability of GA o Wrong patient
o Type
o Power source issue o Wrong Procedure
o Wrong
o Oxygen supply issue o Wrong body part
patient
o Human factor issue o Others
o Monitoring
o Knowledge-based (errors due to a lack of
o Wrong rate
knowledge or experience with a particular
o Others
process or situation)
(specify)
o Rule-based (misinterpretation or misuse of
relevant data or applying the wrong rule); and
o Skill based (attention and memory failures,
including omitted tasks)

4. Staff / Patient Type of an incident


Exposure o Wrong Un Natural Death Failure or delay in diagnosis of co-
Type of drug patient o On OR Table morbid illness
o Sharp instrument o Wrong o Anesthesia
injury prescriptio related death o Poor communication
o Blood / body n o Others o Negligence
fluid Spillage o Wrong o Dishonesty
o Other dose o Documentation error
o Wrong o Others
frequency
o Wrong
time

97
Other types of incident
o OR instrument and o Intubation failures
supply shortage/ mal o Struck by equipment
function o Struck by patient
o Hospital fall o Contaminated food
o Laboratory workup Others(specify)____________________
o Self-inflicted
o Needle puncture

Environmental hazard Level of incident


o the patient
experienced the
event, but the event
did not cause harm;
o low potential of
residual disability;
o high potential of
residual disability;
o event resulted in
death
o unknown

Seen by a physician?
o Yes
o No
If yes, mention physician name and position

98
If yes date and time of evaluation
Give brief factual description of incident

Physical findings, diagnosis at time of incident and treatment provided

Present diagnosis
Reported by Title Signature Date Phone number

Supervised by Title Signature Date Phone number

Clinical/Incident Notification Form


This form is to be accompanied by the Clinical Risk Assessment Tool
Ward: Department:
Date of Incident: Time of Incident:
Name of Incident:
Type of Incident (Serious/Major/Near miss):
Admitting Diagnosis:
Brief Description of Incident/Clinical Event:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Notified By: Date:

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7. Monitoring and Evaluation

The objectives of monitoring and evaluation are to improve the quality of services, optimum use of
resources and management, and to make timely decisions to resolve problems and/or constraints of
implementation. The sources of information for timely monitoring are routine service and
administrative records compiled through the Health Management Information System (HMIS) and/or
facilities Key Performance Indicators (KPIs). Monitoring happens regularly throughout the lifetime of a
plan. It includes the collection and review of information available from HMIS/KPIs sources,
supervisory visits, review meetings and annual reports. Some of the core indicators listed below are
used for monitoring the implementation of Health Sector Development Program (HSDP IV) and they
are relevant at facility, regional and federal levels. Every facility should track and monitor the
following surgical KPIs on a monthly basis. The data obtained should be analyzed and used for
decision making accordingly.

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R. KPI Operational Numerato Denominator Formula Data Source
No. definition r

1. Elective Elective surgery The The number of Institution’s waiting


Surgery patients treated are number of patients who received list management data
Patients those who were patients elective surgery for base; OT
Treated registered on a who each respective 𝑇ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑒𝑟𝑦 𝑤ℎ𝑜 𝑤𝑒𝑟𝑒 log/registration book
Within surgical waiting list received category 𝑡𝑟𝑒𝑎𝑡𝑒𝑑 𝑤𝑖𝑡ℎ𝑖𝑛 30 𝑑𝑎𝑦𝑠 (≤ 30 𝑑𝑎𝑦𝑠)
Clinically as a category 1, 2 or elective 𝑖𝑓 𝑎 𝑐𝑎𝑡𝑒𝑔𝑜𝑟𝑦 1, 𝑤𝑖𝑡ℎ𝑖𝑛 90 𝑑𝑎𝑦𝑠 (≤ 90 𝑑𝑎𝑦𝑠)𝑖𝑓 𝑎 𝑐𝑎𝑡𝑒𝑔𝑜𝑟𝑦 2,
Recommen 3, with a surgical surgery 𝑜𝑟 𝑤𝑖𝑡ℎ𝑖𝑛 365 𝑑𝑎𝑦𝑠 (≤ 365 𝑑𝑎𝑦𝑠) 𝑖𝑓 𝑎 𝑐𝑎𝑡𝑒𝑔𝑜𝑟𝑦 3
ded Time specialty, and were who were 𝑇ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑒𝑟𝑦
removed because treated 𝑓𝑜𝑟 𝑒𝑎𝑐ℎ 𝑟𝑒𝑠𝑝𝑒𝑐𝑡𝑖𝑣𝑒 𝑐𝑎𝑡𝑒𝑔𝑜𝑟𝑦
they received their within 30
surgery as an days (≤ 30
elective patient. days) if a
category 1,
within 90
days (≤ 90
days) if a
category 2,
or within
365 days
(≤ 365
days) if a
category 3.

2. Utilization Operating theater Total Total number of Efficiency


Rate utilization measures number of working days 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑐𝑡𝑖𝑣𝑒 𝑑𝑎𝑦𝑠 tool
the percentage of active 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑟𝑘𝑖𝑛𝑔 𝑑𝑎𝑦𝑠
OT time used days
against that, which
was budgeted.

101
3. First Case First case on-time OT Schedule,
Starting on start is measured by planned session start time- first case in OR time intraoperative
Incision the difference nursing
Time between the planned check list, efficiency
session start time tool
and first case in OR
time
4. Number of The difference Number of Number of patients Institution waiting
clients in between the number patients treated from the 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑎𝑑𝑑𝑒𝑑 𝑡𝑜 𝑤𝑎𝑖𝑡𝑖𝑛𝑔 𝑙𝑖𝑠𝑡 list
the waiting of patients added to added to waiting list or number 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑡𝑟𝑒𝑎𝑡𝑒𝑑 𝑓𝑟𝑜𝑚 𝑡ℎ𝑒 𝑤𝑎𝑖𝑡𝑖𝑛𝑔 𝑙𝑖𝑠𝑡 management
list for the elective surgery waiting of patients removed 𝑜𝑟 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑟𝑒𝑚𝑜𝑣𝑒𝑑 𝑓𝑟𝑜𝑚 𝑡ℎ𝑒 𝑤𝑎𝑖𝑡𝑖𝑛𝑔 𝑙𝑖𝑠𝑡 database
elective waiting list and the list from the waiting list
surgical number of patients
service removed (either
treated or removed)
5. Changeove Measure of the Intraoperative
r Time difference between nursing
(Turn Over patient wheels in patient wheels in (next on the order) in minutes- patient wheels out check list, sign out
Time) (next on the order) (already in OT) in minutes time, efficiency tool
and patient wheels
out (already in OT)
in minute
6. Day of The percentage of Total Total number of Operation theatre
Surgery all elective patients number of scheduled cases schedule
(DOS) cancelled on the day cancelled 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑛𝑐𝑒𝑙𝑙𝑒𝑑 𝑐𝑎𝑠𝑒𝑠 management
Cancellatio of surgery for both cases 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑐ℎ𝑒𝑑𝑢𝑙𝑒𝑑 𝑐𝑎𝑠𝑒𝑠 database, annexed
n Rate hospital and patient- efficiency tool
initiated reasons
7. Average The average time Sum (‘In Anesthetic’ to ‘Procedure 𝑆𝑢𝑚 (‘𝐼𝑛 𝐴𝑛𝑒𝑠𝑡ℎ𝑒𝑡𝑖𝑐’ 𝑡𝑜 ‘𝑃𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒 𝑆𝑡𝑎𝑟𝑡’)𝑓𝑜𝑟 𝑓𝑖𝑟𝑠𝑡 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎𝑛 Anesthesia record
Elective from which an Start’) for first cases of an elective 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑚𝑜𝑟𝑛𝑖𝑛𝑔 𝑜𝑟 𝑎𝑙𝑙 − 𝑑𝑎𝑦 𝑠𝑒𝑠𝑠𝑖𝑜𝑛 Sheet
Pre- anesthetic agent is morning or for all-day sessions 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑖𝑟𝑠𝑡 𝑐𝑎𝑠𝑒𝑠 𝑖𝑛 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑒𝑠𝑠𝑖𝑜𝑛𝑠
Procedural administered or Number of first cases in elective
Anesthesia anesthetist/anesthesi sessions
Care Time ologist enters the
room (‘In
anesthetic’) to the
initiation of cleaning
of the surgical site
(‘Procedure start’)
for the first case of
an elective morning
or all day session.

