The Anesthesia Policy And Procedure Manual is part of MCN Healthcare’s ellucid® Policy Library. MCN Healthcare is the health care industry’s leading provider of TJC (formerly JCAHO) accreditation tools and CMS accreditation help, consisting of policy and procedure templates, forms, competencies and other compliance tools. MCN’s policy and procedure manuals are used in more than 25,000 healthcare organizations throughout the world to help with compliance, accreditation, and health care quality improvement.

All customizable policies, procedures, forms and compliance tools are provided as templates in Microsoft Word format. MCN’s policy and procedure library consists of 87 policy and procedure manuals and more than 18,000 compliance tools. This is the most comprehensive collection of customizable policy templates, policies, procedures, forms, competencies, job descriptions, and performance evaluations available anywhere—all kept up to date with the latest standards from CMS, Joint Commission, FDA, HIPAA, OSHA, ACHC, AAAHC, USP, and utilizing standards of practice from ANA, AORN, ENA, and more.

INTRODUCTION

Approval/Signature Sheet

Introduction

SECTION I - ETHICS, RIGHTS AND RESPONSIBILITIES

Patient Rights and Responsibilities

Informed Consent

Advance Directives

Do Not Resuscitate (DNR)

Confidentiality of Information - General Issues

Patient Rights and Responsibilities for Pain Management

Blood/Blood Component - Informed Consent

Blood/Blood Component Transfusion Consent Form

Refusal of Blood/Blood Component Transfusion

Refusal to Permit Blood/Blood Component Transfusion Form

Staff Rights and Ethical Dilemmas in Patient Care

SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES

Rules and Regulations

Anesthesia Responsibilities

Anesthesia Responsibilities for Outpatient Procedures

Preoperative Testing/Assessment for Inpatients

Ambulatory Surgery Preoperative Assessment Criteria

Patient Identification for Clinical Care and Treatment

Preanesthesia Assessment

Preanesthesia Assessment by CRNA

ASA Classification System

Care of the Latex Sensitive Patient

Latex Allergy Assessment Form

Latex and Non-Latex Alternatives

Surgical Site Identification

Invasive Procedure Site Identification

Pre and Post Anesthesia Evaluation Policy

Pre and Post Anesthesia Evaluation Form

Assessment Prior to Induction of Anesthesia/Sedation

Anesthesia Awareness

Guidelines for Administration of Anesthesia

Intraoperative Anesthesia Care

Completion of Anesthesia Record

Anesthesia Record Form

Patient Positioning

Acquisition, Identification and Administration of Blood Products

Pain Assessment in Children

Assessment Pain Scale

Pain Scale Examples

Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients

Postoperative Anesthesia Care

Sedation

Sedation Monitoring Form

Cardiopulmonary Resuscitation in the Operating Room

Patient Defibrillation

Emergency Equipment in the PACU

Criteria for Notifying Anesthetist

Surgeon/Anesthetist Discharge Responsibilities

Management of Patient with Malignant Hyperthermia

Malignant Hyperthermia Cart

Capnography

Patients with Sleep Apnea

Placement of Epidural Blood Patch (EBP)

SECTION III - MEDICATION MANAGEMENT

Security of Medications - Anesthesia Carts

Concentrated Electrolyte Solutions and Other Drug Concentrations

Emergency Crash Carts

Emergency Crash Cart Security and Accountability

Emergency Medications

Emergency Medications List

Telephone, Verbal and Written Orders for Medication

Medication and Solution Administration in the OR

Pediatric Dosing - General Guidelines

Administration of Preoperative Antibiotics

Adverse Drug Reaction Reporting

Adverse Drug Reaction Reporting Form

Potential Adverse Drug Reaction Form

Medication Inadvertent Incident Report Form

Medication Error Analysis Tool

SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control

Standard Precautions

Asepsis

Hand Hygiene - CDC Guidelines

Attire in the Operating Room

Waterless, Scrubless, Brush-Free Surgical Hand Rub Antiseptic

Gowning and Gloving Technique

Patient Skin Prep

Transmission-Based Precautions (Isolation Precautions)

