New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 12 - SURGICAL AND ANESTHESIA SERVICES › Section 8:43A-12.6 - Surgical policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				develop and implement written bylaws, rules, regulations, policies, and procedures
				for surgical and anesthesia services, in accordance with the governing authority and
				medical staff bylaws. The policies and procedures shall be reviewed at least every
				three years and revised as needed, and shall include at least the following:
1. Delineation of the surgical and anesthesia
				services which may be performed in the facility;
2. Delineation of the responsibilities of medical
				staff members in providing care to patients;
3. Designation of a time frame and of persons
				responsible for completing a medical history, physical examination, and laboratory
				tests prior to surgery;
4. Policies and
				procedures regarding preanesthesia evaluation, patient preparation, and
				intraoperative management;
i. A patient
				identification system shall be implemented and patient identification shall be
				verified prior to any surgical procedure;
ii. There shall be a policy and procedure to
				verify the site and side of any and all surgical procedures. The procedure site and
				side shall be documented on the operative consent form.
iii. There shall be oral verification of the
				correct site and side of the surgical procedure in the operating room by a surgical
				team member in accordance with the facility's policy;
5. Policies and procedures to ensure that every
				patient is examined by a practitioner immediately prior to surgery;
6. A registered professional nurse shall be
				assigned to circulating nurse duties in each room where surgery is being
				performed;
7. Policies and procedures
				for use of analgesia and anesthesia, including types which may be used for each
				procedure, safety regulations, and responsibilities and qualifications of persons
				who administer anesthesia and monitor patients;
8. Policies and procedures for the preoperative
				and postoperative recording of vital signs (blood pressure, temperature, pulse and
				respiration rate);
9. Policies for
				reporting of morbidity and mortality in accordance with
				8:43A-12.7(b);
10. Policies and procedures for monitoring of
				patients in any special procedure room or other location where patients receive
				anesthesia;
11. Policies and procedures
				for postoperative observation and care required for each type of
				procedure;
12. Methods to ensure that
				gross and microscopic tissue removed surgically or by any other procedure, including
				termination of pregnancy in accordance with the regulations of the New Jersey State
				Board of Medical Examiners,
				13:35-4.2, is examined by a pathologist
				and a report of the findings is documented in the patient's medical record;
i. The facility shall ensure that the tissue is
				disposed of in accordance with
				8:43A-14.7 of this chapter whether it is
				examined on the facility's premises or off the facility's premises;
13. Policies for discharge criteria
				from the facility;
14. Requirements for
				written documentation of surgical procedures performed, including at least a
				description of the findings, procedures used, specimens removed, patient's
				condition, any unusual events occurring during the procedure, postoperative
				diagnosis, and names of the surgeon and assistants. This operative note shall be
				written or dictated immediately following the procedure by the person performing the
				surgery and incorporated into the patient's medical record;
15. Policies and procedures for the provision of
				written instructions to the patient (multilingual, if indicated) on preoperative and
				postoperative care, including, but not limited to, restrictions on food and
				beverages before surgery and procedures for obtaining help in the event of surgical
				wound infection or other postoperative problems;
16. Policies and procedures regarding infection
				prevention and control shall be reviewed at least every three years and revised more
				frequently if needed, including, but not limited to, the following:
i. Designation of a person with training or
				experience in surveillance, prevention, and control of nosocomial infection who
				shall be responsible for the direction, provision, and quality of infection
				prevention and control services;
ii. Use
				of aseptic technique and scrub procedures;
iii. Detailed specification of attire in all the
				operative areas according to facility infection control policies, to include at a
				minimum the commercial laundering of scrub attire between uses;
iv. Traffic control, including restricted access
				to the surgical suite;
v. Cleaning of
				the operating room after each procedure including documentation of training in
				cleaning the surgical suite and the specific assignment of this task thereafter by
				individuals who are trained;
vi. Care of
				operating room equipment and anesthesia equipment; and
17. All surgical staff shall comply with the
				universal precautions set forth in the Centers for Disease Control and Prevention
				Guideline for Handwashing and Hospital Environmental Control. (Centers for Disease
				Control and Prevention Guideline for Prevention of Surgical Site Infections (1999)
				(Infection Control and Hospital Epidemiology 1999; 20:247-278), incorporated herein
				by reference, as amended and supplemented. That publication may be obtained by
				telephoning the Centers for Disease Control and Prevention at (800)
				311-3435.)