Policy & Procedure Document

Section 11C: SEC 11 — Intra-Operative Safety & Conduct (11.8 to 11.13)

Independent Policies for Each Title

Operating Theatre Policy

POLICY 11.8 — Surgical Smoke Safety

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + Engineering/Biomed + OT QPS Lead
Policy Code & Title OT-IO-11.8
Surgical Smoke Safety (Smoke Evacuation Use, PPE, Maintenance)
Related Policies: SEC 9 (Environmental control), SEC 11.1 (Theatre discipline), FMS preventive maintenance policy

1.0 PURPOSE

1.1 Purpose Statement

  • 1.1.1 To protect patients and staff from exposure to surgical smoke (plume) generated by electrosurgery, lasers, and ultrasonic devices by enforcing source capture, appropriate PPE, and equipment maintenance.
  • 1.1.2 To ensure smoke evacuation is used as a standard of work (not optional), including correct capture distance, activation timing, filter/tubing management, and documentation/audit.

2.0 SCOPE

  • 2.1 Applies to all procedures where plume is generated (open, minimally invasive, and specialty cases).
  • 2.2 Applies to all persons present in the OR during plume generation (surgeon, scrub/circulating, anesthesia personnel, observers/vendors).
  • 2.3 Applies to smoke evacuation equipment, filters, tubing, accessories, and maintenance interface.

3.0 DEFINITIONS

  • 3.1 Surgical Smoke/Plume: Aerosol and gaseous byproduct of thermal tissue disruption from energy devices. (osha.gov)
  • 3.2 Local Exhaust Ventilation (LEV): Source capture using smoke evacuator or in-line filtered suction positioned close to the plume source. (cdc.gov)
  • 3.3 Capture Distance Standard: Keeping the inlet close to the surgical site (NIOSH specifies within 2 inches) to effectively capture airborne contaminants. (cdc.gov)

4.0 POLICY STATEMENT

  • 4.1 Smoke evacuation shall be used during all smoke-generating procedures, and the evacuator shall be ON whenever plume is generated. (cdc.gov)
  • 4.2 The smoke evacuator/suction inlet shall be positioned within 2 inches of the surgical site whenever feasible to achieve effective capture. (cdc.gov)
  • 4.3 Tubing, filters, and absorbers used for smoke evacuation shall be treated as contaminated and disposed of according to facility IPC waste rules; NIOSH notes these components should be considered infectious waste after use. (cdc.gov)
  • 4.4 PPE is required as an additional protective measure, but engineering controls (smoke evacuation) are the primary exposure control. (digitalassets.jointcommission.org)
  • 4.5 Equipment readiness and preventive maintenance shall be ensured by OT and Biomed/Engineering; failures must trigger contingency actions and documentation.

5.0 ROLES AND RESPONSIBILITIES

5.1 OT Charge Nurse

  • 5.1.1 Ensures smoke evacuation equipment is available and functional for all plume-generating cases.
  • 5.1.2 Enforces compliance and escalates repeated nonuse.

5.2 Circulating Nurse

  • 5.2.1 Confirms availability, correct setup, and function of the smoke evacuator during room setup.
  • 5.2.2 Ensures the correct filter/tubing and capture accessory are available and used.
  • 5.2.3 Initiates contingency actions and notifies Biomed if equipment fails.

5.3 Scrub Nurse/Technologist

  • 5.3.1 Maintains effective source capture by positioning or assisting positioning of the inlet close to the source.
  • 5.3.2 Alerts immediately if plume is visible in room air (indicating ineffective capture).

5.4 Surgeon/Proceduralist

  • 5.4.1 Uses smoke evacuation during plume generation and cooperates with positioning of inlet close to source as standard practice. (cdc.gov)

5.5 Engineering/Biomed

  • 5.5.1 Performs preventive maintenance, functional testing, and repairs; ensures device accessories are available and compatible.

6.0 PROCEDURE

6.1 Pre-Case Planning and Room Readiness

6.1.1 Plume-generating cases are identified during list planning (electrosurgery, laser, ultrasonic, long cautery-heavy cases).

6.1.2 Circulating nurse verifies:

  • a) evacuator present and powers on,
  • b) filter installed per manufacturer requirements,
  • c) tubing connected, intact, and unobstructed,
  • d) capture device available (smoke pencil, suction nozzle, laparoscopic evacuation accessory),
  • e) waste disposal path for used tubing/filters.

6.2 Intra-Operative Use Standards

  • 6.2.1 Evacuation is activated whenever smoke is produced. (cdc.gov)
  • 6.2.2 Inlet positioning is maintained within 2 inches of the surgical site whenever feasible. (cdc.gov)

6.2.3 If smoke becomes visible in room air, the team treats this as inadequate control and corrects immediately by:

  • a) moving inlet closer,
  • b) increasing capture effectiveness per device settings,
  • c) checking tubing kinks/connection,
  • d) checking filter saturation/occlusion.

