Ga. Comp. R. & Regs. R. 111-8-40-.28 - Surgical Services

If the hospital provides surgical services, the services shall be provided in a manner which protects the health and safety of the patients and follows current accepted standards of medical and surgical practice. Personnel, equipment, policies and procedures, and the number of operating rooms shall be appropriate for the scope of services offered.

(a) Organization of Surgical Services. The hospital shall have an organizational plan which defines lines of authority, responsibility, and accountability within all operating room areas where surgical procedures are performed.

1. There shall be a current roster of surgical privileges granted each medical staff member available to nursing and scheduling staff in the surgical services area(s).

2. The hospital shall have bylaws, rules, or policies and procedures developed by the medical staff which require that within twenty-four (24) hours prior to surgery either a history and physical examination or an update of a previous history and physical is completed for every surgical patient. Where an update is used, the previous history and physical examination must not have occurred more than thirty (30) days prior to surgery.

3. Roles, responsibilities, and qualifications for any non-physician first and second assistants participating in surgery shall be defined by the hospital medical staff, including any limitations to their roles in patient care.

4. Chief(s) of Surgery. Physician member(s) of the medical staff, who have been appropriately trained in the provision of surgical services, shall be designated by the medical staff to direct the hospital's surgical services, and shall be responsible for all clinical aspects of organization and delivery of the particular surgical services including the evaluation of the effectiveness of the services in coordination with the hospital's quality management program.

(i) The chief(s) of surgery shall be responsible for implementation of hospital policy related to medical staff utilizing the surgical suite.

(ii) In conjunction with the hospital's medical staff, the chief(s) of surgery shall implement procedures requiring an operative report for each surgery performed.

(I) The operative report shall describe techniques, findings, complications, tissues removed or altered, and the general condition of the patient during and following surgery.

(II) The full operative report shall be written or dictated immediately after surgery and signed or authenticated by the surgeon. Where the full operative report is not available to be placed immediately in the record, an operative/progress note by the surgeon must be entered into the medical record immediately.

5. Nurse Manager. A licensed registered nurse, who has been appropriately trained in the provision of surgical nursing services, shall manage the surgical suite(s) and shall be responsible for:

(i) Ensuring that a sufficient number of nursing personnel are on duty in the surgical suite to meet the needs and safety of the patients;

(ii) Ensuring that surgical technicians perform scrub functions only under the supervision of a licensed registered nurse who is immediately available to respond to emergencies;

(iii) Delineating the duties of scrub personnel and circulating registered nurses in the surgical suite;

(iv) Providing for orientation and on-going education and training of surgical personnel providing services within the surgical suite, to include at least equipment usage and inspections, infection control and safety in the surgical area, cardiopulmonary resuscitation, patient rights, and informed consent;

(v) Ensuring that patients are monitored and provided with nursing care from the time they enter the surgical suite to the time they exit the area;

(vi) Developing criteria for the use of equipment and supplies brought into the surgical suite from other areas; and

(vii) Ensuring that the operating room register is current and complete.

(b) Infection Control in the Surgical Suite. The hospital shall develop and implement infection control procedures specific to the surgical services areas, which include at least requirements for:

1. Surgical attire;

2. Surgical scrub procedures;

3. Housekeeping functions;

4. Cleaning, disinfecting, and sanitizing the area;

5. Appropriate maintenance of the heating, ventilation, and air conditioning systems for the surgical suite;

6. Packaging, sterilizing, and storage of equipment and supplies;

7. Waste disposal;

8. Traffic control patterns, including who may enter the operating room areas and under what circumstances; and

9. A surgical site surveillance system appropriate to the population served.

(c) Minimum Equipment for the Surgical Suite. The following emergency equipment shall be available and functional for the operating room(s) and for the post-anesthesia area, as appropriate:

1. A call system;

2. Cardiac monitors;

3. Resuscitation equipment;

4. A defibrillator;

5. Aspiration/suction equipment;

6. A traecheostomy kit;

7. A pulse oximeter; and

8. A end-tidal carbon dioxide monitor.

(d) Post-Anesthesia Care Unit.

1. The post-anesthesia care unit shall be located in an area of the hospital in close proximity to but physically separated from the operating room.

2. Policies and procedures for the post-anesthesia care unit shall include at a minimum the criteria for admission to and discharge from the unit.

3. If patients are not transferred to the post-anesthesia care unit following surgery, provisions shall be made for monitoring the patient until it is determined that the patient is stable.

Notes

Ga. Comp. R. & Regs. R. 111-8-40-.28

O.C.G.A. §§ 31-7-2.1 and 31-9-6.1.

Original Rule entitled "Surgical Services" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.