Date First Published: April 8, 2015
Date Last Revised: September 17, 2017

 SCOPE OF PERI-OPERATIVE SERVICES

Peri-operative services Information system is designed to facilitate patient care activities in relation to the performance of surgery.  The peri-operative period begins when a decision is made to offer surgery as a treatment modality and ends in the immediate period after surgery. Even though the care during this period is continuous, for convenience it is divided into three phases

• Preoperative
• Intraoperative
• Post-operative

The preoperative phase may start at the outpatient, emergency or inpatient setting. Entrance and exit of the patient to and from the Operation Room (OR) demarcates. the intra-operative phase. The period after that until the patient recovers fully from  anaesthesia and the immediate effects of surgery is the post-operative phase. For the initial part of this phase, the patient is usually nursed in the recovery area (room) of the Operation Theatre Complex/OR Suite. During the latter part, the patient may be nursed in the Intensive Care Unit, the inpatient ward or, in the case of day-care patients, the recovery room of the Day Care ward.

The Operation Theatre (OT) Complex or Operation Room (OR) Suite (consisting of surgical operation rooms) is a common user facility that facilitates the performance of surgical operations by surgeons, the assistance surgical assistants, nursing care by nurses and the provision of anaesthesia by anaesthetists. In addition, specific diagnostic, therapeutic or invasive procedures and tests are also performed by specialists or technicians from a variety of disciplines.
The main workload is derived from a host of surgical disciplines / specialties, encompassing the following and more:

1. General surgery,
2. Obstetrics,
3. Gynaecology
4. Orthopaedics
5. Trauma surgery
6. Ophthalmology
7. Otorhinolaryngology,
8. Urology surgery,
9. Neurosurgery,
10. Oral surgery,
11. Maxillofacial surgery,Pplastic and reconstructive surgery,
12. Endocrine surgery,
13. Cardiothoracic surgery
14. and others.

The conduct of surgery itself requires precise planning to ensure safety, effectiveness and efficiency. 

Functions in the Peri-operative Period

The functions are basically clinical functions and the surgical team would use the CIS as practised in the rest of the hospital.
Fundamental to the provision of optimal perioperative care is the consideration for patient safety during the administration of anaesthesia and the performance of the surgical procedure.

Critical success factors in the effective, safe and efficient delivery of peri-operative care include:

1. Physical facility and equipment that is functional,conducive and safe
2. An environment where cleanliness and where necessary asepsis is assured
3. The availability of reliable monitoring equipment
4. Good procedure-specific instrumentation and above all
5. Adherence to well thought out policies and procedures
6. Strict supervision
7. Trained and properly credentialed personnel
8. Proper identification of patients
9. Proper scheduling
10. Complete documentation of the procedure performed
11. Maintenance of a register of the procedures performed
12. Regular review of outcome

Good governance supported by predefined policies, guidelines and standards are therefore essential prerequisites.

SCOPE OF INFORMATION SYSTEM FOR PERIOPERATIVE SERVICES

The system for Peri-operative Services facilitates a multitude of activities that take place mainly within the Operation Theatre (OT) complex and provided by the surgical, anaesthetic and operation room nursing team. However some aspects of preoperative and postoperative care may occur in clinics and wards where care is provided by staff of those areas.

The information system that facilitates peri-operative functions  system though often called the OT Management System (OTMS) must be seen as part of the Clinical Information System. It is a sub-system that is served by the other components of HIS such as Patient Management System, Clinical Support Systems (PhIS, LIS, RIS-PACS) and the Critical Care Information System.

The activities that are facilitated by OTMS are as follows:

1. Case Management
   • Scheduling of cases and creation of lists
   • Patient Tracking (Checking-in / Transfer within the complex / Checking-out)
2. Nursing Care of the Patient
3. Monitoring
4. Ordering and Performance of Procedures
5. Handling of Pathological Specimens
6. Management of Death in OT
7. Management of Organ and Tissue Procurement in OT
8. Documentation of clinical care and procedures performed
9. Quality Control
10. Data and Information Management
11. Facility and Utility Management
12. Material Management
13. Human Resource (Rostering)

The peri-operative clinical care of the patient would use the same Clinical Information System similar to the care of patients at other locations. It supports the implementation of the care plan for the patient from the time surgery is planned (scheduled) to the return of patient to the original nursing unit.