102
8. Delayed Average time (in [Discharge time (in Hour) – Ready [𝐷𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒 𝑡𝑖𝑚𝑒 (𝑖𝑛 𝐻𝑜𝑢𝑟) – Round progress note/
Hospital hours) taken for Discharge time for each patient 𝑅𝑒𝑎𝑑𝑦 𝑓𝑜𝑟 𝐷𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒 𝑡𝑖𝑚𝑒 𝑓𝑜𝑟 𝑒𝑎𝑐ℎ 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 round note, ward
Discharge between when an (in Hour)] (𝑖𝑛 𝐻𝑜𝑢𝑟)] DHIS_2 register
elective patient is Number of Discharges 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐷𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠
ready for discharge
to when they are
actually discharged.
9. Emergency Percentage of Sum of Sum of planned Operation theater
Cases in planned elective emergency elective session 𝑠𝑢𝑚 𝑜𝑓 𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑐𝑎𝑠𝑒 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 𝑝𝑒𝑟𝑓𝑜𝑟𝑚𝑒𝑑 𝑤𝑖𝑡ℎ𝑖𝑛 𝑎𝑛 schedule
Elective session time case minutes 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑒𝑠𝑠𝑖𝑜𝑛 management data
Session occupied by minutes 𝑠𝑢𝑚 𝑜𝑓 𝑝𝑙𝑎𝑛𝑛𝑒𝑑 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑒𝑠𝑠𝑖𝑜𝑛 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 base
emergency case performed
within an
elective
session
10. Elective The proportion of Sum total Sum total number of 𝑆𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑝𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒𝑠 𝑐𝑎𝑛𝑐𝑒𝑙𝑙𝑒𝑑 Cancellation book,
x100
surgery elective surgical number of elective surgical 𝑆𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑝𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒𝑠 𝑠𝑐ℎ𝑒𝑑𝑢𝑙𝑒𝑑 efficiency tool
cancellatio procedures cancelled elective procedures scheduled
n rate compared with surgical
elective surgical procedures
procedures cancelled
scheduled
11. Number of The total number of Sum total Total number of OT 𝑠𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑝𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒𝑠 𝑐𝑜𝑛𝑑𝑢𝑐𝑡𝑒𝑑 OR registry book
surgeries surgeries operated number of tables x total number 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑂𝑇 𝑡𝑎𝑏𝑙𝑒𝑠 𝑥 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑎𝑦𝑠 𝑖𝑛 𝑡ℎ𝑒
per table per major operating surgical of days in the 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑚𝑜𝑛𝑡ℎ
room table procedures reporting month
conducted
12. Number of Number of surgeries Sum total Total number of 𝑠𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑝𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒𝑠 𝑐𝑜𝑛𝑑𝑢𝑐𝑡𝑒𝑑 OR registry book
surgeries that are performed number of surgeons x total 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑔𝑒𝑜𝑛𝑠 𝑥 𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑎𝑦𝑠 𝑖𝑛 𝑡ℎ𝑒
per by a surgeon surgical number of days in the 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑚𝑜𝑛𝑡ℎ
surgeon procedure reporting month
per day conducted
13. Bed This is the average Sum total Average no of 𝑆𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑓 𝑠𝑡𝑎𝑦 𝑖𝑛 𝑑𝑎𝑦𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 Surgical ward
Occupancy percentage of length of operational beds 𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑁𝑜.𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑎𝑙 𝑏𝑒𝑑𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 x 100 register
𝑥
Rate occupied beds stay in during reporting 𝑁𝑜.𝑜𝑓 𝑑𝑎𝑦𝑠 𝑖𝑛 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑𝑠
(BOR) during the reporting days period x number of
period during days in reporting
reporting period
period

103
14. Average The average number Sum total No of patients 𝑆𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑓 𝑠𝑡𝑎𝑦 𝑓𝑜𝑟 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑤ℎ𝑜 𝑤𝑒𝑟𝑒 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑 Inpatient register
Length of of days from length of discharged alive (𝑖𝑛𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑑𝑒𝑎𝑡ℎ𝑠
Stay admission to stay for (including transfer 𝑎𝑛𝑑 𝑡𝑟𝑎𝑛𝑠𝑓𝑒𝑟 𝑜𝑢𝑡)
discharge, death or patients out)+no of deaths 𝑁𝑜. 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑 𝑎𝑙𝑖𝑣𝑒(𝑖𝑛𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑡𝑟𝑎𝑛𝑠𝑓𝑒𝑟 𝑜𝑢𝑡) + 𝑁𝑜.
transfer out who were among admitted 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠
discharge inpatients 𝑎𝑚𝑜𝑛𝑔 𝑎𝑑𝑚𝑖𝑡𝑒𝑑 𝑖𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠
d
15. Inpatient The number of No of No of deaths among 𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑖𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 Inpatient register
Mortality deaths per 100 deaths admitted 𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 + 𝑁𝑜.𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 x100
discharged 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑 𝑎𝑙𝑖𝑣𝑒
among patients+no of
(𝑖𝑛𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑡𝑟𝑎𝑛𝑠𝑓𝑒𝑟 𝑜𝑢𝑡)
inpatients admitted patients discharged
patients alive (including
transfer out)
16. Delay for The average number Sum total No of patients who 𝑆𝑢𝑚 𝑡𝑜𝑡𝑎𝑙 𝑜𝑓 𝑁𝑜. 𝑑𝑎𝑦𝑠 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑑𝑎𝑡𝑒 𝑎𝑑𝑑𝑒𝑑 𝑡𝑜 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑤𝑎𝑖𝑡𝑖𝑛𝑔
Elective of days between the of no of were admitted for 𝑙𝑖𝑠𝑡
Surgical dates each patient days elective surgery 𝑏𝑎𝑠𝑒𝑑 𝑜𝑛 𝑡ℎ𝑒 𝑐𝑎𝑡𝑒𝑔𝑜𝑟𝑦 𝑡𝑜 𝑑𝑎𝑡𝑒 𝑜𝑓 𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛 𝑓𝑜𝑟 𝑠𝑢𝑟𝑔𝑒𝑟𝑦 Operation theater
Admission was added to the between during the reporting schedule
waiting list to their date period management data
date of admission added to 𝑁𝑜 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤ℎ𝑜 𝑤𝑒𝑟𝑒 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑓𝑜𝑟 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑟𝑔𝑒𝑟𝑦 𝑑𝑢𝑟𝑖𝑛𝑔 base
for surgery surgical 𝑡ℎ𝑒 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑
waiting
list to
date of
admission
for
surgery