Sharps Precautions

Sharps Injury Protection Plan

Sharps Injury Log Form

Definition of Biohazardous Waste

Visitor Control

SECTION V - IMPROVING ORGANIZATION PERFORMANCE

Department of Anesthesia Performance Improvement Plan

Performance Improvement Activities

Anesthesia Committee PI Monitoring and Evaluation Plan

Anesthesia Committee PI Trending Sheet

Anesthesia Committee PI Outcome Evaluation

Anesthesia Committee PI Volume Measures/Statistics

Performance Improvement Quarterly Report Form

Anesthesia Generic Screens Form

Incident Reporting

Performance Improvement indications and Notification Form - Surgery - Anesthesia - PACU

Sentinel Event

SECTION VI - LEADERSHIP

Scope of Services

Anesthesia Coverage

Anesthesia Coverage - Captured Call

Emergency Service Coverage

Nurse Anesthesia Services Organization and Direction

Jail Custody Patients

SECTION VII - MANAGEMENT OF THE ENVIRONMENT OF CARE

Patient Safety in the Operating Room

Standards for Anesthesia Performance and Maintenance Criteria

Anesthesia Safety

Anesthesia Equipment Safety

Anesthesia Apparatus Check Recommendations

Anesthesia Apparatus Checklist

Use of Clinical Alarms on Medical Equipment

Stocking and Cleaning Anesthesia Machines

The Anesthesia Workplace

Fire Safety in an Oxygen Rich Environment - Operating Room

Anesthesia Gas and Nitrogen Storage

Compressed Gas and Oxygen Use

SECTION VIII - MANAGEMENT OF HUMAN RESOURCES

Position Description/Performance Evaluation - Chief CRNA

Performance Evaluation - Population-Specific/Age-Related Competency - Chief CRNA

Annual Competency Clinical Skills Assessment - Chief CRNA

Position Description/Performance Evaluation - Certified Registered Nurse Anesthetist (CRNA)

Performance Evaluation - Population-Specific/Age-Related Competency - Certified Registered Nurse Anesthetist (CRNA)

Annual Competency Clinical Skills Assessment - Certified Registered Nurse Anesthetist (CRNA)

Position Description/Performance Evaluation - Surgical Services Pain Management RN

Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Pain Management RN

Annual Competency Clinical Skills Assessment - Surgical Services Pain Management RN

Annual Competency - 2008 Joint Commission National Patient Safety Goals

Educational Responsibilities of the Department of Anesthesia

SECTION IX - MANAGEMENT OF INFORMATION

Legibility of Medical Record Documentation

Documentation Required for a Surgical Case

Documentation and the Use of Abbreviations, Acronyms and Symbols

Unacceptable Abbreviation and Symbol List

Acceptable Abbreviations List

SECTION X - MEDICAL STAFF

Organization of the Department of Anesthesia

Anesthesia Medical Staff Rules and Regulations

Duties and Responsibilities of Chief Anesthesiologist

General Guidelines in the Credentialing and Privileging Process

Medical Staff Reappointment and Renewal of Clinical Privileges

Anesthesia Staff Categories

Continuing Medical Education Requirements

Continuing Medical Education Record Form

SECTION XI - PAIN MANAGEMENT

Admission to Pain Management Program

Comprehensive Pain Assessment Form

Pain Management Flowsheet

Discharge from Pain Management Program

Patient Controlled Analgesia

Patient Controlled Analgesia (PCA) - Sample Physician’s Orders Form

Postoperative Epidural Narcotic Continuous Infusion - Sample Physician’s Orders Form

PCA Infusion Pump

Nursing Procedure for Intermittent, Continuous and PCA Infusions via Epidural Catheter

PCA Follow-Up Visit Form

Pain Management Services Patient Satisfaction Survey

Cryo-Neurolysis

Monitoring and Infusion Protocols for Patients Receiving Epidural Analgesia

Epidural Analgesia for Chronic Pain Management - Continuous Infusion

Protocol for the Administration of Epidural Anesthesia for OB Patients

Postoperative Epidural Narcotic (Continuous Infusion Mode)

Epidural Catheter Dressing Changes

Removal of Epidural Catheter

Hypertonic Saline Injection for Neurolysis

Intravenous Local Anesthetic Infusion Protocol

Intravenous Local Anesthetic Infusion Procedure

Lumbar Sympathetic Nerve Block

Phenol for Use in Nerve Blocks

Trigger Point Injection