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LOS ALAMITOS MEDICAL CENTER
RULES AND REGULATIONS
DEPARTMENT OF SURGERY
I.
II.
ORGANIZATION
1.
Composition: The Department of Surgery shall be composed of those physicians who
primarily diagnose and treat surgical diseases. This shall include but not be limited to
practitioners with privileges in Dentistry, General Surgery, Neurosurgery, Ophthalmology,
Otolaryngology, Plastic and Reconstructive Surgery, Thoracic Surgery, Vascular Surgery,
Urology, Anesthesia and other surgical sub-specialties. Representation from the
Departments of Pathology, Medicine, Family Medicine, Emergency Medicine, Diagnostic
Imaging, Psychiatry, OB-GYN/Pediatrics, and Orthopedics may be appointed. Only those
physicians with Active staff status in the Department of Surgery shall be eligible to vote or
make nominations or hold office. In addition, representatives from Nursing and
Administration shall be invited to participate.
2.
Department Chair: The Department Chair shall be an Active member of the Department of
Surgery whose qualifications, selection and tenure shall be in accordance with the Bylaws of
the Medical Staff and whose duties and responsibilities are as defined in the Medical Staff
Bylaws, Article 9.6-5.
3.
Clinical Service Chief: There shall be a chief of the Anesthesia Section whose qualifications
and selection shall be in accordance with the Bylaws of the Medical Staff and whose duties
and responsibilities are defined in the Medical Staff Bylaws, Article 9.7.
4.
Attendance: Active members of the Department shall be required to attend at least 50% of
the departmental meetings held per year with the following exception. Any Section member
who attends his/her Department Section meeting will be granted departmental meeting
attendance credit for each Section meeting attended.
5.
Quorum: The presence of 25% of the voting members of the department at any regular or
special meeting shall constitute a quorum.
DUTIES AND RESPONSIBILITIES
1.
Frequency and Reportability: The Department of Surgery shall meet at least quarterly, or as
needed, and shall report to the Executive Committee.
2.
Functions, Duties, Responsibility: The functions, duties and responsibilities of the
Department of Surgery shall be as set down in the Bylaws of the Medical Staff.
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III.
3.
Emergency Equipment and Supplies: The Department of Surgery has been assigned the
responsibility to make recommendation for determination of what emergency equipment and
supplies should be available in the Surgery Suite.
4.
Emergency Room Call Panels: The Department is responsible for establishing and approving
Emergency Room Call Panels for this service. Physicians may not be designated on the
Emergency Room Call Panel until their proctoring and observation period is completed and
approved by the department. Priority should be given to those physicians on Active Staff.
All members with full, Class I, unrestricted Ophthalmology privileges are required to serve
on the emergency room call panel for Ophthalmology as a condition of membership with the
following exemption allowed: if the physician’s age plus years of service at Los Alamitos
Medical Center equals 65. Calculations will be made at the end of each call panel (4 times
per year). It is the responsibility of call panel members to arrange for alternate coverage and
notify the Emergency Room and Medical Staff Office.
PRIVILEGES
1.
Jurisdiction: All matters pertaining to privileges in the Department of Surgery shall be
governed by the Bylaws of the Medical Staff and shall be reviewed by the Department of
Surgery with their recommendations made to the Medical Staff Executive Committee.
2.
Determination of Privileges: Determination of privileges shall be based on documented
background, experience, education and training and current competence demonstrated with
sufficient adequacy to assure that any patient treated will receive quality care. The privileges
for each specialty will be limited to those types of procedures that fall within the anatomical
areas covered by the specialty as described by the American Board of Medical Specialties.
The initial granting of full, Class I surgical privileges is dependent upon completion of a fully
accredited residency program in the appropriate surgical specialty, making the applicant
eligible for or certified by the applicable surgical specialty board as approved by the
American Board of Medical Specialties. All anesthesiologists and pain management
physicians must be certified in Advanced Cardiac Life Support (ACLS).
3.
Delineation of Privileges: Requests for privileges shall be made on an approved Delineation
of Privileges Form and will be granted on a case-by-case basis. Two (2) categories of
surgical privileges shall be granted:
1)
Class Ia - Indicates that the requested procedure has been granted with
observation/proctoring (focused professional practice evaluation) required.
