Final Perioperative Guideline For Print
Final Perioperative Guideline For Print
GUIDELINE
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.
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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.
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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
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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
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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
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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
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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
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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.
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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.
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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.
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1. Leadership and Management
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.
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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).
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2. Teamwork and Communication
Contact
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
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❖ Ask the consultant if they would like any additional studies or therapies to be initiated prior to
their evaluation
❖ 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
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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:
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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:
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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
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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:_____________________________________________________________________
The preoperative surgical checklist for pediatric patients is annexed (Annex 4).
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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
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Current Yes No If yes, document illness:
medical
illness
Current Yes No If yes, document medications:
medications
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
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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.
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Table 3: Recommended pre-operative screening test
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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.
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Table 5: American Society of Anesthesiologists physical status classification system (ASA
classification)
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.
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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:
❖ 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:
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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.
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 ___________
Surgical related
Date surgical evaluation is done__________________________
Surgical diagnosis______________________________________
Planned procedure_____________________________________
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Estimated blood loss____________________________________
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) ___________
Anesthesia related
Date pre-anesthesia evaluation is done ________________ASA status ________________
Comorbid conditions_____________________________________________________________
Medications patient is taking _____________________________________________________
______________________________________________________________________________
Known allergy (Y/N) _____________________________
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Preparation for difficult airway management is complete, If applicable (Y/N) __________
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) ___________
Administrative related
Patient has deposited the required payment or has free patient stump (Y/N) ________ (confirm
by seeing admission card)
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
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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.
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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.
ሆነ የማይጠበቁ
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 --------------------------------------------
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
የሐኪሙ ስም----------------------------------------ፊርማ---------------------------ቀን---------------------
የእማኞች ስምና ፊርማ
1. ስም----------------------------------- ፊርማ------------------
2. ስም----------------------------------- ፊርማ------------------
3. ስም----------------------------------- ፊርማ------------------
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.
42
Table 6: Preoperative conference checklist
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.
▪ 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
45
Table 8: Fasting guide
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
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.
BP__________PR___________RR____________T__________SPO2__________RBS_______
Chart review
Patient has signed both anesthesia and surgical consent (Y/N) _______________
List of medications patient used in the past clearly indicated in the chart (Y/N)
_________________
49
Day of surgery
BP__________PR___________RR____________T__________SPO2__________RBS_______
50
At the OR gate the anesthesia and OR nursing team shall:
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.
Patient Identification
Name _______________________________________
MRN ________________________________________
Ward: Bed number______________________________
Age _________________________________________
Sex _________________________________________
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
THE
T Timing—Prioritization of actions
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
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
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
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
55
8 Count sheet
YES NO YES NO
10 Foot stools
YES NO YES NO
11 IV stand X2
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
17 Prep table
YES NO YES NO
56
22 Suction plugged in and suction working
YES NO YES NO
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.
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.
4.1.3 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:
➢ 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.
➢ Verifying availability and proper functioning of all necessary surgical equipment and
instruments, and identifying any implant concerns
➢ 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
60
(Annex 6).
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.
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 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:
61
➢ Confirms that all team members have been introduced by name and role
➢ Reviews the anticipated critical events
➢ Nursing staff review confirmation of sterility, equipment availability, and other concerns
➢ 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:
➢ Key concerns for recovery and management of the patient are discussed
62
Figure 5: World Health Organization's Surgical Safety Checklist
63
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.
Environment
64
Assesses the patient’s physical and emotional status
Procedure Initial/Signature
65
Scrubs, gowns, gloves self and other members of the
surgical team
Assists with draping procedures
1. Any machine or apparatus that supplies gases, vapors, local anesthesia or intravenous
anesthetic agents to induce or maintain anesthesia
66
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.
67
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
68
Anesthesia Machine
In preparing for anesthesia, the anesthetic machine should be checked by the anesthesia provider:
Every anesthetic machine should meet the following minimum standard requirements:
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.
69
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.
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
70
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.
71
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.
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).
72
Table 14: Anesthesia parameters to be monitored intraoperatively
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.
73
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.
74
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.
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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
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.
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.
• 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
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
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.
Handover Procedure:
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.
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
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.
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.
❖ 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
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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
❖ 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
❖ 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
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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
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.