17. Surgical The proportion of all No of No of major surgeries 𝑁𝑜.𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ 𝑛𝑒𝑤 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑠𝑖𝑡𝑒 𝑖𝑛𝑓𝑒𝑐𝑡𝑖𝑜𝑛 𝑎𝑟𝑖𝑠𝑖𝑛𝑔 𝑑𝑢𝑟𝑖𝑛𝑔 SSI registration book
Site major surgeries with patients performed during the 𝑡ℎ𝑒 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑
Infection an infection reporting period on 𝑁𝑜.𝑜𝑓 𝑚𝑎𝑗𝑜𝑟 𝑠𝑢𝑟𝑔𝑒𝑟𝑖𝑒𝑠(𝑏𝑜𝑡ℎ 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑎𝑛𝑑 𝑛𝑜𝑛−𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒)𝑝𝑒𝑟𝑓𝑜𝑟𝑚𝑒𝑑 x1
with new
𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑𝑠 𝑜𝑛 𝑝𝑢𝑏𝑙𝑖𝑐 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠+
occurring at the site surgical public patients + no of
𝑁𝑜.𝑜𝑓 𝑚𝑎𝑗𝑜𝑟 𝑠𝑢𝑟𝑔𝑒𝑟𝑖𝑒𝑠(𝑏𝑜𝑡ℎ 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑎𝑛𝑑 𝑛𝑜𝑛−𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒)𝑝𝑒𝑟𝑓𝑜𝑟𝑚𝑒𝑑
of the surgical site major surgeries 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑛 𝑝𝑟𝑖𝑣𝑎𝑡𝑒 𝑤𝑖𝑛𝑔 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠
wound prior to infections performed during the
discharge. arising reporting period on
during the private wing patients
reporting
period

104
18. Pressure Proportion of No of 𝑁𝑜 𝑜𝑓 𝑖𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤ℎ𝑜 𝑑𝑒𝑣𝑒𝑙𝑜𝑝𝑒𝑑 𝑎 𝑛𝑒𝑤 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒 𝑢𝑙𝑐𝑒𝑟 𝑑𝑢𝑟𝑖𝑛𝑔 Inpatient register
Ulcer inpatients who inpatients No. of patients 𝑡ℎ𝑒 𝑟𝑒𝑝𝑜𝑟𝑡𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑𝑠
Incidence develop a pressure who discharge 𝑁𝑜 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑 𝑎𝑙𝑖𝑣𝑒(𝑖𝑛𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑡𝑟𝑎𝑛𝑠𝑓𝑒𝑟 𝑜𝑢𝑡)+𝑁𝑜 𝑜𝑓 x100
𝑑𝑒𝑎𝑡ℎ𝑠
ulcer during their developed alive(including 𝑎𝑚𝑜𝑛𝑔 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑖𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠
hospital/department a new transfer out)+No
stay pressure deaths among
ulcer inpatient admission
during the
reporting
period

19. Pre- The no. of days a ∑(Day of No. of operated ∑(𝑑𝑎𝑦𝑠 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛 − 𝑑𝑎𝑦𝑠 𝑜𝑓 𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛) Waiting list and
operative patient waits until Operation- patients 𝑁𝑜. 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 scheduling
Stay getting operated day of
(PrOS) admission)
20. Post- No. of days a patient ∑(day of Total no. of operated ∑(𝑑𝑎𝑦 𝑜𝑓 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒 − 𝑑𝑎𝑦 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛 Patient chart
operative stayed after getting discharge- patients discharged 𝑇𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑
Stay operated day of
(PoOS) operation
21. Percentage Percentage of No of Total no of admitted (𝑁𝑜 𝑜𝑓 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 − 𝑁𝑜 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠) Cancelation book
x100
of cases admitted patients admitted patients 𝑇𝑜𝑡𝑎𝑙 𝑁𝑜 𝑜𝑓 𝑎𝑑𝑚𝑖𝑡𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠
not not operated patients-no
Operated of
(CnO) operated
patients
22. Unplanned Percentage of Total no Total no of 𝑇𝑜𝑡𝑎𝑙 𝑁𝑜 𝑜𝑓 𝑟𝑒𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑠 Re-admission register
x100
Return to operated patients re- of operations 𝑇𝑜𝑡𝑎𝑙 𝑁𝑜 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑠
the Theatre operated reoperati
(URT) ons
23. Average The time elapsed ∑Time No of operations – No ∑ 𝑇𝑖𝑚𝑒 𝑒𝑙𝑎𝑝𝑠𝑒𝑑 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑡𝑤𝑜 𝑐𝑜𝑛𝑠𝑒𝑐𝑢𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑒𝑟𝑖𝑒𝑠 𝑖𝑛 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 OR Register
Time between two elapsed of operation days 𝑁𝑜. 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑠 – 𝑁𝑜. 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛 𝑑𝑎𝑦𝑠
Interval consecutive between
between operations two
Surgeries consecutiv
(TIS) e surgeries
in minutes
24. Percentage The proportion of Number of Number of major 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑆𝐶 𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒𝑑 Patient chart
x100
of Surgical safe surgery SSC operations 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑀𝑎𝑗𝑜𝑟 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑠
Safety checklist utilization completed
Checklist per each operations
use (SSC-
use)

