1. INTRODUCTION & REGULATORY FRAMEWORK
1.1 Purpose
The purpose of this policy is to establish comprehensive, evidence-based standards for the safe conduct of anesthesia in all intraoperative settings. This document mandates standardized processes for minimum monitoring, documentation, induction safety, maintenance of physiological stability, and safe emergence to minimize perioperative morbidity and mortality. It integrates rigorous safety checks, including the World Health Organization (WHO) Surgical Safety Checklist, into the workflow of anesthesia care to ensure correct patient, procedure, and site verification, as well as readiness for critical events.
1.2 Scope
This policy applies to all anesthesia services provided within the institution, encompassing:
- Operating Rooms (OR): All main surgical suites, ambulatory surgery centers, and specialty ORs (Cardiac, Neuro, Orthopedic).
- Non-Operating Room Anesthesia (NORA) Locations: All procedural areas where anesthesia services are delivered, including but not limited to:
- Gastroenterology/Endoscopy Suites (EGD, Colonoscopy, ERCP)
- Interventional Radiology (IR) and Neuro-Interventional Suites
- Cardiac Catheterization and Electrophysiology Labs
- Diagnostic Imaging (MRI, CT)
- Bronchoscopy Suites
- Psychiatry (ECT)
- Emergency Department and Trauma Bays (when anesthesia team is involved)
This policy applies to all anesthesia professionals (anesthesiologists, CRNAs, anesthesia residents/fellows) and support staff involved in intraoperative care.
1.3 Regulatory Alignment & Evidence Base
This policy is strictly aligned with the following national and international standards:
- CBAHI (Saudi Central Board for Accreditation of Healthcare Institutions): Perioperative Safety Standards (POR.10, POR.11), requiring standardized protocols for monitoring, sedation, and documentation.
- American Society of Anesthesiologists (ASA): Standards for Basic Anesthetic Monitoring (Last Amended Oct 15, 2025) and Statement on Documentation of Anesthesia Care (2020).
- Australian and New Zealand College of Anaesthetists (ANZCA): PG18(A) Guideline on Monitoring During Anaesthesia (2025 Edition).
- European Society of Anaesthesiology and Intensive Care (ESAIC): Intra-operative Haemodynamic Monitoring and Management Guidelines (2025).
- World Health Organization (WHO): Surgical Safety Checklist and Global Guidelines for the Prevention of Surgical Site Infection.
- Difficult Airway Society (DAS): 2025 Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults.
2. DEFINITIONS & TERMINOLOGY
| Term |
Definition |
| Anesthesia Professional |
A qualified physician (anesthesiologist) or nurse anesthetist (CRNA/Advanced Practice Nurse) credentialed and privileged to provide anesthesia services. |
| Minimum Monitoring Standards |
The mandatory baseline physiologic monitoring required for all patients under general anesthesia, regional anesthesia, or monitored anesthesia care (MAC), comprising continuous evaluation of oxygenation, ventilation, circulation, and temperature. |
| Continual vs. Continuous |
Continual: Repeated regularly and frequently in steady rapid succession (e.g., non-invasive blood pressure every 5 minutes).
Continuous: Prolonged without any interruption at any time (e.g., ECG, pulse oximetry, capnography). |
| Induction Phase |
The transition from a state of baseline consciousness to the anesthetized state, involving administration of hypnotic agents and airway management. |
| Maintenance Phase |
The period of anesthesia following induction until the beginning of emergence, focusing on maintaining anesthetic depth, physiologic stability, and analgesia. |
| Emergence Phase |
The transition from the anesthetized state to wakefulness and restoration of protective reflexes, culminating in extubation or removal of airway devices. |
| Neuromuscular Blockade (NMB) Terms |
TOF (Train-of-Four): Four supramaximal electrical stimuli delivered to a peripheral nerve.
TOF Ratio: The ratio of the amplitude of the 4th twitch to the 1st twitch.
Residual Paralysis: TOF ratio < 0.9, indicating incomplete recovery from NMB. |
| Quantitative Monitoring |
Objective measurement of neuromuscular transmission (e.g., acceleromyography) yielding a numeric TOF ratio, as opposed to subjective visual/tactile assessment (qualitative). |
| Rapid Sequence Induction (RSI) |
A specialized induction technique designed to minimize the time between loss of protective airway reflexes and tracheal intubation to reduce aspiration risk, typically involving preoxygenation, rapid administration of induction/paralytic agents, and optional cricoid pressure. |
3. POLICY STATEMENTS
4.1 Standardized Protocols Requirement: The Department of Anesthesia shall utilize standardized, evidence-based protocols for all phases of anesthesia care to ensure consistency, reduce variability, and enhance patient safety in compliance with CBAHI POR standards.