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
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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
Within 12 hours
Investigate
Incident Design an action
plan
OR manager
/Salt focal person
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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
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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)
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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
Seen by a physician?
o Yes
o No
If yes, mention physician name and position
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If yes date and time of evaluation
Give brief factual description of incident
Present diagnosis
Reported by Title Signature Date Phone number
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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.
100
R. KPI Operational Numerato Denominator Formula Data Source
No. definition r
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.
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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
107
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.
• 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
109
• 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
110
Annex 3: Perioperative Process Maps for Emergency Procedures
No
Take patient to OR
111
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.
112
Emergency Surgery Intra-operative Process Map
Patient transferred
to PACU
113
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
NO
Transfer to ICU
In OR according to hospital
protocol
115
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.
116
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)
117
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
Confirm
administration of IV
antibiotics
Conduct vaginal
cleansing and sterile
catheterization
Client transfer to PACU
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
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)
Pleurodesis 2
Cholecystectomy (open/laparoscopic) 3
127
Cholecystectomy (open/laparoscopic) with potential common bile duct stone or
severe frequent attacks (two within 90 days) 2
Hemorroidectomy 3
Herniorrhaphy – 3
femoral/inguinal/incisional/umbilical
Lipoma – excision of 3
Mastectomy 1
Parathyroidectomy 2
128
Thyroidectomy/hemi-thyroidectomy 2
Colposcopy 2
Cone biopsy 1
Endometrial ablation 3
Female sterilization 3
Mirena insertion 3
129
Myomectomy 3
Warts - diathermy of 3
130
Craniotomy for removal of benign tumor (no neurological deficit)
3
Cranioplasty 3
Laminectomy 3
131
Ventricular peritoneal shunt for normal pressure hydrocephaly 2
Cataract extraction (+/- intra-ocular lens insertion) with angle closure glaucoma
1
Chalazion - excision of 3
Corneal graft 3
Dacrocystorhinostomy 3
Ectropion – correction of 3
Pterygium - excision of 3
132
Ptosis – repair of 3
Squint - repair of 3
Trabeculectomy 2
Acromioplasty 3
Arthrodesis 3
Arthroplasty – revision of 2
Arthroscopy 3
133
Exostosis – excision of 3
Ganglion - excision of 3
Meniscectomy 3
Nerve decompression 2
Osteotomy 3
Shoulder reconstruction 3
Tendon release 3
Tenotomy of hip 2
134
OTOLARYNGOLOGY HEAD AND NECK URGENCY CATEGORISATION
SURGERY
Adenoidectomy 3
Ethmoidectomy 3
Laryngectomy 1
Mastoidectomy 3
Microlaryngoscopy 2
Myringoplasty/tympanoplasty 3
Myringotomy 3
Nasal cautery 3
Nasal polypectomy 3
Nasendoscopy 2
Panendoscopy 1
Pharyngoplasty 3
135
Pharynx – excision of 2
Septoplasty 3
Stapedectomy 3
Sub-mucosal resection 3
Turbinectomy 3
Fundoplication 2
136
Herniorrhaphy - epigastric/umbilical 3
Hydrocele – repair of 3
Hypospadias - repair of 2
Orchidopexy 2
Pectus surgery 3
Pyeloplasty 2
137
Thyroglosssal remnant –removal of 2
Toenail surgery 3
Ureteric re-implantation 2
138
Skin lesions, non-malignant – excision of 3
Cystectomy 1
Cystoscopy 3
Hydrocele - repair of 3
Hypospadias – repair of 3
Lithotripsy 2
Meatoplasty 3
Nephrectomy 2
Orchidectomy 1
139
Orchidopexy 3
Prostate biopsy 1
Pyeloplasty 2
Retrograde pyelogram 2
Ureters re-implantation 3
Urethra – dilatation of 2
Amputation of limb
1
Carotid endarterectomy
1
140
Dialysis access surgery
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?
CASE 2
NAME:
CASE 3
NAME:
CASE 4
NAME:
CASE 5
NAME:
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
ACTION PLAN
143
Annex 7: Anesthesia Recording Template
144
Annex 8: Operation Note Sample
Name, ______________ Date______________ Age, ____Sex ______Card number_____
Surgeon____________________ Assistant Surgeon ___________________________
Anesthetist/Anesthesiologist: ________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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
149
Annex 12: Discharge Form
Patient name Date of Birth (Age)
Address Sex
Admission date
Discharge Date
Attending physician
Operating surgeon:
Condition on discharge
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______________
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
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