Provisionally appointed members are granted this category of privileges. Proctoring
requirements outlined in the Medical Staff Bylaws and the department's rules and
regulations are to be followed.
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2)
Class I - Indicates that the requested procedure has been granted without restriction;
observation/proctoring requirements have been met.
4.
Additional Privileges: Additional privileges will be considered and recommended for
applicants who provide documented evidence of additional training and/or experience
acceptable, in accordance with III.2 above, to the Department of Surgery. All considerations
in this area will be governed by the rules set down herein.
5.
Probationary Privileges: All initially granted privileges in the Department of Surgery are
subject to an observation period (focused professional practice evaluation) whose terms and
conditions are set down hereinafter and in the Medical Staff Bylaws. Upon completion of
these requirements, reevaluation based upon observation of the practitioner and his/her
medical records will be carried out and recommendations regarding final privileges status
will be made. Additional observation periods may be assigned at the discretion of the
Department of Surgery.
Focused professional practice evaluation:
A.
Definitions
Proctor - A physician appointed by the Department chairman to orient the appointee
to hospital protocols and to review charts and observation reports completed by
observers. The proctor must be an Active member of the Medical Staff, an ad hoc
member of the Credentials Committee, and have been granted, without restriction,
the same or similar privileges as the physician being proctored.
Observer - A physician who observes a procedure. The Chairman of the Department
shall appoint members, subject to ratification by the Department, to serve as
observers for the various specialties under the Department of Surgery. To be an
observer, the member must be on the Active category, an ad hoc member of the
Credentials Committee, and approved, without restriction, for the same or similar
privileges as the physician being observed. A list of qualified observers shall be
available in the Medical Staff Office.
Courtesy staff members may be permitted to observe procedures performed at Los
Alamitos Medical Center in those instances where there are few or no Active
category members who have been granted, without restriction, the same or similar
privileges as the physician being proctored.
B.
Responsibilities:
Assignment of proctoring is the responsibility of the Chairman of the Department.
All members shall assist with departmental proctoring and observation.
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Proctor. The role of the proctor is to review charts and observation reports and
discuss them with the new member when necessary in the opinion of the proctor. It
is not necessary for the proctor to serve as the observer during the initial observation
period; however, the proctor may serve as the observer. It will be the responsibility
of the proctor to review a representative number of the new physician's charts and
observation reports. A written evaluation and recommendation will be prepared by
the proctor which will be used by the Department to determine the appointee's
eligibility for regular medical staff membership and privileges.
Observer. An observer shall observe, review and prepare a written report concerning
the new staff member's professional performance during surgical procedures.
Observers are to be arranged from at least three qualified observers (refer to Section
5-A), who are not associates or relatives. If an observer has not been obtained prior
to the procedure, the chairman of the Department of Surgery, in his/her discretion,
may appoint an observer or cancel the proposed procedure.
C.
Observation Protocol:
Observations shall cover a number of cases deemed sufficient by the Department for
the scope of clinical privileges requested. All surgical cases performed must be
observed until required proctoring and observation period is complete. An observer
or proctor shall not receive a fee for the time spent observing or reviewing charts.
Observer/Proctor's Report
1.
The observer/proctor shall prepare a written report for the Department that
describes the type of each case observed/proctored and an evaluation of the
applicant's performance. Blank report forms will be available in the Medical
Staff Office, Operating Room, nursing stations and Medical Records
Department. Completed reports should be handled in a confidential manner
and sent to the Medical Staff Office.
2.
The observer/proctor's report shall be maintained in the physician's
confidential file and shall be taken into consideration at the time the new staff
member is considered for promotion from provisional status, completion of
focused professional practitioner review, or advancement of privileges.
3.
It is the responsibility of the applicant to assure that observation/proctoring
reports are submitted for evaluation.
4.
If observation/proctoring indicates variations from established standards, the
observer/proctor shall document the same in the report with recommendation
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specific to the problem, which may include consultation requirements,
education or additional training.
D.