6.3 PPE Requirements (OT Side)

  • 6.3.1 Eye protection is used when plume/splash risk exists.
  • 6.3.2 Respiratory protection follows facility risk assessment and policy; Joint Commission safety guidance notes worker protection expectations and references OSHA’s general duty considerations in controlling smoke hazards. (digitalassets.jointcommission.org)

6.4 Failure / Downtime Contingency

6.4.1 If smoke evacuation fails during active plume generation:

  • a) pause smoke-producing activity when safe,
  • b) troubleshoot (power, tubing, filter blockage),
  • c) obtain backup device,
  • d) notify charge nurse and Biomed,
  • e) document equipment failure and action taken.

6.4.2 If no functional evacuation is available, elective plume-generating cases are delayed until control is restored unless emergency risk-benefit requires continuation; decision authority and rationale are documented.

6.5 Post-Case Disposal and Decontamination

  • 6.5.1 Dispose of used tubing/filters per IPC waste handling; NIOSH indicates these should be treated as infectious waste after use. (cdc.gov)
  • 6.5.2 Reusable components are cleaned per IFU and OT cleaning policy.

6.6 Preventive Maintenance and Readiness Checks

  • 6.6.1 Biomed performs preventive maintenance as scheduled.
  • 6.6.2 OT performs daily/shift readiness checks for assigned devices (power on, suction function, alarms).

7.0 DOCUMENTATION / RECORDS

  • 7.1 Smoke evacuation readiness checklist (if used).
  • 7.2 Maintenance logs (Biomed).
  • 7.3 Filter/tubing change log (if tracked).
  • 7.4 Incident reports for device failure or repeated noncompliance.

8.0 AUDIT / KPIs

  • 8.1 % plume-generating cases with smoke evacuation used (target set by OT QPS). (osha.gov)
  • 8.2 Observation audit: inlet positioned close to source per standard. (cdc.gov)
  • 8.3 Equipment uptime and failure frequency.

9.0 REFERENCES

  • 9.1 NIOSH: Control of Smoke from Laser/Electrical Surgical Procedures (capture within 2 inches; evacuator on during plume; disposal guidance). (cdc.gov)
  • 9.2 OSHA: Laser/Electrosurgery Plume overview and eTool recommendations including “evacuate all smoke” and 2-inch capture guidance. (osha.gov)
  • 9.3 Joint Commission Quick Safety: Alleviating the Dangers of Surgical Smoke. (digitalassets.jointcommission.org)

10.0 APPENDICES

  • 10.1 Smoke Evacuation Setup Checklist (Per Case)
  • 10.2 Daily Smoke Evacuation Readiness Check
  • 10.3 Filter/Tubing Replacement Log
  • 10.4 Smoke Evacuation Noncompliance Coaching Form
Operating Theatre Policy

POLICY 11.9 — Tourniquet Use (If Used)

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + Orthopedic Service Lead + OT QPS Lead
Policy Code & Title OT-IO-11.9
Pneumatic Tourniquet Use (Documentation, Time/Pressure Recording, Escalation)
Related Policies: SEC 11.12 (Documentation), SEC 11.5 (Positioning), SEC 7 (Transfers)

1.0 PURPOSE

  • 1.1 To ensure tourniquets are used safely with standardized assessment, application, monitoring, documentation, and escalation to reduce risks of nerve injury, skin injury, ischemia, thrombotic complications, and pain-related complications.
  • 1.2 To align OT practice with recognized perioperative guidance for pneumatic tourniquet safety. (Aorn.org)

2.0 SCOPE

  • 2.1 Applies to all cases where pneumatic tourniquets are used (upper and lower limb).
  • 2.2 Covers: patient assessment, cuff selection/placement, pressure selection, time monitoring, intraoperative documentation, and escalation rules.

3.0 DEFINITIONS

  • 3.1 Tourniquet Time: Continuous inflation duration (inflation start time to deflation time).
  • 3.2 Inflation Pressure: Pressure set to occlude arterial flow (selected per patient and limb).
  • 3.3 Tourniquet-related adverse event: Nerve deficit, skin blistering/burn, excessive pain, ischemic injury, or unexpected complication temporally related to use.

4.0 POLICY STATEMENT

  • 4.1 Tourniquet application and inflation shall only occur with documented clinical indication and surgeon order, and under a standardized OT tourniquet safety process consistent with perioperative best practices. (Aorn.org)
  • 4.2 OT shall document cuff site/size, limb, inflation pressure, inflation start time, deflation time(s), total inflation time, and any complications or deviations.
  • 4.3 OT shall monitor tourniquet time actively and escalate when time approaches defined thresholds; published summaries commonly cite time guidance such as ~60 minutes upper limb and ~90 minutes lower limb, with maximum durations requiring careful risk-benefit assessment and rarely exceeding extended limits. (PMC)
  • 4.4 Tourniquet equipment shall be maintained and safety-checked under FMS/biomed schedules.

