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Out of OR Procedures

As anesthesiologists, we are often called to other areas to perform procedures.  This document also applies to L&D.

The common denominator for any “out of OR” procedure is that we do not have a dedicated physiologic monitor.  We are relying on vitals being captured by this non-dedicated monitor.

In the Operating Room, any vital sign obtained by our physiologic monitor automatically populates our grid and graph.  Outside of the OR, this is NOT the case.  In all other areas, the vital signs that are collected on this non-dedicated monitor need to be VALIDATED.  If they are not validated, you will NEVER see them in your procedure note. 

Unfortunately, I was not aware that unvalidated data would not flow over to our procedure notes.

In the example below, you are called to the floor (A2) to intubate a patient.  Every room has a vital sign monitor attached to the hospital network.  You decide to alter the frequency of vital sign measurement to capture the physiologic changes associated with your med administration and intubation.  You perform the procedure and you are now ready to document.

Before you proceed, kindly ask the RN responsible for the patient to log into EPIC and validate the vital signs that have been collected.  This is the KEY step .

Navigate to “Patient Lists” and identify your patient on the unit.

Double click on the patient.  You are presented with a list of options and you choose “Intubation”.

This is a procedure note.  Although it has quick tools, reminders and events, it does NOT contain a grid/graph like the OR.  Follow the events and reminders like the Operating Room.



 

 

 

 

 

 

 

The time you pick will be used as a midpoint to collect up to an hour of vital signs. 



In this example the system will bring in vital signs from 14:01 to 15:01.  If this covers the time for your procedure, then great.  If you intubated at 13:45, you would need to move the selected time back to around 14:00 to capture vitals between 13:30 and 14:30.

 

 

 

Below is a Labour Analgesia Px note.  Notice the vital signs in the note.  Note a section titled, “ Vitals Near Anesthesia Start ” and “ Nursing Vitals ”.  I don’t think we need to get too excited about the different sections and whether the same vitals are populating both sections.  We are happy just to see the vitals. 

If a procedure is to be done in PACU, there are two scenarios. 

1.       If the patient is coming from the floor, think of it as you having to go to the floor to do the Procedure. 



Under “ Available Lists ”, you will see PACU.  We will request that this list be deleted .  Even if an admitted patient is in the PACU, this list will be EMPTY.  The lists reflect the admission location of the patient.  Using the intubation example above, should that patient have been brought to the PACU for a procedure, you still search for her under the CIV A2 patient list.

Please do NOT use the nursing computer to complete your documentation.  It is best to maintain consistency regarding our approach.  The patient needs to be admitted to the PACU bed and the monitor needs to be assigned to the patient.  This is a nursing responsibility. 

Once the Procedure is complete, kindly ask the RN to validate the vitals.

Locate another computer, find the patient on the list as shown above and document your procedure.  “Pull vitals” will now populate as noted above.

2.       If the patient is being admitted for the sole purpose of performing a procedure, you will NOT find them under a patient list.  As per above, the patient needs to be admitted to the PACU bed and the monitor needs to be assigned to the patient.  This is a nursing responsibility. 

Once this is done, you can identify the patient on the PACU status board.

Now, employing the powerful RIGHT CLICK , select “ Open Chart\Procedure

 

You will now be presented with a slimmed down “intraop procedure” and you need to “ Apply Macro



In this case, I’m going to choose an “EPIDURAL Blood Patch” because I have now seen two Neurology requests in the last few days for low pressure and dural puncture headaches.

 

 

 

 

 



I am now presented with a familiar looking procedure note.  Same principals apply as above with regard to avoiding the nursing computer and asking the RN to validate data.

 

 

 

 

 

 

 

 

Note that this would be the most appropriate process to follow if you had a postop patient who required a procedure.

 

 

 

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