5. PROCEDURES

5.1 K1 — OR Sign-In / Time-Out / Sign-Out Checklist Policy (WHO-Based Local Adaptation)

5.1.1 Governance and Local Adaptation

• A. The facility shall adopt the WHO checklist structure and adapt it to local workflows while keeping the three phases and core safety checks intact. (منظمة الصحة العالمية)
• B. Adaptation may include adding local elements (e.g., implant verification, special equipment readiness, antibiotic timing prompts) without removing core steps. (Iris)
• C. The checklist shall be integrated into the OR/procedure documentation process (paper or electronic), with defined accountability for completion.

5.1.2 Roles and Responsibilities During Checklist

• A. Sign-In: led by the nurse, with anesthesia participation.
• B. Time-Out: led by the nurse (or designated team member), with active verbal confirmation by surgeon/proceduralist and anesthesia.
• C. Sign-Out: led by the nurse, with surgeon/proceduralist and anesthesia participation to confirm key concerns for recovery and ongoing management. (منظمة الصحة العالمية)

5.1.3 Minimum Content Requirements (Local Checklist Must Capture These)

• A) Sign-In (Before induction of anesthesia)
  • Patient identity confirmed (two identifiers).
  • Procedure and site/side confirmed; site marking verified when applicable.
  • Consent confirmed (procedure + anesthesia as applicable).
  • Allergies and key risks (aspiration risk, difficult airway risk, major comorbidities).
  • Anesthesia safety checks complete (equipment/medications/emergency readiness).
  • Pulse oximeter applied and functioning. (منظمة الصحة العالمية)
• B) Time-Out (Before incision / procedure start)
  • Team introduces name/role when appropriate and confirms readiness.
  • Patient/procedure/site reconfirmed.
  • Surgeon/proceduralist: critical steps, anticipated blood loss, special concerns.
  • Anesthesia: patient-specific concerns and plan for hemodynamics/airway/PONV/pain.
  • Nursing: sterility confirmation, equipment issues, essential imaging displayed.
  • Antibiotic prophylaxis confirmation when applicable (given within required window). (منظمة الصحة العالمية)
• C) Sign-Out (Before patient leaves the room)
  • Procedure performed recorded/confirmed.
  • Instrument/sponge/needle counts completed as applicable.
  • Specimen labeling confirmed (read back).
  • Equipment problems noted for action.
  • Surgeon/anesthesia/nurse: key concerns for recovery and ongoing management communicated. (منظمة الصحة العالمية)

5.1.4 Stop-the-Line Rule

• A. Any team member may pause progression (induction, incision, leaving room) if checklist items are incomplete or inconsistent.
• B. Discrepancies must be resolved before proceeding unless emergent, with rationale documented.

5.1.5 Documentation of Checklist Completion

• A. Checklist completion must be recorded in the patient record (electronic tick box/scan/form).
• B. If an exception is required, document: item omitted, reason, and mitigation actions.

5.2 K2 — OR → PACU Standardized Handover Policy (ASA-Aligned)

5.2.1 Accompaniment and Transfer of Responsibility

• A. A member of the anesthesia care team knowledgeable about the patient shall accompany the patient to PACU. (ASA)
• B. Transfer of responsibility occurs only when the PACU nurse accepts the patient and the handover is completed per this policy. (qpp.cms.gov)

5.2.2 Minimum Handover Format

• A. Use a standardized structure (SBAR or equivalent):
  • Situation: patient, procedure, anesthesia type, immediate status
  • Background: key comorbidities, ASA class, relevant history
  • Assessment: intraoperative course, current concerns
  • Recommendation: monitoring needs, orders, escalation triggers

5.2.3 Minimum Content (Must Be Communicated and Documented)

• Patient identification and procedure performed.
• Anesthetic technique (GA/MAC/RA), airway device used, airway difficulty, aspiration concerns.
• Intraoperative events: hypotension/hypertension, arrhythmia, bronchospasm/laryngospasm, anaphylaxis, difficult ventilation/intubation, significant bleeding/transfusion, temperature issues.
• Current status on arrival: vitals trend, oxygen requirement, ventilation concerns, level of consciousness, pain level, nausea/vomiting risk.
• Analgesia plan: opioids/non-opioids given, regional block/catheter status, PCA plan if used.
• PONV prophylaxis given and rescue plan.
• Neuromuscular blockade and reversal summary (when applicable).
• Fluids/blood products total, lines/drains, urine output if relevant.
• Destination plan: expected discharge path (Phase II/ward/ICU), required monitoring intensity, and specific escalation triggers. (ASA)

5.2.4 PACU Arrival Documentation

• A. Patient status on PACU arrival shall be documented in the PACU record. (ASA)
• B. Handover completion shall be documented (checkbox or note) including name/role of giver and receiver.

5.3 K3 — PACU → Ward/ICU Handover Policy

5.3.1 Preconditions for Transfer

• A. Phase I discharge criteria must be met and documented, or an exception documented with physician decision and mitigation. (Local discharge policy governs details; this policy governs communication.)
• B. Receiving unit acceptance must be confirmed (bed readiness, monitoring capability, oxygen/NIV availability if needed).

5.3.2 Minimum Handover Content (PACU Nurse to Ward/ICU Nurse; With Physician Input When Needed)

• Patient identification, procedure, anesthesia type.
• PACU course: vitals trend, respiratory events, interventions given, response.
• Airway/oxygen plan: baseline SpO₂, oxygen device/flow, OSA precautions, CPAP/NIV plan.
• Hemodynamics: BP/HR stability, vasoactive drugs used/ongoing.
• Pain plan: current pain score, analgesics administered, timing of last opioid, PCA/regional catheter details, next dose timing.
• PONV: episodes, antiemetics given, ongoing plan.
• Temperature status and warming/shivering management.
• Wounds/drains/bleeding concerns; urine output if relevant.
• Labs/imaging pending and required follow-up actions.
• Safety concerns and explicit escalation triggers (e.g., desaturation threshold, hypotension, excessive sedation, bleeding).