4.2 Continuous Presence: A qualified anesthesia professional shall be continuously present in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care to monitor the patient and provide immediate intervention.
4.3 Minimum Monitoring Standards: All patients receiving anesthesia care shall be monitored in accordance with ASA and ANZCA standards, including continuous evaluation of oxygenation, ventilation, circulation, and temperature. These standards apply equally to OR and NORA settings.
4.4 Documentation Integrity: Intra-anesthesia documentation shall be accurate, contemporaneous, and complete, capturing all physiologic trends, medication administrations, interventions, and critical events to support continuity of care and medico-legal integrity.
4.5 Induction Safety: Induction of anesthesia shall be preceded by a safety verification check (Sign-In) and shall utilize risk-stratified protocols for aspiration prevention (RSI) and hemodynamic stability.
4.6 Maintenance Management: Anesthetic maintenance shall target optimal physiological parameters, including normothermia, euglycemia, and hemodynamic stability within 20% of baseline, tailored to patient comorbidities.
4.7 Emergence Safety: Extubation shall proceed only when predefined criteria for airway protection, ventilation, oxygenation, and hemodynamic stability are met. High-risk extubations require a documented plan.
4.8 Neuromuscular Blockade Management: Quantitative monitoring of neuromuscular blockade is required when NMB agents are used. Pharmacologic reversal is mandatory unless objective criteria for spontaneous recovery (TOF ratio ≥ 0.9) are met and documented.
4.9 Glucose Management: Intraoperative glucose levels shall be monitored in indicated patients, targeting a range of 140-180 mg/dL (general) or 180-250 mg/dL (ambulatory consensus) to prevent hypoglycemia and reduce infection risk.
4.10 Antibiotic Prophylaxis: The anesthesia team shall verify and document the administration of prophylactic antibiotics within the appropriate pre-incision window (typically 60 minutes) as part of the surgical safety checklist.
4.11 Verification Support: The anesthesia professional shall actively participate in the "Time-Out" and "Sign-Out" phases of the WHO Surgical Safety Checklist to verify patient identity, procedure, implants, and specimens.
4. MINIMUM MONITORING STANDARDS
4.1 General Monitoring Requirements
Continuous Presence (ASA Standard I): Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care. In the event of a direct known hazard (e.g., radiation), intermittent remote observation is permitted provided monitoring continuity is maintained.
Definitions:
- Continuous: Prolonged without any interruption at any time.
- Continual: Repeated regularly and frequently in steady rapid succession.
Equipment: All monitoring equipment must have functioning audible and visual alarms. Alarm limits shall be set appropriate to patient age and condition. Alarms must be enabled and audible at all times.
4.2 Oxygenation Monitoring
Pulse Oximetry (SpO2)
- Requirement: Continuous pulse oximetry is mandatory for all anesthetics (ASA 2025, ANZCA PG18).
- Audible Tone: A variable pitch pulse tone derived from the plethysmograph signal must be audible to the anesthesia professional. The low threshold alarm must be active.
- Placement: Probe placement on a digit, ear, or forehead must be verified for signal quality.
- Limitations: Poor perfusion, motion, ambient light, nail polish, or dyshemoglobinemias may affect accuracy.
Inspired Oxygen Concentration (FiO2)
- Requirement: During general anesthesia using an anesthesia machine, the concentration of oxygen in the patient breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm.
- Documentation: FiO2 shall be documented at regular intervals (minimum every 5-15 minutes).
Clinical Assessment
Adequate illumination and exposure of the patient should be available to assess skin color and perfusion continuously.
4.3 Ventilation Monitoring
Requirement: Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated.
Capnography/Capnometry (End-Tidal CO2)
- Mandatory Requirement: Continuous quantitative monitoring of expired carbon dioxide (capnography/capnometry) shall be performed from the time of endotracheal tube/supraglottic airway device placement until extubation or transfer (ASA 2025, ANZCA 2025).
- Waveform Analysis: Waveform capnography is strongly encouraged to detect obstruction, rebreathing, and circuit disconnection.
