REQUIREMENTS for patients receiving anesthesia support

PRE-OP requirements – MUST be completed prior to 30-minutes prior to scheduled start time:

1. Attending for case MUST show face in preop, so the preop nurse sees you. The preop nurses are not allowed to release the patient from the preop holding area until the attending is visualized.
2. Attending must mark operative site if with your initials IF laterality is crucial. “Site marking is not required before procedures in which there is no predetermined site of insertion such as cardiac catheterization and other interventional procedures.” Thus, this is rarely needed for percutaneous procedures.
3. Attending should consent patient – leave in preop room with patient/preop nurse. For outpatients, this can be done in clinic, with consent scanned into EPIC.
4. Attending must “Update H&P” (can be done remotely, and can be done up to 24 hours in advance for inpatients). See info below for more detail.
5. There is NO need for our resident to enter a presedation H&P, since the IR attending is not administering sedation.
6. If significant risk for periprocedural hemorrhage, consider obtaining type and screen/cross.

POST-OP:

6. A physician involved in the procedure (resident/fellow/attending) MUST accompany the patient from procedure room to the PACU (or ICU) in order to provide “handoff” to the PACU/ICU nurse. Convey:
   1. what procedure was performed
   2. where dressings are
   3. any complications, whether there is anything special to look out for such as SOB/hypoxia (PTX), additional labs/rad studies needed in postop period
   4. disposition (d/c home from PACU versus to inpatient floor)
   5. your pager number for nurse to call if any procedure-related questions or issues
7. Write a brief Op note. Ideal to call primary team if possible to update them.
8. Speak to family, who is likely waiting in the waiting room, who will otherwise ask anesthesiologists what happened (and they are often unsure).

IF PLANNED DISCHARGE HOME FROM PACU:

9. Write prescriptions
10. Write discharge summary
11. Write patient instructions
12. EPIC instructions for these discharge items: While in the patient’s “Patient Station” for that encounter (not the usual chart), click, on “Discharge” from the top row under the patient’s tab.
    • For Prescriptions: In the left “Discharge” column, click on “Order Reconciliation”
      1. Under “1. Review Orders for Discharge” tab, under the Home Medications, click on the green arrow pointing right, so that they continue all of their home meds (assuming that’s what you want).
      2. Then under the “Inpatient Medications” click on the red circle with a slash, to indicate you are not prescribing their inpatient meds.
      3. Then in the far right box, in the text entry box for “Discharge order”, enter in the med you want to Rx. When given choices, just remember it needs to be in the “After Visit” category. Then you can fill out the medication details. If it is a narcotic, you will need to review their narcotic risk history (click reviewed), do multi-step authentication, and double check it is going to the right pharmacy.

• • For discharge summary, in the left “Discharge” column, click on “Discharge Summary”. I just enter in a sentence or two saying which procedure they underwent, under GA or MAC, and that they are recovering in the PACU, and their disposition
  • For patient instructions, in the left “Discharge” column, click on “Patient instructions” . Enter activity and dressing and medication instructions

Notes:

All preop requirements MUST be completed by 30 minutes prior to the scheduled procedure time. So, if it is a 7:30am case, this all needs to be completed by 7am, in order for the case to be able to start anywhere around 7:30am. The patient is instructed to arrive in preop 1.5 hours prior the scheduled time. Not completing these requirements is guaranteed to delay the procedural schedule and the anesthesiology schedule.

FOR ATTENDINGS – HOW TO UPDATE H&P (note – this is true for “DUKE NORTH NEURO/VASC IR” EPIC environment, unsure about other environments):

 While in the patient’s “Patient Station” (not the usual chart), click on “PREPROCEDURE” that is in the vertical menu on the left. If you do not see it, go to the bottom and click the “MORE” button, then highlight the “RARELY USED” button, then you should find the “PREPROCEDURE” button there. After clicking on it, click on “Update H&P” in the new vertical menu on the left, which will pull up a list of notes where you can “Add Interval.” Find one of the most recent notes, and click on the “Add Interval” button, which will pull up a text box that states “The H&P has been reviewed and the patient has been examined. There is no change in the overall  assessment and no contraindication for surgery.” Click on “Accept” and then you are done. You can add comments to this box if you want.

How to quickly locate GA patients (If you have a status board with access to Anesthesiology schedules):

Click on status board, then click on Settings along the top ribbon, then in the popup box find “Anes OOOR – VIR CK”

This will have a listing of all patients who are posted with anesthesiology for the VIR suites or CT J1. If you make it a ‘favorite’, then it will always be at the top of the list.