Completion of Focused Professional Practice Evaluation
Focused Professional Practice Evaluation must be completed within one year from
the date of initial appointment to the Medical Staff. Physicians who do not complete
their FPPE within this time period may be terminated from the Medical Staff.
Termination from the Medical Staff is done without prejudice and those physicians
who wish to re-apply may do so at a later date.
E.
Reciprocal Observation for Surgical Procedures
Concurrent or retrospective observation reports of a new member's performance may
be accepted from another facility if:
l.
The observing physician is an Active member in the Department of Surgery
of Los Alamitos Medical Center;
2.
The same range and level of privileges are sought at Los Alamitos Medical
Center that have been granted by the other facility.
At least one observation must be performed at Los Alamitos Medical Center. Copies
of reciprocal observation/proctoring reports will be requested only with the written
authorization of the physician being observed.
Reciprocal proctoring/observation reports may also, upon the approval of the
Chairman of the Department of Surgery, be supplied to other facilities upon the
request accompanied by the written authorization of the physician.
IV.
GENERAL RULES AND REGULATIONS
1.
2.
Scheduling:
a.
Only members of the Medical Staff or their designee may schedule surgery.
Scheduled surgery must be in accordance with procedures listed on surgeon's
delineation of privileges form and his/her classification.
b.
Scheduling times will be granted as openings exist, with priority for emergency
situations.
Operating Room Reservations: Surgery may be scheduled based on time and resource
availability. When scheduling surgery, the following information must be supplied: patient
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name, age, telephone number, pre-operative diagnosis, primary surgeon, assisting surgeon,
and procedure.
V.
3.
Emergency Cases: In emergency situations, defined as a condition in which delay might
endanger the patient's life and health, priority over all other cases will be granted and the
surgeons' schedule rearranged to accommodate the emergency. In any emergency, the
practitioner shall make at least a comprehensive note regarding the patient's condition prior
to induction of anesthesia and start of surgery. If the emergency situation is questioned, it
will be reported to and resolved by the Chairman of the Department of Surgery.
4.
Orders: All orders are canceled when a patient goes to surgery.
5.
Prompt Commencement of Surgery: Surgeons should be present in the Operating Room area
at least 15 minutes prior to the scheduled case and must be present in the Operating Room
ready to commence at the scheduled time unless there is reasonable excuse for delay. A
surgeon may be assigned at a later time, at the discretion of the Surgical Services Director or
designee if they are over 30 minutes late.
6.
Surgical Assistant: It is the responsibility of the operating surgeon to secure an appropriate
surgical assistant on all cases in which an assistant is indicated.
CONSENTS
The latest edition of the California Association of Hospitals and Health Care Systems Consent
Manual shall serve as policy governing all matters of consent.
1.
No surgical operation shall be done without the informed consent of the patient or his/her
legal representative except in life threatening emergencies, or to prevent deterioration or
aggravation of the patient's condition, and with the documented concurrence of two
physicians, on the progress record.
2.
It is the surgeon's responsibility to discuss with the patient the risks and complications of the
impending surgery and to document in the medical record that such discussion took place.
Preoperative medication shall not be given to the patient nor shall the patient be taken to
surgery until the above is done and written consent for the contemplated surgery has been
completed.
3.
Appropriate informed consent must be on the chart prior to surgery. All anticipated
procedures must be listed on the consent. A sterilization consent form shall be signed, in
accordance with California law and hospital policy on all fertile patients, male and female,
undergoing sterilization procedures.
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VI.
4.
Physicians shall see that one parent signs consent for surgery for unemancipated minors. The
consent of both parents is recommended whenever possible if it will not delay service to the
child.
5.
Surgical consents are valid as long as there is no change in the patient’s condition. If there is
a change in the patient’s condition, a patient must execute a new consent. The exceptions to
this policy are consents for sterilization procedures.
CONSULTATIONS
l.
Consultation Requirements: Consultation shall be required at the discretion of the
Department Chairman or the Chief of Staff when:
a.
b.
c.
2.
VII.
The patient is not a good medical or surgical risk.
The diagnosis is obscure.
There is doubt as to the best therapeutic measures.