105
25. Emergency The proportions of Number of Numbers of 𝑁𝑢𝑚𝑏𝑒𝑟𝑠 𝑜𝑓 𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑟𝑒𝑓𝑒𝑟𝑟𝑎𝑙𝑠 𝑚𝑎𝑑𝑒 Liaison and referral
Surgical emergency surgical emergency emergency surgical 𝑥100
(𝑁𝑢𝑚𝑏𝑒𝑟𝑠 𝑜𝑓 𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑟𝑒𝑓𝑒𝑟𝑟𝑎𝑙𝑠 𝑚𝑎𝑑𝑒 +
Referrals referrals made surgical referrals made + 𝑁𝑢𝑚𝑏𝑒𝑟𝑠 𝑜𝑓 𝑛𝑜𝑛 − 𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑟𝑒𝑓𝑒𝑟𝑟𝑎𝑙𝑠)
as a among emergency referrals Numbers of non-
Proportion and non-emergency made emergency surgical
of all surgical referrals referrals
surgical
referrals
made
(ESRP)
26. Percentage The proportion of Number of Total number of 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛𝑠 1𝑠𝑡 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛 𝑡𝑖𝑚𝑒 𝑠𝑡𝑎𝑟𝑡𝑒𝑑 OR Register
x100
of 1st Operations 1st operations operation days 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑜𝑛 𝑑𝑎𝑦𝑠
operations Operation time first
started on started to total operation
the agreed operation days time
time started

106
8. Annexes
Annex 1: Summary of team leadership roles and responsibilities
Health facility structure Roles and responsibilities

Hospital/health center chief Establish a facility surgical and anesthesia services directorate/office
executive officer/clinical Assign SaLTS office director, OR manager, and necessary team members
director/senior management Supervise overall SaLTS activities
team (SMT) Conduct baseline and ongoing assessment
Engage senior professionals in leadership
Allocate and mobilize resources
Evaluate implementation progress
Assess and reward champion provider
Ensure availability of necessary supplies
Ensure the availability and utilization of the WHO safe surgery essential
checklist
Facility surgical service Lead, mobilize, and motivate the facility SaLTS multidisciplinary team
directorate/office Develop SaLTS-specific action plan for the facility
Prepare agenda’s for weekly/every two week SALTs multidisciplinary team
meeting
Prepare monthly clinical audit forum to discuss with anesthesia, surgery and
nursing staffs
Ensure that the surgical team works together and feels valued
Review and report collected data monthly
Participate on the SMT representing the surgical team
SaLTS multidisciplinary team Support implementation of the facility SaLTS plan
Conduct ongoing assessment to advise the SMT and provide feedback to
service units
Provide training to clinical and nonclinical surgical staff
Plan and supervise the activity of the respective units
Discuss with team how to improve the quality of surgical activities

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Organize hospital-wide advocacy and communications
Engage in all surgical team meetings
Document all activities and submit reports
Full-time Anesthesia service Member of SALTs multidisciplinary team
manager Supervise anesthesia team lead in each surgical centers
Supervise and monitor daily activities of anesthesia team leads in the
hospital
Plan, organize and report weekly and monthly anesthesia service report
Lead anesthesia clinical audit team
Full-time nursing manager Member of SALTs multidisciplinary team
Supervise nursing team lead in each surgical centers
Undergo daily supervision of the nursing service delivery with nursing team
leads
Plan, organize and report weekly and monthly nursing service report of the
hospital
Lead nursing clinical audit team of the hospital
Anesthesia team lead Oversee day-to-day OR activity related to anesthesia workforce
Conduct daily supervision of key anesthesia function and service
Nursing team lead Oversee day-to-day OR activity related to nursing workforce
Conduct daily supervision of key Nursing function and service
Undergo daily supervision of the Central supply staff and activities

108
Annex 2: Role and responsibility of team leads: OR nurses, surgeon,
anesthetists/anesthesiologists and OR managers
An overview of the key nursing and medical leadership roles involved in the management of an
efficient OT is described in the tables below; roles for heads of departments and roles of the floor
(OT) coordinator.

Leadership Roles for the Heads in the Operating Theater


Nurse Surgeon Anesthetist/Anesthesiologist
• Overall management of budget and resources • Take an active governance role • Take an active governance role
within the perioperative service in theatre management to in theatre management to ensure
• Ensure appropriate nursing workforce availability ensure that the surgical care the anesthetic care provided is
for the perioperative environment provided is patient centered patient centered
• Review and monitor surgical services in • Ensure appropriate surgical • Ensure appropriate anesthetic
collaboration with relevant stakeholders to achieve workforce availability for the workforce availability for the
performance benchmarks perioperative environment perioperative environment
• Review and analyze service activity and resource • Review and monitor services in (including pre-admission,
allocations to assist capacity planning for future collaboration with relevant theatre, and postoperative care)
service provision stakeholders to achieve • Review and monitor services in
• Coordinate the capital equipment list and performance benchmarks collaboration with relevant
collaborate in the prioritization and negotiation for • Advocate and liaise with stakeholders to achieve
equipment hospital administration to performance benchmarks
• Provide mentorship and support to the ensure services are adequately • Advocate and liaise with
professional development of the nursing staff staffed and equipped to provide hospital administration to ensure
within perioperative services a safe, efficient and effective services are provided in a safe,
• Actively celebrate successes and encourage high working environment efficient and effective working
performers • Ensure that processes and environment

• Address root causes of poor performance protocols are in place that • Provide advice and direction
• Promote quality activities and coordinate quality reflect best practice in the regarding issues relating to
improvement projects within the department operating theatre environment anesthesia and sedation

• Foster collaborative teamwork to drive continuous • Ensure that a professional and governance

improvement respectful work environment is • Provide feedback to the


maintained department of anesthetics
• Provide feedback to all surgical regarding perioperative issues of
departments regarding importance
perioperative issues of • Actively celebrate successes and
importance encourage high performers

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• Actively celebrate successes • Address root causes of poor
and encourage high performers performance
• Address root causes of poor • Ensure audit processes are in
performance place to monitor and assess key
• Ensure audit processes are in quality and safety practices
place to monitor and assess key
quality and safety practices

Role of the OR Manager


Full-time OR manager Oversee day-to-day OR activity
Conduct daily supervision of key function units and provide information to the surgical service director
Supervise teamwork and collaboration effectiveness between surgical workforce
Develop annual and quarterly plan
Organize Clinical audit forum from Surgical, Anesthesia and nursing care delivery
Lead SaLTS multidisciplinary team meeting

110
Annex 3: Perioperative Process Maps for Emergency Procedures

Emergency Surgery Pre-operative Process Map

Complete Prepare for Yes


Patient arrives with evaluation and emergency Check for Obtain surgical
Surgical/gynecologic investigation of surgery bed informed written
emergency patient availability consent

No

Referral out Communicate OR team


(including the level of
urgency)

Take patient to OR

Obtain anesthesia (According to institution


Patient evaluation by transfer protocol)
informed written consent
anesthesia team

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Emergency Surgery Pre-operative Process Map
1. A patient that arrives at the emergency department with an indication for emergency surgery should be evaluated and
investigated upon arrival after triage.
2. The management of the patient should be initiated, and the patient is prepared for emergency surgery.
3. The surgical team should confirm the presence of bed for admission for the patient:
4. If a bed is available for admission, the surgical team should obtain surgical informed written consent from the patient.
• If there is no bed for admission available, refer the patient to a center where bed is available after communication.
5. Once surgical consent is obtained, the operating room (OR) staff should be communicated regarding the patient’s diagnosis
and condition (i.e. the level of urgency).
6. The patient should be transferred and handed over to the OR team according to the hospital protocol.
7. The anesthesia team evaluates the patient before entering the OR.
8. Anesthesia team will then counsel the patient and if the patient agrees, obtain anesthesia informed written consent.