- Sedation: During moderate or deep sedation, adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs, and monitoring for the presence of exhaled carbon dioxide shall be employed unless precluded by the nature of the patient, procedure, or equipment.
- Alarms: An audible alarm for loss of CO2 or high/low ETCO2 limits must be active.
Mechanical Ventilator Monitoring
- Disconnect Alarm: When mechanical ventilation is used, there shall be in continuous use a device capable of detecting disconnection of components of the breathing system. The device must give an audible signal when its alarm threshold is exceeded.
- Parameters: Tidal volume, respiratory rate, and airway pressures (peak/plateau) should be monitored and displayed.
Airway Device Position Confirmation
Correct positioning of an endotracheal tube or supraglottic airway must be verified by clinical assessment (auscultation, chest rise) AND identification of carbon dioxide in the expired gas. Continuous capnography shall be used for ongoing verification.
4.4 Circulation Monitoring
Electrocardiogram (ECG)
- Requirement: Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location (ASA 2025).
- Lead Selection: Lead II (rhythm detection) and V5 (ischemia detection) are recommended for most adult patients.
Blood Pressure Monitoring
- Requirement: Arterial blood pressure and heart rate shall be determined and evaluated at least every 5 minutes (ASA 2025).
- Frequency: More frequent measurement (e.g., every 1-3 minutes) is indicated during induction, emergence, and periods of hemodynamic instability.
- Invasive Monitoring: Continuous invasive arterial pressure monitoring is indicated for deliberate hypotension, major hemodynamic instability, or frequent blood sampling.
Additional Circulatory Evaluation
Every patient receiving general anesthesia shall have circulatory function continually evaluated by at least one of the following additional methods: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography/oximetry.
4.5 Temperature Monitoring
Requirement: Every patient receiving anesthesia shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated, or suspected (ASA 2025).
- Indications: General anesthesia > 30-60 minutes, regional anesthesia with risk of hypothermia, pediatric patients.
- Sites: Core temperature sites (esophageal, nasopharyngeal, bladder, rectal) are preferred for general anesthesia.
- Goal: Maintenance of normothermia (36°C - 37°C) unless hypothermia is therapeutically indicated.
4.6 Additional Risk-Based Monitoring
- Neuromuscular Monitoring: Quantitative monitoring required when NMB agents are used (See Section 9).
- Processed EEG (Depth of Anesthesia): Recommended for TIVA, patients with high risk of awareness, or when neuromuscular blockade is used without potent volatile agents.
- Urine Output: Indicated for major procedures, long duration, or hemodynamic instability.
5. INTRA-ANESTHESIA DOCUMENTATION STANDARDS
5.1 Documentation Principles
Anesthesia documentation must be accurate, contemporaneous, and complete. It serves as the legal record of care, supports continuity, and facilitates quality improvement. All entries must be timed and authenticated.
5.2 Required Documentation Elements
The intra-anesthesia record must contain the following 25 detailed elements:
- Patient Demographics: Name, MRN, DOB, Gender, Weight, Height.
- Procedure & Team: Planned procedure, Surgeon, Anesthesia Providers (Attending, CRNA, Resident), Location.
- Pre-Anesthesia Assessment Summary: ASA-PS Classification, Allergies, NPO status, Airway Assessment, Relevant History.
- Monitors & Equipment: Standard monitors applied (SpO2, NIBP, ECG, Temp, ETCO2), Line placement, Airway equipment check.
- Times: Anesthesia Start, Induction, Procedure Start, Procedure End, Emergence, Anesthesia End.
- Medications: All drugs administered (Name, Dose, Route, Time).
- Intravenous Fluids & Blood Products: Type and volume of crystalloids, colloids, and blood products administered.
- Vital Signs: Graphic or numeric record of BP, HR, SpO2, ETCO2, RR, Temp at least every 5 minutes.
- Airway Management: Technique (Mask, LMA, ETT), Size, Depth, Attempts, Grade of View (Cormack-Lehane), Confirmation method.
- Ventilation Parameters: Mode, TV, RR, PEEP, Peak Pressure, FiO2.
- Gas Flows & Agents: O2 flow, Air/N2O flow, Volatile agent concentration (Insp/Exp).
- Neuromuscular Blockade: Agent, Dose, TOF monitoring data (Counts/Ratio), Reversal agent and response.
- Antibiotic Prophylaxis: Drug name, Dose, Time of administration (verification of timing).
- Output: Urine output, Estimated Blood Loss (EBL), Gastric suction output.