5.3.3 ICU Transfer Special Requirements

• A. When transferring to ICU, include: ventilation mode/settings if intubated, invasive line status, sedation/analgesia infusions, hemodynamic goals, and active infusions/pump settings.
• B. If the patient remains high risk for airway compromise, anesthesia/ICU physician-to-physician communication must occur.

5.3.4 Documentation

• A. Transfer note/time, receiving unit, receiving nurse name, and confirmation of handover completion.
• B. Any “critical information” must be documented in the patient chart (e.g., difficult airway, aspiration, major hemorrhage, allergy/anaphylaxis).

5.4 K4 — NORA → PACU / Unit Handover Policy

5.4.1 General Rule

• A. NORA patients must receive the same structured handover standard as OR patients, with additional NORA-specific risk communication.

5.4.2 Minimum NORA-Specific Elements

In addition to the OR→PACU content (5.2.3), include:

• NORA location and procedure-related constraints (positioning restrictions, limited airway access during procedure).
• Radiation/MRI considerations (if applicable), including any device restrictions, monitoring limitations encountered.
• Transport risks: sedation depth residual effect, oxygen requirement, airway events, need for continuous monitoring during transport.
• Any procedural complications specific to NORA service (contrast reaction concern, access-site bleeding, perforation risk, etc.).

5.4.3 Destination Decision (PACU vs Local Recovery vs ICU)

• A. Destination must be decided and communicated before leaving the NORA area, based on patient risk and recovery capability.
• B. High-risk patients or any airway rescue event should recover in PACU or ICU as clinically indicated (per facility recovery policy).

5.4.4 Documentation

• A. NORA handover must be documented with time, giver/receiver identification, and destination confirmation.

5.5 K5 — Anesthesia Record Retention & Confidentiality Policy

5.5.1 Confidentiality and Access Control

• A. Patient anesthesia records are confidential health data and shall be protected from unauthorized access, use, or disclosure. (sdaia.gov.sa)
• B. Access to anesthesia records shall be role-based (minimum necessary access) and logged in electronic systems.
• C. Printed records must be stored in secured areas; unattended patient-identifiable documents in clinical areas are prohibited.
• D. Sharing patient-identifiable information outside approved clinical/administrative processes is prohibited except as permitted by law and hospital policy.

5.5.2 Release of Information

• A. Release of anesthesia records to external parties must follow the hospital’s Medical Records Release policy and applicable law.
• B. When used for teaching/audit, data should be de-identified whenever possible.

5.5.3 Retention Period

• A. The organization shall retain anesthesia and perioperative records according to applicable national requirements and accreditation standards.
• B. As a minimum benchmark referenced in some CBAHI standards, records may be retained for at least ten (10) years after the patient was last seen, with special retention requirements for minors (kept until adulthood, then additional retention period) when applicable by the adopted standard set. (استطلاع)
• C. The hospital shall publish a retention schedule covering: anesthesia records, PACU records, consent forms, incident reports, and medico-legal case records (which may require longer retention).

5.5.4 Record Integrity and Amendments

• A. Corrections must preserve original entry integrity (date/time/author traceability).
• B. Late entries must be labeled with the actual entry time and the event time.

5.5.5 Data Security Measures (Minimum)

• A. Apply organizational and technical safeguards for health data (access controls, secure authentication, encryption where required, backup and disaster recovery, secure disposal). (sdaia.gov.sa)

5.6 K6 — Documentation Minimums (Aligned with ASA Documentation Expectations)

5.6.1 General Documentation Principles

• A. Documentation must be accurate, timely, legible (or electronically readable), and sufficient for continuity of care and quality review. (ASA)
• B. Key clinical decisions and adverse events must be documented with actions taken and patient response.
• C. Documentation must support safe handover and postoperative management.

5.6.2 Minimum Required Elements — Pre-Procedure

Document at minimum:

• Pre-anesthesia assessment summary and day-of update (as applicable).
• ASA physical status classification.
• Airway assessment and airway plan.
• Fasting status and aspiration risk considerations when relevant.
• Medication review and allergy status.
• Consent documentation for anesthesia plan and postoperative pain plan. (ASA)

5.6.3 Minimum Required Elements — Intra-Procedure

Document at minimum:

• Start/end times and anesthesia technique.
• Monitors applied and key parameters recorded at clinically appropriate intervals.
• Airway management details: device, attempts, confirmation method, complications.
• All medications administered: name, dose, route, time (including antibiotics, vasoactives, analgesics, sedatives, neuromuscular blockers and reversal when used).
• Fluids, blood products, estimated blood loss, urine output when relevant.
• Significant intraoperative events and interventions with response. (ASA)

5.6.4 Minimum Required Elements — Post-Procedure / Transfer

Document at minimum:

• Patient status at end of anesthesia and immediate postoperative condition.
• Destination (PACU/ICU/ward) and rationale if not routine.
• Structured handover completion (OR→PACU or NORA→PACU/unit). (ASA)
• Postoperative orders relevant to anesthesia care (analgesia plan, oxygen/ventilation plan, monitoring needs).
• Any unresolved concerns and explicit escalation triggers communicated.

5.6.5 Minimum Required Elements — PACU Documentation (Coordination)

• A. PACU documentation includes arrival status and ongoing monitoring until discharge criteria are met; anesthesia documentation should align with and support PACU record completeness. (ASA)