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 Surgeon/Proceduralist: orders tourniquet use, confirms site/side, reviews time alerts, decides on deflation/reperfusion strategy if prolonged.
  • 5.2 Circulating Nurse: coordinates tourniquet application readiness, time/pressure documentation, active monitoring, and escalation alerts.
  • 5.3 Scrub Nurse/Technologist: assists with sterile considerations and ensures tourniquet tubing/lines do not compromise sterile field or positioning.
  • 5.4 OT Charge Nurse: supports escalation and additional staffing/equipment if issues occur.
  • 5.5 Biomed/Engineering: maintains tourniquet devices and accessories.

6.0 PROCEDURE

6.1 Pre-Use Patient Assessment

  • 6.1.1 Identify risk factors (vascular disease, neuropathy, diabetes, sickle cell disease/trait if relevant, severe edema, fragile skin, DVT risk factors, prior limb injury).
  • 6.1.2 Confirm limb/site and planned cuff location (proximal placement, avoid bony prominences where possible).
  • 6.1.3 Confirm skin integrity and padding needs.

6.2 Equipment Readiness

  • 6.2.1 Verify tourniquet device is functional, alarm-enabled, and has been safety checked.
  • 6.2.2 Select correct cuff size and type; cuff should fit limb circumference appropriately to reduce required pressure and prevent focal injury (per perioperative tourniquet safety guidance). (Aorn.org)

6.3 Application and Inflation

  • 6.3.1 Apply cuff on clean, dry skin with appropriate protective layer per facility practice; ensure no wrinkles or folds.
  • 6.3.2 Verify tubing is secured and does not create pressure points.
  • 6.3.3 Inflate only after final position is stable and site is confirmed (wrong-site prevention alignment).
  • 6.3.4 Record inflation start time immediately at inflation.

6.4 Pressure Selection and Verification

  • 6.4.1 Inflation pressure is determined according to approved local method (e.g., limb occlusion pressure method if used, or standardized pressure rules approved by surgical service and OT).
  • 6.4.2 Record selected pressure and method reference in documentation.
  • 6.4.3 If pressure needs adjustment intraoperatively, document time and reason.

6.5 Time Monitoring and Escalation

  • 6.5.1 Circulating nurse actively tracks tourniquet time using wall clock/time-out board/EHR timer.
  • 6.5.2 Escalation alerts: OT sets local thresholds; published evidence summaries commonly cite 60 min upper limb and 90 min lower limb as guide points for review/alerting, and higher durations require explicit surgeon review and documented rationale. (PMC)
  • 6.5.3 At the alert threshold, circulating nurse informs surgeon and documents the communication and plan (continue, deflate, reperfuse, or alternative strategy).

6.6 Deflation / Reperfusion

  • 6.6.1 Deflation time is documented.
  • 6.6.2 If reinflation occurs, each cycle’s start/stop time is documented and total inflation time calculated.

6.7 Post-Use Checks

  • 6.7.1 After removal, inspect skin under cuff for injury; document any abnormal finding and notify surgeon/anesthesia/PACU as appropriate.
  • 6.7.2 Communicate tourniquet details during OT→PACU handover when relevant.

6.8 Incident Handling

6.8.1 Suspected tourniquet-related injury triggers incident reporting and QPS review.

7.0 DOCUMENTATION / RECORDS

  • 7.1 Tourniquet documentation fields: limb, cuff type/size, location, pressure, inflation start, deflation time(s), total time, reinflation cycles, skin check findings, complications.
  • 7.2 Maintenance and calibration logs (biomed).

8.0 AUDIT / KPIs

  • 8.1 % cases with complete tourniquet documentation.
  • 8.2 % cases with documented time alerts when thresholds reached.
  • 8.3 Tourniquet-related adverse event rate (trend).

9.0 REFERENCES

  • 9.1 AORN: Guideline in Focus—Pneumatic Tourniquet Safety. (Aorn.org)
  • 9.2 AORN: Guideline for Pneumatic Tourniquet Safety (journal/guideline resource). (ovid.com)
  • 9.3 Evidence summary on safe use of pneumatic tourniquets including duration guidance. (PMC)

10.0 APPENDICES

  • 10.1 Tourniquet Documentation Tool (OT Record Insert)
  • 10.2 Tourniquet Time Alert Log (Optional)
  • 10.3 Post-Tourniquet Skin Check Tool
Operating Theatre Policy

POLICY 11.10 — Contrast Media / Dyes Handling in OT (OT Side)

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + Pharmacy Liaison + OT QPS Lead
Policy Code OT-IO-11.10
Related Policies: SEC 10 (Medication management/labeling), SEC 6 (Identification), SEC 9 (IPC), Emergency response policies

1.0 PURPOSE

  • 1.1 To ensure contrast media and dyes used in OT are stored safely, labeled correctly when prepared/transferred to sterile field, documented reliably, and managed with readiness for adverse reactions.
  • 1.2 To align OT handling with national and international safety practices for contrast media and perioperative labeling controls (including labeling discipline and storage controls).