Arranging Consultations: It is the responsibility of the attending physician to arrange
consultation.
THE MEDICAL RECORD
1.
Preoperative Requirements: All patients undergoing invasive procedures requiring moderate
sedation, general, spinal and regional anesthesia must have an appropriate history and
physical examination recorded on the chart prior to surgery. When the H&P is performed up
to 30 days prior to admission, an updated H&P must be performed and documented. The
H&P, including updates, must be performed within 24 hours after registration or inpatient
admission but prior to surgery or a procedure requiring anesthesia services. Additional H&P
requirements are located in Medical Staff General Rules and Regulations, Section VI.2.
When the history and physical examination is not recorded before an operation or any
potentially hazardous diagnostic procedure, the procedure shall be canceled unless the
attending practitioner states in writing that such delay would be physically detrimental to the
patient. If the history and physical is dictated but not on the chart, the attending physician
must indicate this and note all positive physical findings, history and the admitting diagnosis.
If these findings are not on the chart at the time of the pre-op, the pre-operative medication(s)
will not be administered and the surgeon will be notified.
Laboratory work, EKG's, chest x-ray and consultations shall be performed as deemed
necessary by the physician. A UCG test is required for women <55 years of age, unless the
woman is known to be infertile due to menopause ≥one year or previous surgery. The
operating surgeon must document his/her preoperative findings and diagnosis, by way of
dictated report or progress notes prior to commencement of surgery.
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VIII.
2.
Emergency Surgery: In the case of an emergency surgery, if time does not permit dictation of
a history and physical, the physician shall at least provide a comprehensive note regarding
the patient's condition prior to induction of anesthesia and surgery. In this case, the history
and physical and/or consultation shall be dictated or written immediately post-operatively.
3.
Operative Note: Upon completion of surgery the surgeon shall immediately document an
operative note. The operative note shall be signed, dated and timed and specify the name of
the primary surgeon and assistants, procedure(s) performed and description of each
procedure, findings, estimated blood loss, specimens removed, and post-operative diagnosis.
4.
Operative Report: Operative reports shall be dictated immediately after surgery and describe
the findings, the technical procedures used, estimated blood loss, the specimen removed, the
post-operative diagnosis, and the name of the primary surgeon and any assistants.
CONDUCT OF CARE
1.
Tissue and Foreign Objects: Tissue and foreign objects removed by operation shall be
delivered to the hospital pathologists and a report of his/her findings shall be filed in the
patient's medical record except for the categories of specimens exempted from this
requirement. Program flexibility for an alternative method of meeting the requirements of
Section 70223(g) has been granted by the state of California which includes the categories
outlined in the letter of approval.
The physician or surgeon will determine if a specimen removed by operation meets the
criteria for exception. If so, s/he will instruct nursing staff to dispose of the specimen or
specifically indicate that the specimen is not to be submitted to the pathologist for evaluation.
2.
IX.
Observers: Observers will be permitted in the Operating Room as outlined in the Observers
in the Operating Room Policy.
ANESTHESIA RULES AND REGULATIONS
1.
All anesthesia services provided by the hospital, in all departments and settings, are
organized into one anesthesia service, directed by a qualified MD or DO. Anesthesia
services include anesthesia and analgesia. Anesthesia may only be administered by
physicians who are qualified and have been granted appropriate privileges.
Definitions:
 Anesthesia: general, regional, MAC, deep sedation (medication to produce a loss of
pain, movement, function and memory and/or consciousness). Anesthesia may only be
given by an anesthesiologist within scope of practice and privileges granted.
 Analgesia/sedation: topical, local, minimal, moderate (relief of pain by blocking pain
receptors). Analgesia/sedation to be given by an appropriately trained physician within
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scope of practice and privileges granted, such as a qualified MD or DO other than an
anesthesiologist, or an oral surgeon or a podiatrist.
2.
Analgesia/Sedation (refer also to Moderate Sedation Policy)
Patients receiving analgesia or moderate sedation shall be monitored and evaluated before,
during and after the procedure by the physician performing the procedure.