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Emergency Surgery Intra-operative Process Map

Complete WHO Anesthesia Complete WHO


Patient on ER OR SSC sign in Confirm induction SSC timeout
table administration of IV
antibiotics

Complete WHO Confirm count Surgery Skin incision


SSC sign out Skin closure and with each cavity conducted
dressing closure (Document Incision
time)

Patient transferred
to PACU

Patient out from OR

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Emergency Surgery Intra-operative Process Map Narration
1. After ‘wheels in’ and the patient is transferred on to the emergency room (ER) operating room (OR) table, the designated
checklist coordinator will call out for completion of the sign-in section of the World Health Organization (WHO) Surgical
Safety Checklist (SSC), ensuring all team members are fully engaged.
NB:
• IV antibiotics administration should be administered only if indicated and if the patient is not already taking
antibiotics.
• A second dose of antibiotics should be considered if the surgery last for more than 2 hours.
2. Anesthesia is then administered, with anesthesia administration time strictly documented.
3. Once patient is positioned and draped, the designated checklist coordinator will call out for the ‘time out’ section of the WHO
SSC, ensuring all team members are fully engaged.
4. Once ‘time out’ is completed, the surgeon can make the skin incision with the incision time strictly documented.
5. Once the surgery is completed, marked by the closure of the skin and applying dressing, the ‘sign out’ section of the checklist
should be completed with all members of the team fully engaged.
• It should be noted that count of gauze, pack, peanut, instruments and stitch materials should be conducted with closure
of every cavity and again, at the end of the procedure (skin closure and dressing application).
6. Once the sign out is completed and the patient is deemed ready for transfer by all team members, the patient will be wheeled
out of the OR to the primary care unit or intensive care unit, implementing the hospitals’ transfer and hand-over protocols.

114
Emergency Surgery Post-operative Process Map

Patient is fit YES


for discharge
Check Continue patient from PACU Communicate with
Patient arrives at PACU documentation and follow up and according to ward
after handover according re-evaluate evaluation hospital
to hospital protocol protocol

NO

Transfer to ICU
In OR according to hospital
protocol

In Ward Discharge from


PACU

Patient fit for Transfer to ward


Continue follow up Check (according to
discharge from ward
(including wound documentation and institution patient
according to hospital
condition) evaluate transfer protocol)
protocol

Provide support (social, Complete discharge


physical and summary (appoint to Discharge Patient
psychological) SRC/GRC)

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Emergency Surgery Post-operative Process Map Narration
1. The postoperative patient who has arrived to the PACU must be handed over to the PACU team by the operating room team
according to the hospital protocol.
2. The receiving team must ensure all necessary documents are attached to the chart, evaluate the patient upon arrival and
document all findings accordingly.
3. The patient is to be on strict follow up according to the physician order and/or hospital policy:
• If the patient is not deemed fit for discharge, patient is to be transferred to the ICU according to the hospitals’ transfer
policy.
• If the patient is deemed fit for discharge from the PACU according to the hospital policy, patient is transferred to the
ward according to the hospitals’ transfer policy after communicating with the ward team and ensuring they are
prepared to accept the patient.
4. Upon acceptance to the ward, the ward team must confirm all documents are complete and attached to the chart. The patient is
to be on strict follow up according to the order sheet.
• Patient wound assessment should always be documented on the postoperative note on the chart, including the day of
discharge
5. Once the patient is deemed fit for discharge according to hospital protocol, the patient should be provided with the necessary
support and information by the ward team (physical, psychological and social).
6. Complete the discharge summary, including the specific date, time and clinic the patient is to be appointed to for follow up.
Leave one copy in the chart. The patient is now ready for discharge.

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Emergency Cesarean Section Pre-operative Process Map

Complete client
Client presents with an Inform OR team and
evaluation and Obtain informed
indication/develops an neonatal care team
investigation anesthesia and surgical
indication for (including level of
(including option written consent
emergency cesarean urgency)
for intraoperative
section FP)

Complete
Transfer client to OR preoperative Prepare client for
nursing check list surgery
(According to institution transfer
protocol)

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Emergency Cesarean Section Pre-operative Process Map
1. Once a patient is a candidate for emergency cesarean section, the operating room (OR) team should be notified immediately:
the anesthesia team, the nursing team, the midwives, the operating surgeon and the pediatric/neonatal team. Level of urgency
should be clearly communicated.
2. Client evaluation and investigation should be finalized. The option of intraoperative family planning (FP) should be disclosed
to the patient.
3. The anesthesia team as well as the operating team will obtain the anesthesia and surgical informed written consent respectively
from the client.
4. Complete the preparation of the patient for surgery.
5. Complete the preoperative nursing checklist.
6. Transfer the client to the OR according to the hospitals’ protocol.

118
7.
Emergency Cesarean Section Intraoperative Process Map

Complete Complete WHO


intraoperative Client taken to OR Confirm fetal heart SSC Sign in
Client arrives at OR
nursing check list table beat

Confirm
administration of IV
antibiotics

Neonatal care team on


stand by
Anesthesia induction

Hand over neonate


to the neonatal care
team

Conduct vaginal
cleansing and sterile
catheterization
Client transfer to PACU

according to hospital Surgery conducted Complete WHO


Complete WHO
protocol Confirm count with SSC time out
SSC sign out
each cavity closure

119
Emergency Cesarean Section Intraoperative Process Map
1. Once the client arrives at the operating room (OR), the intraoperative nursing checklist should be completed.
2. The client is then transferred to the OR table.
• The neonatal care team should be in the room preparing for the management of the newborn.
3. Fetal heart beat is confirmed on the table.
4. The designated checklist coordinator will call out for completion of the sign-in section of the World Health Organization
(WHO) Surgical Safety Checklist (SSC), ensuring all team members are fully engaged.
5. IV antibiotics administration is confirmed.
• IV antibiotics administration should be administered only if indicated and if the client is not already taking antibiotics.
6. Anesthesia is then administered, with anesthesia administration time strictly documented.
7. Vaginal cleansing and aseptic urethral catheterization will be conducted for all clients.
8. Once the client is positioned and draped, the designated checklist coordinator will call out for the ‘time out’ section of the
WHO SSC, ensuring all team members are fully engaged.
9. Once ‘time out’ is completed, the surgeon can make the skin incision with the incision time strictly documented.
10. Once the newborn is delivered, it should be handed over to neonatal care team.
11. Once the surgery is completed, marked by the closure of the skin and applying dressing, the ‘sign out’ section of the checklist
should be completed with all members of the team fully engaged.
12. It should be noted that count of gauze, pack, peanut, instruments and stitch materials should be conducted with closure of
every cavity and again, at the end of the procedure (skin closure and dressing application).
13. Once the sign out is completed and the client is deemed ready for transfer by all team members, the client and newborn will be
wheeled out of the OR to the primary care unit or intensive care unit, implementing the hospitals’ transfer and hand-over
protocols.