2.0 SCOPE

  • 2.1 Applies to all contrast media and dyes handled by OT workflow (e.g., intraoperative dyes, contrast used for imaging guidance in OR, irrigation additives, topical dyes).
  • 2.2 Does not replace Radiology contrast administration policy when radiology staff administer contrast; OT applies labeling/storage and documentation requirements in the OR environment.

3.0 DEFINITIONS

  • 3.1 Contrast Media (CM): Iodinated contrast agents or other imaging contrast substances used to enhance imaging.
  • 3.2 Dyes: Agents used for surgical identification/visualization (e.g., sentinel mapping dyes), handled as medications/solutions requiring labeling when transferred/prepared.
  • 3.3 Contrast Reaction: Acute allergic-like or physiologic reaction; ACR provides categories and management guidance. (acr.org)

4.0 POLICY STATEMENT

  • 4.1 Contrast media and dyes stored in OT shall be secured, protected from inappropriate temperature conditions, and checked for expiry and integrity per pharmacy policy and product requirements.
  • 4.2 Any contrast media/dye transferred into syringes, bowls, cups, or basins on the sterile field shall be labeled immediately with medication name and concentration/strength as applicable (no unlabeled containers). Labeling discipline aligns with perioperative medication safety expectations. (ECRI and ISMP)
  • 4.3 If contrast media warmers are used in OT (or shared), bottles must be labeled with the date placed in the warmer and monitored to prevent prolonged storage; Saudi MOH contrast protocols describe dating bottles placed in warmers and monthly expiry checks.
  • 4.4 OT shall maintain readiness to respond to acute contrast reactions via an approved emergency response pathway; ACR provides structured categories and treatment tables for acute reactions. (acr.org)

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 Circulating Nurse: ensures correct storage, prepares/labels sterile-field containers, documents usage, and ensures reaction readiness pathway is clear.
  • 5.2 Scrub Nurse/Technologist: ensures sterile-field labeling is applied and maintained; discards unlabeled solutions.
  • 5.3 Surgeon/Proceduralist: confirms intended agent and site/use; informs team of planned dye/contrast use.
  • 5.4 Pharmacy Liaison: supports formulary, storage conditions, LASA controls, and expiry/inspection.
  • 5.5 OT Charge Nurse: ensures availability of labels, correct storage controls, and escalation for deviations.

6.0 PROCEDURE

6.1 Storage and Security

  • 6.1.1 Store contrast media and dyes in designated OT medication storage areas under SEC 10 rules (secure, organized, controlled access).
  • 6.1.2 Separate look-alike containers and similar packaging using LASA controls.
  • 6.1.3 Perform expiry checks per OT/Pharmacy schedule; MOH protocols emphasize routine expiry checking and controls for warmed contrast stock.

6.2 Warmer Use (If Applicable)

  • 6.2.1 Place a dated sticker on each contrast bottle prior to placement in the warmer.
  • 6.2.2 Monitor duration of storage in warmer; items at risk of prolonged storage must be controlled and removed per policy.

6.3 Sterile-Field Preparation and Labeling

6.3.1 Transfer one agent at a time to the sterile field.

6.3.2 Label syringes/bowls/cups/basins immediately after filling with:

  • a) agent name,
  • b) concentration/strength (if applicable),
  • c) preparer initials,
  • d) time prepared if required by local policy.

6.3.3 Unlabeled containers are discarded; this is treated as a near-miss event and reported (perioperative medication safety expectations). (ECRI and ISMP)

6.4 Documentation (OT Side)

6.4.1 Document:

  • a) agent name and amount/volume used,
  • b) route/use (e.g., topical, intraluminal, imaging),
  • c) time used (if required),
  • d) any adverse reaction and actions taken.

6.4.2 Record lot/expiry if required for specific dyes/agents or per hospital traceability rules.

6.5 Adverse Reaction Readiness and Response (Interface)

  • 6.5.1 OT maintains ability to activate emergency response (Code Blue/RRT) immediately.
  • 6.5.2 Reaction management follows the hospital emergency medication pathway; ACR resources provide structured tables for acute reaction management that inform emergency readiness kits and protocols. (acr.org)
  • 6.5.3 Document reaction type, time, interventions, and outcome; file incident report.

7.0 DOCUMENTATION / RECORDS

  • 7.1 Contrast/dye usage documentation field (OT record).
  • 7.2 Warmer log and bottle date labels (if warmer used).
  • 7.3 Incident reports for labeling failures, storage breaches, or reactions.

8.0 AUDIT / KPIs

  • 8.1 % sterile-field contrast/dye containers labeled correctly (target: 100%). (ECRI and ISMP)
  • 8.2 Warmer dating compliance (if used).
  • 8.3 Number of contrast/dye-related near misses and reactions (trend).