SCHEDULING AND LISTING

The Operation Theatre or Operating Room Suite is (usually) a common user facility shared between units or individuals. The allocation of sessions and slots, which are usually scarce, are determined by rules and policies usually decided by the Operation Theatre/Rooms Committee.  The session or ‘OT Time’ refers to a designated room and time that is made available for use. The allocation of sessions can follow two different policies.:

• All sessions are under the control of Operation Theatre manager 
• Rooms/sessions are predesignated to a particular surgical team or specialty unit
  

If sessions and slots are placed under the control of a Theatre/OR Manager, then he/she assigns them based on a request list or wait-list requests built from Orders from those who want to use the OT/OR service.Once the allocation is made the Scheduling book can be viewed by those concerned. They may make requests for modification but only the OT/OR manger may make changes. This arrangement is certainly necessary for emergency cases where the availability of resources are limited. Surgeons will have to make a request (via orders) and name of patients will be inserted into the wait list. The degree of urgency can be indicated in the order details. The Theatre/OR manager should also have access to the CIS or at least the clinical summary, in order to determine the order of urgency and therefore priority.

Slots can be assigned to individual surgeons or units/departments, in which case they will have control over use of their allocated sessions. Even so some policies and rules need to be put in place. A view of the schedule is available to the OT/OR manager so he/she is aware of what surgical procedure are being scheduled so he/she can make plans for them.

The Appointment-Scheduling Application

In an integrated HIS, the scheduling process uses the same Scheduling application used in the Patient Management System. The application allows for the assignment of privileges for the allocation of slots to specific persons by care provider category or name to perform surgical procedures. The software is equipped with tools for trained users to design new books according to needs based on the basic structure and layout. Each book have pages for sessions defined by the date and time period. Each page have time slots which can be categorized into different types based on user defined criteria such as availability, priority, ownership and privileges. The privileged user is able to add, disable, delete and reserve slots. Each page of an appointment book displays the availability status of slots for each room denoting vacancy, booked / taken and non-availability, with the help of a colour scheme.

If the software is web-enabled, it will allow for integration with applications system of sister facilities or a centralized scheduling unit.

The OT Scheduling Application Software is capable of displaying draft lists and the final list of patients (OT Lists), that are printable, for each Operation Room (OR) and also for individual care providers (anaesthetist, surgeon and assistants).

RESOURCE PLANNING

Well designed Operation Theatre/OR suites would have rooms specially designed or equipped for various types of procedures. The OT/OR Manager woukd have taken this into consideration when scheduling cases. However, having allocated patients to rooms, his/her next task of  is to ensure:

1. adequate personnel of the right skill category is assigned
2. the OR is prepared and ready, taking into consideration
   • the necessary equipment  instruments and material are made available
   • the  environment is conducive for conduct of surgery, provision of anaesthesia and care of the patient

Staff Assignment

Many categories of staff are involved in the successful conduct of surgery. Usually they are supplied by:

1. Staff the Operation theatre under the direction of the OT/OR Manager
   • nursing team
   • procedure assistants
   • ancillary staff
2. The Surgical Operation Team
3. The Anaesthetic team
4. Clinical Support team (Radiology, Laboratory)

The clinical case manager who leads the care team is usually a doctor who is often referred to as the primary provider (doctor). Others in the team may be co-providers (other doctors and nurses) and providers of clinical support services that include:

1. Nursing Services
2. Anaesthetic Services
3. Laboratory services
4. Diagnostic Imaging services
5. Others

The application should enable tasks to be assigned to individuals by name or by designation (e.g. person on duty) and work-lists created. It can also be used to determine client-provider relationship which in turn facilitates assignment of access privileges. This functionality within the Client-Resource Management Application is made available for all services / settings / locations, with some modifications.