120
Emergency Cesarean Section Post-operative Process Map

Client is fit
for discharge YES
from PACU
Check Continue client according to Communicate with
Client arrives at PACU documentation and follow up and hospital ward
with handover re-evaluate evaluation protocol
conducted according to
hospital protocol

NO

Transfer to ICU
In OR according to hospital
protocol

In Ward Discharge from


PACU

Client fit for Transfer to ward


Continue follow up Check (according to
discharge from ward
(including wound documentation and institution patient
according to hospital
condition) evaluate transfer protocol)
protocol

Provide support (social, Complete discharge


physical and summary (appoint to Discharge client
psychological) postnatal clinic)

121
122
Emergency Cesarean Section Post-operative Process Map Narration
1. The postoperative client and newborn who have arrived to the PACU must be handed over to the PACU team by the operating
room team according to the hospital protocol.
2. The receiving team must ensure all necessary documents are attached to the chart, evaluate the client upon arrival and
document all findings accordingly.
3. The client is to be on strict follow up according to the physician order and/or hospital policy:
• If the client is not deemed fit for discharge, patient is to be transferred to the ICU according to the hospitals’ transfer
policy.
• If the client is deemed fit for discharge from the PACU according to the hospital policy, client is transferred to the ward
according to the hospitals’ transfer policy after communicating with the ward team and ensuring they are prepared to
accept the client.
4. Upon acceptance to the ward, the ward team must confirm all documents are complete and attached to the chart. The client is
to be on strict follow up according to the order sheet.
• Client wound assessment should always be documented on the postoperative note on the chart, including the day of
discharge
5. Once the client is deemed fit for discharge according to the hospital protocol, the client should be provided with the necessary
support and information by the ward team (physical, psychological and social).
6. Complete the discharge summary, including the specific date, time and clinic the patient is to be appointed to for follow up.
Leave one copy in the chart. The client is now ready for discharge.

123
Annex 4: Preoperative Surgical Checklists for Pediatric Patients
Surgical Perioperative Checklist: Pediatric
Patient Name: __________________________ MRN: ______________________
Age: _______________ Gender: ____________________
Ward and Bed number: ___________________
Present Absent Not Applicable
HISTORY
11. History of upper respiratory tract infections in the last two weeks
(runny nose, cough, fever, difficulty of swallowing)
12. History of acute gastroenteritis symptoms (vomiting, diarrhea)
13. History of recent skin rashes
14. History of vaccination in the last two weeks
15. History of any current medication (antibiotics, anticoagulants)
16. History of known medical illnesses (diabetes, bleeding disorders,
thyroid disorders, renal disease, cardiac disease)
17. History of previous surgery
18. History of known allergies
19. Last menstrual period
PHYSICAL EXAMINATION Present Absent Not Applicable
9. General appearance:
Signs of respiratory distress:
If present, specify:
Signs of cardiac failure:
If present, specify:
10. Vital signs
Blood pressure
PR (Regular/Irregular)
Respiratory rate
Temperature

124
11. Weight of the patient (kg)
12. MUAC
13. Anthropometric assessment:
Wasting:
Stunting:
14. Signs of anemia (assess conjunctiva, palm of hand)
15. Erythematous/swollen tonsils
16. Runny nose
17. Abnormality of respiratory system
If present, specify:
18. Abnormality of cardiovascular system
If present, specify:
19. Colostomy washout adequate (determined by nature of colostomy
output)
20. Presence of skin lesions/rashes
INVESTIGATIONS Done Not Done Not Applicable
10. CBC within normal range and updated within the last week
11. Blood group and Rh factor
12. Serum electrolyte within normal range and updated within the last
one week
13. RFT within normal range and updated within the last two week
14. LFT within normal range and updated within the last two week
15. Echocardiography
16. Chest X-ray
TREATMENT Done Not Done Not Applicable
8. Family/patient counseled about the proposed procedure and
written consent acquired
9. Family/patient counseled about keeping the patient NPO for
at least four hours before surgery
10. Required amount of cross matched whole blood prepared
(calculated by 20ml/kg)

125
11. For Patients on bowel preparation
- Clear fluid diets started 24 hours before day of surgery
- Cleansing enema BID started 48 hours before day of surgery
12. Vitamin K administration (only for neonates and patients with
jaundice)
13. Anesthesiologist/senior anesthetist notified with consultation
paper about subcritical/critical patients 24 hours prior to the
day of surgery
14. ICU bed reserved for patients requiring postoperative ICU
care
Diagnosis: _____________________________________________________
Is the patient fit for surgery? 1. Yes 2. No
If no, specify the reason for cancellation: _________________________________________________________
Physician’s Name: __________________ Signature: _________ Date (DD/MM/YY): ___________

126
Annex 5: Urgency of Admission (set criteria related to pathology of the disease)

CARDIO-THORACIC PROCEDURES URGENCY CATEGORISATION

Congenital cardiac defect/s 2

Coronary artery bypass grafting 2

Heart valve replacement 2

Lobectomy / wedge resection / pneumonectomy 1

Pleurodesis 2

GENERAL SURGERY URGENCY CATEGORISATION

Anal fissure – surgery for 2

Axillary node dissection 1

Breast lump – excision and/or biopsy 1

Cholecystectomy (open/laparoscopic) 3

Cholecystectomy (open/laparoscopic) with biliary pancreatitis 1

127
Cholecystectomy (open/laparoscopic) with potential common bile duct stone or
severe frequent attacks (two within 90 days) 2