- Positioning: Patient position, pressure point padding/protection measures.
- Eye Protection: Taping or lubrication method.
- Procedures performed: Arterial line, CVP, Nerve blocks (Site, Technique, Drug).
- Glucose Management: Glucose values and insulin/dextrose administration if indicated.
- Critical Events: Hypotension, Desaturation, Arrhythmias, and interventions taken.
- Tourniquet (if applicable): Location, Pressure, Inflation time, Deflation time.
- Implants/Specimens: Verification of implants and specimens (Time-Out/Sign-Out).
- Emergence: Extubation criteria met, patient condition upon leaving OR.
- Handover: Report given to PACU/ICU nurse and receiving provider.
- Post-Anesthesia Condition: Vital signs, consciousness level, O2 delivery method on transport.
- Provider Signature: Authentication of the record.
5.3 Timing & Corrections
- Frequency: Physiological data must be recorded at least every 5 minutes. Critical events should be documented in real-time or as soon as patient care permits.
- Corrections:
- Paper: Single strike-through, initialed and dated. Do not obliterate original entry.
- Electronic: Addendum or modification with audit trail showing original entry, time of change, and author.
6. INDUCTION SAFETY PROTOCOLS
6.1 Pre-Induction Safety Verification
Before induction of anesthesia, the "Sign-In" phase of the WHO Surgical Safety Checklist must be completed. This includes:
- Confirmation of patient identity (two identifiers).
- Confirmation of procedure, site, and side.
- Verification of consent.
- Confirmation of fasting status (NPO).
- Check of anesthesia machine and suction.
- Verification of airway difficulty and aspiration risk.
- Confirmation of known allergies.
- Verification of functional pulse oximeter on patient.
6.2 Hemodynamic Safeguards for High-Risk Induction
Patients at risk for induction-related hypotension (e.g., sepsis, hypovolemia, cardiomyopathy, elderly) require a modified induction strategy:
- Preparation: Pre-induction fluid loading if indicated. Vasopressors (Phenylephrine, Ephedrine, Norepinephrine) drawn up and immediately available.
- Medication Selection: Dose reduction of propofol or use of alternative agents (Etomidate, Ketamine). Titration to effect rather than bolus dosing.
- Monitoring: Consideration for pre-induction arterial line placement for beat-to-beat blood pressure monitoring.
6.3 Aspiration Risk Mitigation & RSI Protocols
Risk Assessment: All patients must be assessed for aspiration risk (e.g., full stomach, bowel obstruction, GERD, pregnancy, morbid obesity, diabetes/gastroparesis).
Rapid Sequence Induction (RSI): Indicated for patients at increased risk of aspiration.
- Preoxygenation: Mandatory to achieve ETO2 > 80% or 3-5 minutes of tidal breathing.
- Technique: Rapid administration of induction agent followed immediately by neuromuscular blocker (Succinylcholine or Rocuronium).
- Cricoid Pressure (Sellick Maneuver): May be applied (10N awake, 30N asleep) but should be released if it impedes ventilation or visualization (DAS 2025). Evidence for efficacy is variable; safety priority is oxygenation.
- Ventilation: Avoid positive pressure ventilation prior to intubation unless hypoxia ensues (Modified RSI may allow gentle ventilation < 15-20 cmH2O).
- Confirmation: Confirmation of tube placement via capnography before release of cricoid pressure (if used).
6.4 NORA Induction Considerations
Induction in NORA locations carries specific risks due to remote location, limited help, and ergonomic constraints.
- Airway Access: Ensure airway is accessible (e.g., turning patient 180 degrees in MRI, away from fluoroscopy equipment).
- Emergency Plan: Verify location of code cart, difficult airway equipment, and evacuation route/plan before induction.
- Backup: Identify method to call for help (phone, intercom) as standard OR call systems may not be available.
7. MAINTENANCE OF ANESTHESIA
7.1 Anesthetic Depth Management
- Volatile Agents: Maintain appropriate MAC (Minimum Alveolar Concentration) adjusted for age to ensure amnesia (typically > 0.5-0.7 MAC).
- TIVA (Total Intravenous Anesthesia): When TIVA is used (e.g., Propofol/Remifentanil), use of processed EEG monitoring (e.g., BIS, Entropy) is recommended to reduce the risk of awareness and prevent overdose.