9.0 REFERENCES

  • 9.1 Saudi MOH: Protocols on Safe Use of Contrast Media (dating bottles in warmer; monthly expiry checks; CBAHI-related labeling concept referenced).
  • 9.2 ACR Manual on Contrast Media (reaction categories and management tables). (acr.org)
  • 9.3 ISMP Perioperative Medication Safety Guidelines (labeling discipline in perioperative/procedural settings). (ECRI and ISMP)

10.0 APPENDICES

  • 10.1 Contrast/Dye Sterile-Field Label Template
  • 10.2 Warmer Log Template (If applicable)
  • 10.3 Contrast/Dye Usage Documentation Tool (OT Record Insert)
Operating Theatre Policy

POLICY 11.11 — Clinical Photography/Video in OT

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + Legal/Privacy Officer + HIM/MOI Lead
Policy Code & Title OT-IO-11.11
Clinical Photography/Video in OT (Consent, Privacy, Storage Controls)
Related Policies: SEC 4 (Privacy/Dignity in Islamic culture), SEC 6 (Consent verification), SEC 11.12 (Documentation)

1.0 PURPOSE

  • 1.1 To ensure clinical photography and video recording in OT is conducted only for legitimate purposes, with appropriate consent, strict privacy protections, and secure storage/retention controls.
  • 1.2 To prevent privacy breaches and unauthorized recording, and to define clear boundaries regarding staff devices, patient/family recording, teaching/marketing use, and medico-legal uses.

2.0 SCOPE

  • 2.1 Applies to any image/video/audio recording in OT areas (restricted/semi-restricted zones), including pre-op holding within OT suite and any procedure room governed by OT.
  • 2.2 Covers staff-initiated recordings, vendor-initiated recordings, teaching recordings, and patient/family recording requests.

3.0 DEFINITIONS

  • 3.1 Clinical Photography: Images captured for clinical documentation, diagnosis, treatment planning, and quality review.
  • 3.2 Educational/Teaching Recording: Recording used for training, teaching, conferences, or publication.
  • 3.3 Identifiable Image: Image where patient identity is recognizable (face, unique marks, identifiers, voice, labels).
  • 3.4 Consent: Authorization consistent with local law and MOH informed consent guidance; MOH emphasizes not exceeding boundaries of consent except life-saving situations.

4.0 POLICY STATEMENT

4.1 Recording in OT is restricted and allowed only when:

  • a) there is a legitimate purpose (clinical documentation, quality review, education, or approved research),
  • b) required consent is obtained and documented,
  • c) privacy and dignity protections are applied,
  • d) storage is secured in approved hospital systems.
  • 4.2 Organizations are advised to obtain informed consent for patient photography; Joint Commission–referenced materials emphasize consent considerations and handling when consent was not obtained beforehand. (AHIMA Journal)
  • 4.3 Personal mobile devices (staff phones) shall not be used for photography/video in OT except through an approved hospital-controlled method explicitly permitted by policy.
  • 4.4 No recording may capture other patients, staff discussions of other patients, whiteboards, monitors with identifiers, or any unintended protected information.
  • 4.5 Any unauthorized recording is a serious incident requiring immediate stop, escalation, documentation, and privacy investigation.

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 Surgeon/Proceduralist: requests recording only when clinically justified; ensures consent requirements are met; defines what is needed (field only vs identifiable).
  • 5.2 Circulating Nurse: controls room environment, confirms consent presence, prevents unauthorized recording, ensures privacy screens/drapes, and documents recording occurrence and storage location.
  • 5.3 OT Charge Nurse: approves operational feasibility; ensures observers/vendors comply; escalates unauthorized attempts.
  • 5.4 HIM/MOI/Privacy Officer: defines approved storage platforms, retention, access controls, release-of-information rules.
  • 5.5 Education/Research Office: approves teaching/research recordings per governance.

6.0 PROCEDURE

6.1 Permitted Purposes and Required Approvals

  • 6.1.1 Clinical documentation: permitted only via approved method and documented in medical record with justification.
  • 6.1.2 Education/teaching/publication: requires explicit consent and governance approval before recording. (AHIMA Journal)
  • 6.1.3 Marketing/social media: prohibited unless explicitly approved by hospital leadership, legal/privacy, and includes explicit patient consent; OT default is not to allow.

6.2 Consent Requirements

6.2.1 Consent must match the purpose and extent of recording; MOH guidance emphasizes staying within consent boundaries except life-saving situations.

6.2.2 Consent documentation must specify:

  • a) purpose (clinical record / teaching / QA / research),
  • b) what will be recorded (images/video, identifiable vs de-identified),
  • c) who may access/use it,
  • d) retention period and withdrawal process when applicable.

6.3 Privacy and Dignity Controls in OT

  • 6.3.1 Limit recording to operative field when feasible.
  • 6.3.2 Use draping and privacy screens; avoid face/genital exposure unless clinically necessary and consented.
  • 6.3.3 Silence/limit room conversations during recording to prevent incidental capture of sensitive information.

6.4 Recording Device and Method Controls

  • 6.4.1 Only hospital-approved devices/platforms may be used (hospital camera, secured system).
  • 6.4.2 Immediate transfer to approved hospital storage is required; no storage on personal devices.
  • 6.4.3 Any temporary storage must be encrypted and controlled per policy.