Pre-sedation evaluation shall include past and present drug history, previous anesthetic
experiences, potential anesthetic problems, choice of anesthesia and results of relevant
diagnostic studies reviewed. An ASA assessment and planned method of administration
shall be included.
Post-sedation note shall include pre- and post-procedure findings, procedure, name of
physician performing procedure, type of analgesia/sedation, specimen, complications,
estimated blood loss, drains, post-procedure condition.
3.
Anesthesia
a.
Pre-Anesthesia Evaluation: There shall be a pre-anesthesia evaluation of the patient
by an anesthesiologist performed within 48 hours prior to first dose of anesthesia with
general, regional or monitored anesthesia. This evaluation shall include:
 Review of the medical history, including anesthesia, drug and allergy history
 Interview and examination of the patient
 Notation of anesthesia risk according to established standards of practice (ASA
classification of risk)
 Identification of potential anesthesia problems, particularly those that may suggest
potential complications or contraindications to the planned procedure (e.g. difficult
airway, ongoing infection, limited intravascular access)
 Additional pre-anesthesia evaluation, if applicable and as required in accordance with
standard practice prior to administering anesthesia (e.g. diagnostic testing, additional
specialist consultation)
 Development of the plan for the patient’s anesthesia care, including the type of
medications for induction, maintenance and post-operative care and discussion with the
patient (or patient’s representative) of the risk and benefits of the delivery of anesthesia.
b.
Intraoperative Anesthesia Record: An anesthesiologist shall be in attendance during
the surgery and shall monitor the patient.
There shall be an intraoperative anesthesia record or report for each patient who receives
general regional or monitored anesthesia, which includes:

Name and hospital identification number of the patient
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





Name(s) of physician who administered anesthesia and the name of the operating
practitioner
Name, dosage, route and time of administration of drugs and anesthesia agents
Technique(s) used and patient position(s), including the insertion/use of any intravascular
or airway devices
Name and amounts of IV fluids, including blood or blood products if applicable
Timed-based documentation of vital signs as well as oxygenation and ventilation
parameters
Any complications, adverse reactions, or problems occurring during anesthesia, including
time and description of symptoms, vital signs, treatments rendered, and patient’s
response to treatment.
c.
Postanesthesia Care: The anesthesiologist accompanies the patient being transported
to the Post anesthesia care unit.
Following surgery, the anesthesiologist shall remain with the patient for as long as s/he feels
is necessary, and personnel responsible for post-anesthetic recovery shall be advised of any
specific problems presented by the patient's condition.
The patient shall be discharged from the post anesthesia care unit only after meeting
discharge criteria – Aldrete score or by the attending surgeon if the patient is detained for a
possible post-surgical complication, such as bleeding.
d.
Postanesthesia Evaluation: The anesthesiologist will perform a postanesthesia
evaluation on inpatients and outpatients within 48 hours of any procedure involving general,
regional or monitored anesthesia and, for outpatients, prior to discharge. Note: The 48 hour
time frame begins at the point the patient is moved into the designated recovery area. The
evaluation would generally not be performed immediately at the point of movement from the
operative area to the designated recovery area. The evaluation may not begin until the patient
has sufficiently recovered from the effects of anesthesia so as to participate in the evaluation
(answer questions and perform tasks). An adequate post-anesthesia evaluation should
include:







Respiratory function, including respiratory rate, airway patency, and oxygen saturation
Cardiovascular function, including pulse rate and blood pressure
Mental status
Temperature
Pain
Nausea and vomiting
Postoperative hydration.
Depending on the specific surgery or procedure performed, additional types of monitoring
and assessment may be necessary.
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X.
POST ANESTHESIA CARE UNIT ADMISSION
1.
All postoperative patients are to go to the Post anesthesia care unit, unless otherwise ordered
by the attending physician or anesthesiologist.
2.
The anesthesiologist is responsible for the patient's condition in the Post anesthesia care unit
and is informed of any changes in the patient's condition, vital signs, and changes in
anesthesia level.
3
Patients who have had a local anesthetic are sent directly to their rooms, unless otherwise
ordered by the attending physician or anesthesiologist.
