R432-100-15. Surgical Services

  (1) Surgical services provided by the hospital shall be integrated with other departments or services of the hospital. The relationship, objective, and scope of all surgical services shall be specified in writing.

  (a) Administrative direction of surgical services shall be provided by a person appointed and authorized by the administrator.

  (b) Medical direction of surgical services shall be provided by a member of the medical staff.

  (c) Qualified registered nurses shall supervise the provision of surgical nursing care.

  (d) The operating room suites shall be directed and supervised by a qualified registered nurse. The supervisor shall have authority and responsibility for:

  (i) assuring that the planned procedure is within the scope of privileges granted to the physician.

  (ii) maintaining the operating room register; and

  (iii) other administrative functions, including serving on patient care committees.

  (e) The hospital shall establish a policy governing the use of obstetrical delivery and operating rooms to ensure that any patient with parturition imminent, or with an obstetrical emergency requiring immediate medical intervention to preserve the health and life of the mother or her infant, is given priority over other obstetrical and non-emergent surgical procedures.

  (f) Qualified surgical assistants shall be used as needed in operations in accordance with hospital by-laws.

  (g) Surgical technicians and licensed practical nurses may serve as scrub nurses under the direct supervision of a registered nurse, but may not function as circulation nurses in the operating rooms, unless the scrub nurse is a registered nurse.

  (h) Outpatient surgical patients shall not be routinely admitted to the hospital as inpatients. A systematic review process shall evaluate patients who require hospitalization after outpatient surgery.

  (2) A safe operating room environment shall be established, controlled and consistently monitored.

  (a) Surgical equipment including suction facilities and instruments in good repair shall be provided to assure safe and aseptic treatment of all surgical cases.

  (b) Traffic in and out of the operating room shall be controlled. There shall be no through traffic.

  (c) There shall be a scavenging system for evacuation of anesthetic waste gases.

  (d) The following equipment shall be available to the operating suite:

  (i) a call-in system;

  (ii) a cardiac monitor;

  (iii) a ventilation support system;

  (iv) a defibrillator;

  (v) an aspirator; and

  (vi) equipment for cardiopulmonary resuscitation.

  (3) The administration of anesthetics shall conform to the requirements of Anesthesia Services, R432-100-16.

  (4) Removal of surgical specimens shall conform with the requirements of Laboratory and Pathology Services, R432-100-22.