6.5 Storage, Access, and Retention

  • 6.5.1 Store images/videos in approved hospital system with role-based access.
  • 6.5.2 Define retention per MOI/HIM rules (e.g., part of medical record or separate education archive).
  • 6.5.3 Release of images follows hospital release-of-information policy.

6.6 Patient/Family Recording Requests

6.6.1 Patient/family recording in OT is generally not permitted due to privacy, staff safety, and risk of capturing other protected information.

6.6.2 If the organization permits limited recording in rare situations, it requires:

  • a) OT director approval,
  • b) privacy officer approval,
  • c) written boundaries (no staff filming without staff consent, no other patients, no identifiers),
  • d) immediate termination if privacy risk emerges.

6.7 Incident Management (Unauthorized Recording)

  • 6.7.1 Stop recording immediately.
  • 6.7.2 Secure evidence if needed (do not confront aggressively; follow security pathway).
  • 6.7.3 Escalate to OT leadership and privacy officer; file incident report.

7.0 DOCUMENTATION / RECORDS

  • 7.1 Consent form reference and purpose.
  • 7.2 Recording event documentation (date/time, device/system used, storage location reference).
  • 7.3 Incident report for unauthorized recording or privacy breach.

8.0 AUDIT / KPIs

  • 8.1 % recordings with documented consent and approved storage. (AHIMA Journal)
  • 8.2 Number of unauthorized recording incidents (trend).
  • 8.3 Privacy breach events related to recording (trend).

9.0 REFERENCES

  • 9.1 Saudi MOH: Saudi Guidelines for Informed Consent (boundaries of consent).
  • 9.2 AHIMA guidance citing Joint Commission consent expectations for patient photography (consent emphasis). (AHIMA Journal)
  • 9.3 ECRI blog (consent/privacy/confidentiality considerations for surgical recordings). (ECRI and ISMP)

10.0 APPENDICES

  • 10.1 OT Photography/Video Consent Addendum Template
  • 10.2 Recording Request Form (Purpose + Approval routing)
  • 10.3 OT “No Recording” Signage Template
Operating Theatre Policy

POLICY 11.12 — Perioperative Documentation Standards (OT Record Completion)

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + HIM/MOI Lead + OT QPS Lead
Policy Code
Related Policies: SEC 6 (Verification), SEC 11.3/11.4 (Counts/RSI), SEC 11.6 (Specimens), SEC 11.7 (Implants), SEC 10 (Medications), SEC 8 (OT→PACU handover)

1.0 PURPOSE

  • 1.1 To ensure OT documentation is complete, accurate, timely, legible, and traceable, supporting continuity of care, legal protection, quality improvement, and accreditation readiness.
  • 1.2 AORN describes perioperative documentation planning as comprehensive, including workflow, data capture, required components, and system design. (Aorn.org)

2.0 SCOPE

  • 2.1 Applies to all OT documentation generated by OT staff (circulating, scrub documentation components as applicable, charge nurse records), including electronic and paper downtime records.
  • 2.2 Includes pre-intra-post documentation elements within OT scope and interface handover records.

3.0 DEFINITIONS

  • 3.1 OT Record: Official intraoperative nursing record and related controlled forms (counts, implants, specimen logs, checklists, equipment logs).
  • 3.2 Late Entry: Documentation entered after the event time; must be clearly labeled as late entry with reason.
  • 3.3 Downtime Documentation: Paper-based documentation used when EHR unavailable, later scanned/entered per MOI rules.

4.0 POLICY STATEMENT

  • 4.1 OT documentation is a patient safety control. If it is not documented, it is treated as not done unless there is clear corroboration and late-entry is justified.
  • 4.2 OT documentation shall be completed:
    • a) in real time whenever feasible,
    • b) before patient leaves the OR for core safety items (counts status, specimen labeling confirmation, implant traceability capture status, handover readiness),
    • c) within defined time limits for full record completion (facility standard).
  • 4.3 Documentation must support traceability of high-risk elements (counts, specimens, implants, contrast/dyes, adverse events) and must be accessible for audit and recall.
  • 4.4 Documentation corrections must follow controlled rules (no erasing; proper amendment process).

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 Circulating Nurse: primary owner of intraoperative nursing record completion and accuracy.
  • 5.2 Charge Nurse: checks completeness for the shift, ensures correction before end of shift when possible.
  • 5.3 OT Nurse Manager: audits documentation compliance and addresses training gaps.
  • 5.4 HIM/MOI: defines record standards, retention, downtime scanning, and amendment rules.

6.0 REQUIRED DOCUMENTATION CONTENT (MINIMUM DATASET)

6.1 Patient and Case Identification

  • 6.1.1 Patient identifiers per policy (as permitted), case number, date/time, OR room.
  • 6.1.2 Procedure name and site/side as recorded; surgeon; anesthesia provider (as applicable).