- Monitoring: Continually assess clinical signs (HR, BP, sweating, lacrimation) and consider depth of anesthesia monitoring for high-risk patients (paralyzed, hemodynamically unstable).
7.2 Oxygenation & Ventilation Management
- Oxygenation: Maintain SpO2 > 94% (or patient baseline). Use lowest effective FiO2 to avoid absorption atelectasis and toxicity, except during induction/emergence.
- Protective Ventilation: Utilize lung-protective ventilation strategies:
- Tidal Volume: 6-8 mL/kg predicted body weight.
- PEEP: 5-10 cmH2O (individualized).
- Recruitment maneuvers: As indicated to treat atelectasis.
- Plateau Pressure: < 30 cmH2O.
7.3 Hemodynamic Management
- Targets: Maintain Mean Arterial Pressure (MAP) within 20% of preoperative baseline or MAP > 65 mmHg, whichever is higher, to ensure organ perfusion.
- Hypotension: Treat promptly with fluids, vasopressors, or inotropes. Prolonged hypotension is associated with AKI, myocardial injury, and stroke.
- Hypertension: Assess for pain, light anesthesia, or hypercarbia before treating with antihypertensives.
- Fluid Management: Goal-directed fluid therapy (GDFT) using dynamic parameters (PPV, SVV) is recommended for major surgery.
7.4 Temperature Management
- Hypothermia Prevention: Maintain core temperature ≥ 36.0°C.
- Interventions: Active warming (forced-air warming blankets), fluid warmers, and increasing ambient room temperature should be employed for cases > 30 minutes.
- Monitoring: Continuous temperature monitoring is required for all general anesthetics > 30 minutes.
7.5 Multimodal Analgesia & PONV Prevention
- Analgesia: Utilize a multimodal approach (Opioids, Acetaminophen, NSAIDs, Regional Blockade, Ketamine, Dexamethasone, Lidocaine) to improve pain control and reduce opioid side effects.
- PONV: Assess risk (Apfel score). Administer prophylactic antiemetics (e.g., Ondansetron, Dexamethasone) for moderate/high-risk patients.
8. EMERGENCE & EXTUBATION PROTOCOLS
8.1 Standard Extubation Criteria
Extubation should be performed only when the following safety criteria are met:
- Oxygenation: SpO2 > 92-95% on FiO2 ≤ 0.5 (or return to baseline).
- Ventilation: Spontaneous respiration with adequate tidal volume (> 5 mL/kg) and respiratory rate (< 30/min). Normal ETCO2.
- Airway Reflexes: Return of gag/cough reflexes and ability to swallow.
- Neuromuscular Recovery: Quantitative TOF Ratio ≥ 0.9 or sustained tetanus/head lift > 5 seconds (if quantitative not available).
- Consciousness: Patient responsive to command (e.g., "Open your eyes", "Squeeze hand") or follows procedure-specific criteria (e.g., deep extubation).
- Hemodynamics: Stable BP and HR.
- Temperature: Core temperature > 36.0°C.
8.2 Extubation Techniques
- Awake Extubation: Standard for most patients, especially those with difficult airway or aspiration risk. Tube removed after patient follows commands.
- Deep Extubation: May be considered for patients at risk of coughing-induced complications (e.g., hernia repair, eye surgery, neurosurgery) provided airway is not difficult and aspiration risk is low. Patient must be spontaneously breathing and deep enough to tolerate oral airway/suction without reaction.
8.3 High-Risk Extubation Planning
For patients with a known difficult airway or risk of airway edema (e.g., prone case > 6 hours, large fluid shifts, anaphylaxis):
- Plan: Formulate a specific extubation strategy (e.g., extubation over Airway Exchange Catheter (AEC), fully awake sitting up).
- Location: Consider extubation in ICU rather than OR.
- Equipment: Difficult airway cart and re-intubation drugs must be immediately available.
9. NEUROMUSCULAR BLOCKADE MONITORING & REVERSAL
9.1 Standard
Residual neuromuscular blockade (RNMB) is a significant patient safety risk. ASA 2023 Guidelines strongly recommend quantitative monitoring and routine reversal.
9.2 Monitoring
- Quantitative Monitoring: Objective monitoring (e.g., acceleromyography, EMG) providing a numeric TOF ratio is the gold standard and should be used whenever non-depolarizing NMB agents are administered.
- Site: Monitoring at the ulnar nerve (adductor pollicis) is preferred for recovery assessment. Facial nerve monitoring may underestimate the degree of blockade at the diaphragm/pharynx.