XI. DENTISTS
1.
Medical Appraisal: A patient admitted for dental care shall receive the same basic medical
appraisal as patients admitted to other surgical services.
2.
Responsibility: A patient admitted for dental care carries a dual responsibility involving the
dentist and physician member of the Medical Staff.
a.
Dentist's Responsibilities:
l.
2.
3.
4.
5.
b.
A detailed dental history justifying hospital admission.
A detailed description of the examination of the oral cavity and preoperative
diagnosis.
A complete operative report, describing the findings and technique. In cases
of extraction of teeth, the dentist shall clearly state the number of teeth and
fragments removed. All tissue shall be sent to the hospital pathologist in
accordance with the tissue policy outlined in Section X-1 of these rules and
regulations.
Progress notes must be pertinent to the oral condition.
Clinical resume (or summary statement).
Physician's Responsibilities:
1.
2.
3.
Medical history pertinent to the patient's general health, including
consultation requirements.
A physical examination to determine the patient's condition prior to
anesthesia and surgery.
A pre-anesthesia evaluation by the anesthesiologist.
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c.
The discharge of the dental patient shall be on the written order of the dentist member
of the Medical Staff and countersigned by the responsible physician member of the
Medical Staff.
3.
Dental Privileges: All matters pertaining to Dental Privileges will be governed by the
Medical Staff Bylaws and as set down in these Rules and Regulations. The Department of
Surgery will only make recommendation for dental privileges after receiving input from at
least one practitioner with dental privileges.
4.
Delineation of Privileges: All terms and conditions as provided for classes of privileges shall
prevail for Dental/Oral Surgery classification.
5.
All surgical procedures performed by dentists shall be under the overall supervision of the
Chairman of the Department of Surgery.
Surgery:
11/2013
Executive Committee:11/2013
Governing Board:
11/21/2013
word\surg\rules-reg.doc
Department of Surgery
Rules and Regulations
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List of Procedures Requiring an Assistant
I.
SCOPE:
Operating Room
II.
PURPOSE:
To establish a list of surgical procedures for the operating room to which the staff will be able to delineate what requires an assistant.
III.
POLICY:
In compliance with Title 22, Section 70223(b)(4), the medical staff has determined which operative procedures require an assistant to the surgeon.
It is acknowledged that there may be circumstances that negate the need for an assist to the surgeon. In those circumstances, the surgeon may make the
determination that the readily available resources are adequate to ensure safe patient care and the surgeon may proceed with the procedure. In making this
determination, the surgeon needs to keep in mind that at no time will the hospital’s personnel acts in any manner or provide any assistance that is beyond their scope
of practice and level of competency.
The PI Department, through the QRS system, will track, trend and report to the appropriate surgical department those cases listed below that are performed without
an assistant to the surgeon. The surgical department will have the responsibility to oversight the judgment exercised by the surgeon and to act upon areas of concern,
if any
Definition of assistant is anyone that the surgeon deems appropriate to assist (i.e. MD, RNFA, and PA)
IV.
PROCEDURE
The following procedures shall require an assistant. A QRS report shall be written by staff for any instances in which an assistant is not present during the below
listed procedures.
General Surgery:
Radical mastectomy
Resections: Whipple
Splenectomy (elective only)
Major liver lobectomy
ENT:
Parotidectomy
Radical neck dissection (exception of modified dissections)
Neurosurgery:
Any and all procedures in which the dura is opened (exception subdural)
Open Sympathectomy
Cardiovascular:
All open or closed heart cases
Surgeries on major vessels of the trunk
Urologv:
Operations on the kidneys and ureter except open renal biopsy
Adrenalectomy
Open operation on the prostate except bladder stent removal
GYN:
Vaginal or abdominal hysterectomy
Exploratory laparotomy and operative laparoscopy (exceptions: ectopic pregnancy, tubal ligation, and ovarian cystectomy)
Obstetrics
Cesarean Section (assistant present at the time of skin incision)
Orthopedics: (note: Total Joints procedures may have a second scrub person to retract and hold extremity versus an assistant)
Total knee
Total hip
Total shoulder
Anterior posterior approach spine surgery