It should enable all categories of staff to be allocated to work areas, rooms, wards, cubicles, beds, machines etc. according to dates and work shifts. Care providers need to sign in to confirm that they are available. The system should allow for constant updating of staff assignment. The application should enable the computation of the degree of efficiency of resource utilization.

PATIENT FLOW AND TRACKING (Check-In/ Check-Out/ Transfer)

The application provides work-lists (patient lists) of all patients for use by the OT reception, OT manager and anaesthetists.  Views are available to view task status of patients grouped according to:

• Sessions/rooms
• Emergency / elective indication
• General-Regional / Local anaesthetics
• A particular surgeon/specialty or anaesthetist

A white-board display enables the status of location and task performance. There is an indicator as to the whereabouts of the patient while in the OT complex for view by both the OT as well as the ward staff.
The application software is capable of capturing time of arrival and departure at various locations. The start and end of processes would also be automatically based on the time of entry of certain predefined data (e.g. task performance). These information can then be used for assessment of efficiency.

QUALITY CONTROL AND PATIENT SAFETY

There is a quality control procedure consisting of check lists for ensuring patient safety.

QUALITY CONTROL AND PATIENT SAFETY

Monitoring requirements will be similar to the intensive care service and is addressed under the Critical Care Information System

PROVISION OF ANAESTHESIA

Processes performed by anaesthetists and anaesthetic nurse are considered as patient care processes. Therefore, the anaesthetic services use the CIS to perform:

1. Patient assessment
2. Ordering for tests, procedures and others
3. Creation of work lists and tracking of task performance
4. Prescribing medication and recording drug administration
5.  Documenting procedure records

PERFORMANCE OF SURGICAL PROCEDURE

All processes performed by the surgical team are considered as patient care processes. Therefore, the surgical services use the CIS to perform:

1. Patient assessment
2. Ordering for tests, procedures and others
3. Creation of work lists and tracking of task performance
4. Prescribing medication and recording drug administration
5. Documenting Procedure Records

PERIOPERATIVE NURSING

Most of the processes performed by the nursing team should be considered as patient care processes. Therefore, perioperative nurse should use the CIS to perform:

1. a. Patient assessment
2. b. Ordering for tests, procedures and others
3. c. Creation of work lists and tracking of task performance
4. d. Monitoring include Intake–Output Charts
5. e. Recording drug administration
6. f. Documenting procedure records and check lists

ORDERING AND CREATION OF TASKS

All intended procedures should be ordered through the Order entry application. There is a need for it to link with the Scheduling application. Based on these, tasks lists should be created for each category of care provider or an individual care provider as well as for a specific room. The lists may have an interim or confirmed status. This replaces the traditional Operation Theatre (OT, OR lists).
Where documentation is required the relevant data entry form should be completed before the task can be considered done.

PROCEDURE RECORDS

The Procedure Record is a document with data contributed by surgeons, anaesthetists and nurses. Identification data of both patients and care givers are derived from the Patient management application and CIS-EMR. The names of procedures are selected from standard terminology / nomenclature lists in reference tables. Names of various categories of care providers shall be selected from a standard provider list. One patient should have one unified procedure record with contributions of all involved in the care of the patient.

CREATION OF REGISTRIES

The data aggregation and analysis tools as described in the Section on Data extraction should be used to create registries of all surgeries performed and anesthetics administered.
The data for the registry is derived from the Procedure Records supplemented by other data sources such as diagnosis from CIS-EMR and Case priority type (elective, emergency) from Order Management (OERRS). Because data is obtained from the database, Registers/registries/lists  can be created  for a time period, departments, named surgeons, procedure type or any other criteria. A care provider or trainee may create a report on all cases he/she is involved in and his/her role in them.

This article is in the process of being written