- Target: A TOF ratio ≥ 0.9 is required before extubation to ensure adequate airway protection and respiratory function.
9.3 Reversal
- Sugammadex: Preferred reversal agent for Rocuronium/Vecuronium, especially for deep block. Dosing based on depth of block (2 mg/kg for moderate, 4 mg/kg for deep).
- Neostigmine/Glycopyrrolate: Indicated for reversal of moderate block (TOF count ≥ 2-3). Should NOT be used for deep block (TOF count 0). Allow at least 10 minutes for peak effect.
- Documentation: Document the reversal agent, dose, time, and the post-reversal TOF ratio.
10. INTRAOPERATIVE GLUCOSE MANAGEMENT
10.1 Indications & Targets
- Indications: Known diabetes (Type 1 or 2), patients on insulin, major surgery > 2 hours, sepsis, trauma, or patients receiving high-dose steroids.
- Targets:
- General Target: 140 - 180 mg/dL.
- Ambulatory Consensus (SAMBA): 180 - 250 mg/dL is acceptable to minimize hypoglycemia risk.
- Hypoglycemia: < 70 mg/dL (Requires immediate treatment).
- Severe Hyperglycemia: > 250 mg/dL (Consider treatment).
10.2 Protocol
- Monitoring Frequency: Check baseline BG. Recheck every 1-2 hours for stable patients, every 30-60 minutes for patients on insulin infusions or with lability.
- Treatment:
- Hypoglycemia (< 70 mg/dL): Administer Dextrose 50% (D50) 25-50 mL IV or Dextrose 10% infusion. Recheck in 15 minutes.
- Hyperglycemia (> 180-200 mg/dL): Treat with subcutaneous or intravenous Regular Insulin (e.g., 2-4 units IV) per sliding scale or start insulin infusion for persistent elevation.
11. ANTIBIOTIC PROPHYLAXIS TIMING VERIFICATION
11.1 Requirement
Surgical site infection (SSI) prevention requires timely antibiotic administration. The anesthesia provider is responsible for ensuring administration within the correct window.
11.2 Timing
- Standard (Cefazolin, etc.): Administer within 60 minutes prior to surgical incision.
- Vancomycin/Fluoroquinolones: Administer within 120 minutes prior to incision (due to longer infusion times).
11.3 Redosing
Antibiotics must be redosed intraoperatively based on the drug's half-life (usually every 2 half-lives) or excessive blood loss (> 1500 mL). (e.g., Cefazolin redose every 4 hours).
11.4 Checklist Integration
Administration status is verbally confirmed during the "Sign-In" and "Time-Out" phases of the Surgical Safety Checklist.
12. SPECIMEN, IMAGING & IMPLANT VERIFICATION
12.1 Specimen Verification (Sign-Out)
During the "Sign-Out" phase (before the patient leaves the OR), the anesthesia provider participates in verifying:
- Correct specimen labeling (Patient Name, MRN, Site, Specimen Name).
- Any specimen-related issues are addressed.
12.2 Imaging & Implants (Time-Out)
- Imaging: Verification that essential imaging is displayed.
- Implants: Confirmation that correct implants are available (Time-Out). Anesthesia ensures patient stability for implantation (e.g., hemodynamics for cement).
14. ROLES & RESPONSIBILITIES
Anesthesia Professional: Solely responsible for continuous monitoring, anesthetic management, medication administration, accurate documentation, and leading safety checks related to anesthesia.
Surgeon: Responsible for communicating surgical steps, duration, and critical events (bleeding, stimulus) to the anesthesia team.
Circulating Nurse: Responsible for assisting with equipment, verifying checklist items, and documenting surgical times.
Anesthesia Technician: Responsible for equipment maintenance, supply availability, and assisting with technical procedures (lines, airway).
16. QUALITY ASSURANCE & COMPLIANCE MONITORING
16.1 Key Performance Indicators (KPIs)
The department will audit the following metrics quarterly:
- Monitoring Compliance: 100% of cases with continuous SpO2, NIBP, ECG, and ETCO2 (for GA).
- Documentation Completeness: > 95% of charts with all 25 required elements.
- Antibiotic Timing: > 95% of eligible cases with Abx within 60 min of incision.
- Normothermia: > 90% of patients normothermic (36-38°C) at end of surgery.
- NMB Reversal: > 95% of cases with documented reversal or TOF ≥ 0.9.