Current through September 2, 2024
A hospital that provides surgical service shall have equipment, facilities and personnel according to the needs of the type of patients served.
01.
Location of Surgical Department. The surgical department shall be segregated from the remainder of the hospital so as to prevent traffic through the area to any other part of the hospital.
02.
Physical Facilities. The facilities of each surgical department shall have the following:
a. Scrub sinks with goose neck spout and knee, elbow or foot action water control; and
b. Operating rooms, that shall have floors, walls and ceilings with easily cleanable surfaces; and
c. A housekeeping closet shall be provided for the sole use of the surgical department; and
d. A utility room for the cleaning of contaminated equipment and supplies; and
e. Separate space for the storage of sterile and non-sterile supplies.
03.
Policies and Procedures. Written policies and procedures concerning surgical service shall be approved by the medical staff, appropriate nursing staff and the administration. They shall include, but not be limited to, the following:
a. Specific delineation of surgical privileges shall be made for each physician or practitioner performing surgery. Privileges for each physician shall be available to the operating room supervisor; and
b. A policy and procedure for all persons admitted for surgery, and shall include the following:
i. Verification of patient identity; and
ii. Site and side of body to be operated upon; and
c. Written procedures for infection control including aseptic techniques for patients and personnel during preoperative, operative and postoperative periods in the surgery suite; and
d. When appropriate, a procedure for accountability of all instruments, sponges, needles used in surgery; and
e. A procedure for the safe handling and transportation of patients.
04.
Records. Prior to surgery patient records shall contain the following:
a. A properly executed informed consent; and
b. Medical history and record of physical examination performed and recorded no more than seven (7) days before or within forty-eight (48) hours after admission; and
c. Appropriate screening tests, based on patient needs, completed and recorded prior to surgery.
d. Record requirements may be modified in emergency surgery cases to the extent necessary under the circumstances.
05.
Records Following Surgery. Patient records following surgery shall contain the following:
a. Operative report of techniques and findings shall be recorded directly after surgery; and
b. All tissues and foreign bodies shall be sent to a pathologist in accordance with Subsection 350.08; and
c. Sponge and needle count, if appropriate.
06.
Operating Room Registry. Operating room registry shall contain the following:
a. Name, age, sex, and hospital admitting number of patient; and
b. Date and time of surgery; and
c. Preoperative and postoperative diagnosis; and
d. Names of surgeons, assistants, anesthetists, scrub and circulating assistants; and
e. Surgical procedure performed; and
f. Complications, if any, during surgery.
07.
Surgical Staff. The surgical staff of a hospital shall consist of the following personnel:
a. A licensed registered nurse with experience in operating room techniques who acts as supervisor; and
b. Sufficient numbers of personnel to assure there is a licensed registered nurse serving as circulating nurse for each separate operating room where surgery is being performed; and
c. A surgical team of one (1) or more physicians and licensed registered nurses on call at all times; and
d. A physician of the active medical staff shall provide overall direction for the surgical service.
08.
Staff Training and Education. There shall be evidence of continuing education and training for the staff.
09.
Surgical Service Supplies and Equipment.
a. Parenterals, drugs, instruments, equipment and supplies necessary for the scope of services provided shall be readily available to the surgical suite; and
b. Emergency IV fluids and medications as approved by the pharmacy and therapeutics committee shall be available; and
c. There shall be a written procedure for the use, care, and maintenance of all supplies, instruments and equipment, and responsibility for such maintenances.
Effective March 17, 2022