Colectomy/anterior resection/large bowel resection 1

Fundoplication for reflux disease 3

Hemorroidectomy 3

Herniorrhaphy – 3
femoral/inguinal/incisional/umbilical

Lipoma – excision of 3

Malignant skin lesion – excision of +/- grafting 1

Mastectomy 1

Obstructing hiatus hernia (para-esophageal hernia) 2

Parotidectomy /submandibular gland – excision of 2

Parathyroidectomy 2

Pilonidal sinus surgery 3

Skin lesions (not malignant) – excision of 3

128
Thyroidectomy/hemi-thyroidectomy 2

GYNAECOLOGY SURGERY URGENCY CATEGORISATION

Bartholin’s abscess drainage 1

Bartholin’s cyst – removal of 3

Curettage and evacuation of uterus 1

Colposcopy 2

Cone biopsy 1

Endometrial ablation 3

Female sterilization 3

Hysterectomy (abdominal / vaginal / laparoscopic) 3

Hysteroscopy, dilatation and curettage 2

Laparoscopy for dye studies / endometriosis 3

Large loop excision of the transformation zone cervix (LLETZ) 2

Mirena insertion 3

129
Myomectomy 3

Salpingo-oophorectomy / oophorectomy / ovarian cystectomy 2

Stress incontinence surgery 3

Vaginal repair - anterior / posterior 3

Warts - diathermy of 3

NEUROSURGERY URGENCY CATEGORISATION

Carpal tunnel release 3

Cerebral hematoma – evacuation of 1

Cervical discectomy and fusion unless 3


neurological deficit

Chiari malformation decompression 3

Common peroneal nerve release 2

Craniotomy for removal of tumor (neurological deficit) 1

130
Craniotomy for removal of benign tumor (no neurological deficit)
3

Craniotomy for ruptured aneurysm 1

Craniotomy for un-ruptured aneurysm 2

Cranioplasty 3

Discectomy with foot drop 1

Intracranial lesion (for example abscess/arteriovenous malformation) – removal


of 1

Laminectomy 3

Muscle biopsy/temporal artery biopsy 1

Nerve decompression of spinal cord 2

Pedicle screw fusion 3

Posterior fossa- decompression for hemorrhage or tumor 1

Untethering of spinal cord 2

Ventricular peritoneal shunt for obstructive hydrocephaly 1

131
Ventricular peritoneal shunt for normal pressure hydrocephaly 2

OPHTHALMOLOGY SURGERY URGENCY CATEGORISATION

Blepharoplasty (for reasons other than cosmetic) 3

Cataract extraction (+/- intra-ocular lens insertion) 3

Cataract extraction (+/- intra-ocular lens insertion) with angle closure glaucoma
1

Cataract extraction (+/- intra-ocular lens


Insertion) with severe disability 2

Chalazion - excision of 3

Corneal graft 3

Dacrocystorhinostomy 3

Ectropion – correction of 3

Examination of eye under anesthesia 2

Probing of naso-lacrimal duct 3

Pterygium - excision of 3

132
Ptosis – repair of 3

Squint - repair of 3

Trabeculectomy 2

Trabeculectomy with high intra ocular pressure 1

Vitrectomy (including buckling/cryotherapy) 2

Vitrectomy (including buckling/cryotherapy) with retinal detachment or infection 1

ORTHOPAEDIC SURGERY URGENCY CATEGORISATION

Anterior cruciate ligament reconstruction 3

Acromioplasty 3

Arthrodesis 3

Arthroplasty – revision of 2

Arthroscopy 3

Arthroscopy shoulder / sub acromial decompression 3

Bunion (hallux valgus) - removal of 3

Dupytrens contracture release 3

133
Exostosis – excision of 3

Fracture non-union - treatment of 2

Ganglion - excision of 3

Hammer/claw/mallet toe – correction of 3

Meniscectomy 3

Muscle or tendon length – change of 3

Nerve decompression 2

Osteotomy 3

Rotator cuff - repair of 3

Shoulder joint replacement 3

Shoulder reconstruction 3

Tendon release 3

Tenotomy of hip 2

Total hip replacement 3

Total knee replacement 3

134
OTOLARYNGOLOGY HEAD AND NECK URGENCY CATEGORISATION
SURGERY

Adenoidectomy 3

Ethmoidectomy 3

Functional endoscopic sinus surgery 3

Laryngectomy 1

Mastoidectomy 3

Microlaryngoscopy 2

Myringoplasty/tympanoplasty 3

Myringotomy 3

Nasal cautery 3

Nasal polypectomy 3

Nasendoscopy 2

Panendoscopy 1

Parotidectomy/submandibular gland – excision of 2

Pharyngoplasty 3

135
Pharynx – excision of 2

Pressure equalizing tubes (grommets) - insertion of 3

Radical neck dissection 1

Rhinoplasty (for reasons other than cosmetic) 3

Septoplasty 3

Stapedectomy 3

Sub-mucosal resection 3

Tonsillectomy (+/- adenoidectomy) 3

Turbinectomy 3

PAEDIATRIC SURGERY URGENCY CATEGORISATION

Branchial apparatus remnant –removal of 2

Circumcision (for reasons other than cosmetic) 3

Congenital pulmonary lesion – removal of 1

Dermoid cyst - removal of 2

Fundoplication 2

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Herniorrhaphy - epigastric/umbilical 3

Hydrocele – repair of 3

Hypospadias - repair of 2

Inguinal herniotomy/herniorrhaphy for age < 6 months 1

Inguinal herniotomy/herniorrhaphy for age > 6 months 2

Lingual or maxillary frenulum surgery 3

Neonatal surgery (e.g. hirschsprungs, anorectal, malrotation, esophageal atresia)


