N.J. Admin. Code § 8:43A-12.6

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43A-12.6 - Surgical policies and procedures

(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.)

N.J. Admin. Code § 8:43A-12.6

Recodified from N.J.A.C. 8:43A-12.4 and amended by R.2003 d.56, effective 2/3/2003.
See: 34 New Jersey Register 224(a), 35 New Jersey Register 857(a).
Former N.J.A.C. 8:43A-12.6, Surgical service emergency equipment, recodified to N.J.A.C. 8:43A-12.9. Rewrote the section.