Safety Laws in Ex Lap

Setup

• Open the back table first, then the ring stand.
• Open the trays back to back: the Major tray at the end first, then the Balfour, so you never reach over the field.
• Pop the supplies, and open your gown last.
• Say it as you start Avagard: “15 minutes starts now.” Setup is timed: 15 minutes or less for full points.

Counts

• Initial count before the case, at the appropriate time.
• Any 4×4 Raytec not mounted on an instrument is removed before the peritoneum is opened.
• Closing count starts halfway through closure: sponges, sharps, instruments.
• The count is completed before the peritoneum is closed.
• Final count after skin closure: sponges and sharps.
• Prepare dressings only after the final count.

Bowel technique (the dirty setup)

• It begins when the bowel is about to be opened. Square off the abdomen with 4 new towels and put a towel down for the “new” Mayo.
• Use only the designated bowel instruments from the dirty basin: Glassman clamps, GIA and reloads, Forester sponge stick, Allis, needle driver, 8″ DeBakey, curved Mayo.
• You cannot touch anything on your clean Mayo or back table.
• Specimens and dirty instruments go in the separate basin.
• It ends when the dirty towels, Bovie, suction and Ligasure are rolled up toward the feet and passed off, the instruments go in the basin, and you change gloves (out loud). Then throw off a new suction, Bovie and laps.

Sharps

• Establish a neutral zone and use it.
• Load and remove blades with an instrument, never your fingers.
• Know your blades: 10 blade on a 7 handle for deep work; the skin knife is removed once the skin incision is made.
• Dispose of sharps safely at breakdown.

Meds and irrigation

• Identify, receive and label every medication.
• At the time out, state the meds on the field: saline (NaCl).
• Irrigation: only fresh, warm saline, to prevent hypothermia.
• At the end, communicate the amount of medication used.

Specimen

• Ask how the surgeon wants it sent, what it is called, and whether it is okay to pass off.
• Put it in the basin and pass it off; never wrap a specimen in a sponge.

Patient safety

• If the patient goes into Trendelenburg, keep clearance between the patient and the Mayo tray as the table tilts.
• SCDs on every patient (Dr. Howard).
• Watch the practical considerations: blood pressure, bleeding, contamination, spillage.
• Guard the sterile field until the patient has left the room.

The checkoff: all 36 steps

Each step is scored 3 (independent, smooth), 2 (with hesitation or prompting, but safe) or 1 (unsafe). Total is out of 108.

1. Performs a proper hand wash, wipes down the OR, and arranges OR furniture appropriately.
2. Checks the preference card. Gathers all necessary supplies and equipment.
3. States patient position and skin prep.
4. Opens back table, supplies and instruments properly and in a sterile manner.
5. Properly performs hand antisepsis.
6. Gowns and gloves off the Mayo stand without contamination. Spins the gown with the circulator before approaching the back table.
7. Properly drapes the Mayo stand.
8. Organizes the back table in an appropriate, functional manner.
9. Performs an accurate initial count at the appropriate time.
10. Properly identifies, receives and labels medication.
11. Sets up the Mayo stand with the instruments needed for the procedure.
12. Setup completed within 15 minutes. 15 minutes or less = 3 points, 15:01 to 16 min = 2 points, 16:01 and over = 1 point.
13. Gowns and gloves team members.
14. Properly drapes or assists with draping the patient. Passes off Bovie, suction and all other supplies needed for surgery.
15. Calls for the time-out. States medication and irrigation.
16. Establishes a neutral (sharp) zone, passes and handles all sharps safely.
17. Anticipates instruments, pairs them together, and passes them properly and safely.
18. Demonstrates knowledge of relevant anatomy and pathology.
19. Bowel technique: knows when bowel technique begins, isolates the bowel with towels, uses only designated bowel instruments, protects the sterile field and prevents cross-contamination.
20. Knows colon anatomy, resection, anastomosis and the linear stapler. Keeps clean and contaminated items strictly separate. Has a separate basin for passing off specimens and dirty instruments.
21. Knows when bowel technique ends: breaks down the dirty setup, changes gloves, and replaces the suction and Bovie.
22. Organizes the Mayo for wound closure. Loads, passes and cuts sutures properly. Assists with tagging and following.
23. Initiates and performs an accurate first (closing) count.
24. Assists with closing the skin; knows how the skin stapler works.
25. Performs an accurate final count at the appropriate time.
26. Prepares wet and dry sponges. Asks the circulator for, and prepares, dressings AFTER the final count.
27. Accurately communicates the amount of medication used.
28. Maintains the sterile field until the patient has left the room.
29. Assists in removing the drapes and disposes of them in the proper receptacle.
30. Assists with moving and tending to the patient.
31. Safely and appropriately disposes of sharps.
32. Properly breaks down the sterile field, handling instruments appropriately.
33. Removes gown and gloves and disposes of them in the proper receptacle.
34. Guards the sterile field from start to finish.
35. Assists in room turnover.
36. Can state the anatomy involved, purpose of the procedure, instruments, supplies and drapes used, and an overall description of the procedure.