6.2 Safety Verification and Checklist Documentation

  • 6.2.1 Verification elements (Sign-In/Time-Out/Sign-Out completion per hospital safe surgery governance).
  • 6.2.2 Discrepancy events and stop-the-line actions when applicable.

6.3 Positioning and Skin Protection (OT Scope)

6.3.1 Position, supports used, reassessment times for long/high-risk cases (Policy 11.5).

6.4 Skin Preparation and Draping (OT Verification Fields)

6.4.1 Prep agent and confirmation of completion per policy; key timing fields if required.

6.5 Counts and RSI Controls

6.5.1 Initial/closure/final counts and outcomes; discrepancy actions documented (Policy 11.3/11.4).

6.6 Specimens

6.6.1 Specimen description/site/laterality; labeling verification; dispatch time and destination (Policy 11.6).

6.7 Implants/Prostheses

6.7.1 Implant traceability fields or confirmation of sticker/UDI capture and log entry (Policy 11.7).

6.8 Medications/Solutions (OT Scope)

6.8.1 Medications/solutions managed by OT on sterile field (name, concentration/amount, labeling compliance) (SEC 10).

6.9 Equipment Issues and Environmental Events

  • 6.9.1 Equipment malfunction, replacement, biomedical call, downtime issues.
  • 6.9.2 Safety events: smoke evacuation failure, spill events, sharps injury, near misses.

6.10 Handover/Transfer Documentation

  • 6.10.1 OT→PACU handover completion fields (Policy SEC 8).
  • 6.10.2 Any special concerns communicated (positioning issues, drains, implants, specimens, isolation).

7.0 DOCUMENTATION RULES AND QUALITY STANDARDS

7.1 Timeliness

  • 7.1.1 Core safety elements documented before patient leaves OR.
  • 7.1.2 Full record completion before end of shift unless defined exceptions.

7.2 Accuracy and Standard Terminology

  • 7.2.1 Use standardized terms for procedures, positions, devices; avoid ambiguous abbreviations.
  • 7.2.2 Ensure consistency across OT record, implant logs, specimen forms, and PACU handover.

7.3 Corrections and Late Entries

  • 7.3.1 Corrections follow HIM rules (single line, date/time/initial; electronic amendment process).
  • 7.3.2 Late entries labeled clearly with event time and reason.

7.4 Downtime Documentation

  • 7.4.1 Use approved downtime pack.
  • 7.4.2 Post-downtime reconciliation and scanning/entry are completed within defined timeline.

7.5 Confidentiality

7.5.1 Keep identifiers protected; do not leave printed lists visible; comply with privacy requirements in OT.

8.0 TRAINING AND COMPETENCY

  • 8.1 Initial training includes OT documentation minimum dataset and legal/quality importance.
  • 8.2 Annual refreshers address frequent defects found in audits.
  • 8.3 Competency may include chart review and observed documentation during cases.

9.0 AUDIT / KPIs

  • 9.1 Record completeness rate per month (random sampling).
  • 9.2 Time-Out/Sign-Out documentation completion rate.
  • 9.3 Counts/specimens/implant documentation completeness rate.
  • 9.4 Late-entry frequency and reasons (trend).
  • 9.5 Downtime documentation reconciliation compliance.

10.0 REFERENCES

  • 10.1 AORN guideline article: patient information management and perioperative documentation planning.
  • 10.2 AORN perioperative nursing scope/standards PDF (guideline evidence-based practice context).

11.0 APPENDICES

  • 11.1 OT Minimum Documentation Dataset Checklist
  • 11.2 Downtime Documentation Pack Index
  • 11.3 OT Record Completion Audit Tool
  • 11.4 Late Entry Template (EHR/Paper)
Operating Theatre Policy

POLICY 11.13 — Blood Loss Estimation & Documentation (OT Tool + Escalation Trigger)

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + OT QPS Lead
Policy Code OT-IO-11.13
Related Policies: SEC 17 (Hemorrhage/MTP if exists), SEC 8 (OT→PACU handover), SEC 11.12 (Documentation)

1.0 PURPOSE

  • 1.1 To establish a standardized OT method for estimating and documenting intraoperative blood loss and communicating it effectively to the surgical/anesthesia team and PACU to support timely escalation and safe postoperative care.
  • 1.2 Visual estimation is known to differ from formula-based or quantitative methods; recent evidence shows visual estimates can be substantially lower than calculated estimates, supporting a structured approach to measurement and documentation.

2.0 SCOPE

  • 2.1 Applies to all OT cases; enhanced requirements apply to high-risk bleeding cases (major surgery, trauma, vascular, obstetric, coagulopathy, anticoagulant use).
  • 2.2 This policy defines OT documentation and communication; it does not replace clinical transfusion decision-making or Massive Hemorrhage Protocol governance.