1

Nephrectomy for congenital abnormality 2

Orchidopexy 2

Pectus surgery 3

Pyeloplasty 2

Pyogenic granuloma - removal of 1

Skin lesion- excision of 3

137
Thyroglosssal remnant –removal of 2

Toenail surgery 3

Ureteric re-implantation 2

PLASTIC AND RECONSTRUCTIVE URGENCY CATEGORISATION


SURGERY

Breast prosthesis - removal of (for reasons other than cosmetic) 2

Breast reconstruction (for reasons other than cosmetic) 3

Breast reduction (for reasons other than cosmetic) 3

Cleft lip and palate – repair of 3

Dupytrens contracture release 3

Lipoma – excision of +/-grafting 3

Lymphangioma – surgery for 3

Malignant skin lesion – excision of +/- grafting 1

Rhinoplasty (for reasons other than cosmetic) 3

138
Skin lesions, non-malignant – excision of 3

Scar revision (for reasons other than cosmetic) 3

Trigger finger / thumb release 2

UROLOGICAL SURGERY URGENCY CATEGORISATION

Bladder neck incision 3

Circumcision (for reasons other than cosmetic) 3

Cystectomy 1

Cystoscopy 3

Epididymal cyst - removal of 3

Hydrocele - repair of 3

Hypospadias – repair of 3

Lithotripsy 2

Meatoplasty 3

Nephrectomy 2

Orchidectomy 1

139
Orchidopexy 3

Prostatectomy (transurethral or open) 2

Prostate biopsy 1

Pyeloplasty 2

Retrograde pyelogram 2

Stone/s urinary tract – removal of 1

Uretero-pelvic junction - correction of 2

Ureters re-implantation 3

Ureteric stent - insertion of 1

Urethra – dilatation of 2

VASCULAR SURGERY URGENCY CATEGORISATION

Abdominal or thoracic aortic aneurysm by any means


1

Amputation of limb
1

Bifurcated aortic graft


1

Carotid endarterectomy
1

140
Dialysis access surgery
2

Femoro-popliteal bypass graft


2

Varicose veins treatment by any means (for reasons other than cosmetic) 3

141
Annex 6: Perioperative Briefing Templates

PREOPERATIVE BRIEFING
NB: THE PREOPERATIVE BRIEF IS TO BE CONDUCTED BEFORE THE FIRST CASE ENTERS THE OPERATING ROOM WITH ALL TEAM
MEMBERS PRESENT.
BRIEF LEADER: _____________________ DATE (DD/MM/YY): _________________ THEATRE NUMBER/SPECIALTY: _______________
1. TEAM MEMBERS:
1. ARE ALL TEAM MEMBERS PRESENT? Nurse: Anesthesia: Surgeon:
(Yes/No)
2. INTRODUCTION OF ALL TEAM 1. Done 2. Not done
MEMBERS
3. ADDITIONS TO THE TEAM/ANY
VISITORS?

2. DISCUSS EACH CASE:


TUBES TO
LIST BE PATIENT SURGERY EQUIPMENT INVESTIGATIONS CRITICAL
ORDER ALLERGY BLOOD ANTIBIOTIC PLACED POSITION DURATION AVAILABILITY DISPLAY CONCERNS
CASE I
NAME:

CASE 2
NAME:

CASE 3
NAME:

CASE 4
NAME:

CASE 5
NAME:

TEAM LEADER SIGNATURE: ____________________________

142
POSTOPERATIVE BRIEFING

NB: THE DEBRIEF IS TO BE CONDUCTED AFTER THE LAST CASE OF THE DAY LEAVES THE ROOM WITH ALL TEAM MEMBERS PRESENT

DEBRIEF LEADER: _____________________DATE (DD/MM/YY): _____________

WHAT WENT DID WE WORK WELL AS A TEAM?


WELL AND DID WE SPEAK UP WHEN REQUIRED?
WHY? WERE WE WELL PREPARED?
WHAT DID DID THE PREOPERATIVE BRIEF MISS ANYTHING?
NOT GO WELL WAS THERE ANY CONFUSION?
AND WHY? WHERE THERE ANY ERRORS/NEAR MISSES?
WHAT DO WE NEED TO CHANGE?
FEEDBACK WHAT CAN WE DO TO IMPROVE?
AND ACTIONS WHAT DO WE NEED TO DO FOR THE NEXT OPERATION
SESSION?

ACTION PLAN

TEAM LEADER SIGNATURE: ___________________________

143
Annex 7: Anesthesia Recording Template

144
Annex 8: Operation Note Sample
Name, ______________ Date______________ Age, ____Sex ______Card number_____
Surgeon____________________ Assistant Surgeon ___________________________

Scrub Nurse_______________________ Runner Nurse__________

Anesthetist/Anesthesiologist: ________________

Time: ___________________________________ Anesthesia Type____________________

Indication, ______________________________ Procedure_________________________

Intra Operative finding________________________ Post Operative


Diagnosis_______________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
145
_________________________________________________________________________________
_________________________________________________________________________________
___________________________________________________________________

146
Annex 9: Operation Registry
S.N Nam Ag se Card Procedu Indicati Anesthe Surge Anesthesiolog Assista Scru Runne Outcom Re
o e e x numb re on sia on ist/ nt b r e ma
er rk
Type Anesthetist

147
Annex 10: Count Sheet
Name of Patient__________________________________________Date__________________

Operation____________________________________________________________________

Count before Items added/removed Total Count before closing Final count (before closing skin)
incision
Cavity Fascia
Gauze
Abdominal packs
Sharp Objects

Blades

Needles
Instruments

Scalpel handle
Towel clips
Dissecting forceps
Scissors
Forceps
Needle holder
Retractor
Other

148
Annex 11: Operating Theatre Table Efficiency Assessment Tool

Time Case 1 Case 2 Case 3 Case 4 Case 5


Patient entry to OT (Wheels In)
Patient Intubation/anesthesia
administration time
Patient incision time
Patient extubation time
Patient transferred out of OT
(Wheels out)

149
Annex 12: Discharge Form
Patient name Date of Birth (Age)

Address Sex

Medical record number

Admission date

Discharge Date

Attending physician

Operating surgeon:

Condition on discharge

Final diagnosis (List primary diagnosis first)

Procedures (list dates, complications)

History of present illness

Laboratory/ Data (mention the most permanent results that need to be followed)

150
Hospital Course (By problem list, not by date)

Discharge medications (most important. List medications that are different from those taken at admission)
______________________________________

Discharge instruction (Diet, activity, discharge to home / nursing facility, etc.) _______________________

Follow up appointment:
Date ____________ Place_________________To be seen by______________

Plan on next appointment (what is to be done on the next appointment) ______________________

Name________________Signature _______

151
Annex 13: SSI Recording Register
SURGICAL SITE INFECTION REGISTRATION
LOGBOOK
INPATIENT ☐ OUTPATIENT☐
PATIE BED DATE OF PROCEDURE DATE SSI POSTOPERAT WOUND
MRN AGE SEX
NT No. SURGERY PERFORMED WAS IVE CULTURE
NAME DIAGNOSED DIAGNOSIS RESULT

152
Annex 14: Cancellation and scheduling (operation theater daily activity report) Register
Operation Theater Activity Daily Report

Day Date
Reporting person

S. N Name MRN Department Diagnosis Planed Procedure Reason for Remark


procedure status cancellation*
Operated / cancelled

*Select reason for cancellation from the list

153
Main Reason Specific reason

Uncontrolled
(1) P /acute medical illnesses (6) Uncontrolled /acute medical illnesses (7)Lack of important investigation
a
Lack of important
t investigation Increase blood pressure Hematocrit
i Uncontrolled DM Electrolyte
e
refusal/request Uncontrolled asthma LFT
n
Poor bowelt preparation Coagulopathy Pulmonary function test

r
Financial shortage Ischemic heart diseases ECG
e
Absent l Uncontrolled Thyroid RFT
a
Not fasting Acute fever X-RAY/CT SCAN
t
e
Taking anticoagulant URTI
d Others
(2) Management related Shortage of OR material
Power breakdown
Lack of ICU bed
Shortage of water supply
Lack of mechanical ventilator
Blood not prepared
Lack oxygen source
Others
(3) Staff related Surgeon
Anesthetist
Nurse
Cleaner
Porter
(4)Shortage of time Previous case prolonged
Emergency priority
Over scheduling
(5)Unexpected Cardiac arrest
emergency Aspiration on the table
failed intubation/spinal

154

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