3.0 DEFINITIONS

  • 3.1 EBL (Estimated Blood Loss): Traditional estimate based on observation and suction totals.
  • 3.2 QBL (Quantitative Blood Loss): Measurement-based approach using suction volume calculation plus weighing of sponges/materials and accounting for irrigation, where implemented. AORN literature describes QBL worksheets used by circulators in OR settings.
  • 3.3 Escalation Trigger: Predefined threshold or pattern requiring immediate notification and activation of bleeding response pathway (facility-defined).

4.0 POLICY STATEMENT

  • 4.1 OT shall document blood loss using a standardized method and ensure it is updated during the case and communicated during handovers.
  • 4.2 OT shall implement either:
    • a) structured EBL method (minimum standard), or
    • b) QBL method (preferred when feasible for high-risk cases) supported by tools and training.
  • 4.3 OT shall activate escalation communication when blood loss reaches facility-defined triggers or when rapid bleeding is suspected, even before numeric thresholds are reached.

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 Circulating Nurse: maintains blood loss documentation tool, coordinates measurements (suction/irrigation, sponge counts/weighing when used), and communicates trend to surgeon/anesthesia.
  • 5.2 Surgeon/Proceduralist: communicates surgical bleeding concerns and confirms whether blood loss estimate aligns with field assessment.
  • 5.3 Anesthesia Provider: manages hemodynamic and transfusion response; OT supports timely information.
  • 5.4 OT Charge Nurse: supports escalation logistics (calling for blood products per pathway, notifying leadership, initiating MTP activation per hospital rule when requested).

6.0 PROCEDURE

6.1 Standard EBL Method (Minimum)

6.1.1 Suction canister:

  • a) record total volume in canister,
  • b) subtract documented irrigation volume (and other fluids intentionally added),
  • c) document calculated blood volume from suction.

6.1.2 Sponges and materials:

  • a) document number/type of blood-soaked sponges,
  • b) where QBL is not available, use structured descriptors (“lightly soaked/fully soaked”) per facility tool to improve consistency.

6.1.3 Ongoing updates:

  • a) update EBL at defined intervals (e.g., hourly or at critical surgical milestones),
  • b) update immediately with any rapid bleeding change.

6.2 QBL Method (Recommended for High-Risk Cases When Implemented)

  • 6.2.1 Use a standardized QBL worksheet.
  • 6.2.2 Weigh sponges/materials:
    • a) weigh dry baseline (or use standard dry weights),
    • b) weigh used items,
    • c) calculate blood volume using weight difference (1 g ≈ 1 mL blood, per facility standardization).
  • 6.2.3 Suction calculation as in 6.1.1.
  • 6.2.4 Combine for total QBL; document method used.

6.3 Escalation Trigger and Communication

6.3.1 Escalation triggers are defined by the hospital Massive Hemorrhage Protocol / surgical service rules (adult vs pediatric vs obstetric).

6.3.2 OT escalation must occur when:

  • a) blood loss meets protocol threshold, OR
  • b) bleeding rate appears rapidly increasing, OR
  • c) surgeon/anesthesia expresses concern requiring preparation for blood products.

6.3.3 Communication standard: circulating nurse announces the current blood loss estimate and trend (“stable/rapidly increasing”), confirms irrigation subtraction, and documents the time of notification.

6.4 Documentation and Handover

  • 6.4.1 Record final EBL/QBL in OT documentation (Policy 11.12).
  • 6.4.2 Communicate final value and any concerns to PACU during handover.
  • 6.4.3 If MTP activated or transfusion occurred, ensure documentation includes timing and references to relevant records (anesthesia record may carry transfusion details; OT records the escalation and confirmation).

6.5 Post-Case Review

6.5.1 Cases with major hemorrhage are reviewed in OT QPS for documentation quality and escalation timeliness.

7.0 DOCUMENTATION / RECORDS

  • 7.1 EBL/QBL worksheet (paper or electronic).
  • 7.2 Irrigation log (if separate).
  • 7.3 Communication/escalation time stamps (notification to surgeon/anesthesia; MTP activation time if applicable).
  • 7.4 Incident report if delay or documentation failure contributed to risk.

8.0 AUDIT / KPIs

  • 8.1 % cases with documented final EBL/QBL.
  • 8.2 % high-risk cases using QBL method (if implemented).
  • 8.3 Time from escalation trigger recognition to communication (trend).
  • 8.4 Audit of suction/irrigation subtraction accuracy (sample review).
  • 8.5 Comparative review: visual vs quantitative methods (quality improvement measure; visual underestimation risk recognized in literature).

9.0 REFERENCES

  • 9.1 AORN Journal: QBL implementation worksheet example for circulators (method standardization concept).
  • 9.2 Evidence showing visual estimation differs significantly from formula-based calculations (supports structured measurement).

10.0 APPENDICES

  • 10.1 EBL Worksheet (Suction minus irrigation + sponge assessment)
  • 10.2 QBL Worksheet (Weighing + suction calculation)
  • 10.3 Escalation Communication Script (OT→Team)
  • 10.4 PACU Handover Addendum: Blood loss + bleeding concerns.

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