Basic registration Procedures

Basic registration Procedures Surgical concepts and slating

Background • As an MAA you may find yourself working for a surgeon or in a hospital slating department. It will be your responsibility to ensure that procedures are scheduled accurately and documents are prepared in the correct format within specified time limits. This package reviews surgical terminology and guides you on various methods used to schedule surgeries.

Surgical specialities & terminology • The next few sections will provide you with the terminology and concepts around surgery • This will make your job easier • Chapters 12 & 13 of your transcription text gives information and examples of various surgical reports and formats. Terminology related to surgery is highly specialized and is related to anesthesia, surgical positions, instruments , incisions, suture material and techniques.

Surgical specialities • General- various organs and system; often intestinal, GB, or gastric surgery • Gynecology- eternal or internal female reproductive system • Neurology- nervous system • Ophthalmology- eyes and associated structures such as tear ducts, muscles and glands • Orthopedics- musculoskeletal system • Otorhinolaryngology- ear, nose and throat • Plastic- repair and reconstruction of various body parts • Thoracic- thorax, and diseases of the bronchi, lungs and mediastinum • Urology- male and female urinary tract and male reproductive system

Review • To review: surgical report : assist in future patient care, secure payment and provide legal documentation to support surgeon’s actions.

The surgical report; see chapter 13 to review the components of the following • Preoperative diagnosis • Postoperative diagnosis; often the same as the preoperative • Name of procedure(s)- what they did • Indications- why they did the surgery • Description of findings techniques: includes information on types of anesthesia, surgical positions, types of incisions, description of the actual procedure ( what was done, how it was done, what they found, condition of organs and structures, how they closed the surgical site, if the sponge count was correct, and how the patient tolerated the surgery).

Surgical positions (1) Recumbent (Lying or reclining), (2) Dorsal (pertaining to the back), (3) Modified Fowler's, (Fowler's position- that in which the head of the patient's bed is raised to 18-20 inches above the level. (4) Genupectoral position- the patient resting on his knees and chest, arms crossed above his head. (5) Left lateral, • (6) Lithotomy position-the patient on his back, legs flexed on his thighs, thighs flexed on his abdomen and abducted. (7) Prone- face downwards. (8) Sim's position- patient on left side and chest, right knee and thigh drawn up, left arm along the back. (9) Trendelenburg'spostion- patient on back, on a plane inclined 45 degrees, legs and feet hanging down over end of the table.

The signature block

Incisions- the cutting; notice how the names describe their location

Anesthesia • There are various forms of anesthesia. The type of anesthesia you will receive will depend on the type of surgery and your medical condition. Usually, an anesthesiologist will administer a sedative in addition to the anesthetic. The different types of anesthesia include the following:

Anesthesia • Local anesthesia. Local anesthesia is an anesthetic agent given to temporarily stop the sense of pain in a particular area of the body. A patient remains conscious during a local anesthetic. • Method of induction: For minor surgery, a local anesthetic can be administered via injection to the site. However, when a large area needs to be numbed, or if a local anesthetic injection will not penetrate deep enough, doctors may use regional anesthetics.

Anesthesia • Regional anesthesia. Regional anesthesia is used to numb only the portion of the body that will receive the surgical procedure. Method of Induction: Usually an injection of local anesthetic is given in the area of nerves that provide feeling to that part of the body. There are several forms of regional anesthetics, two of which are described in the following slides

Anesthesia continued • Spinal anesthetic. A spinal anesthetic is used for lower abdominal, pelvic, rectal, or lower extremity surgery. This type of anesthetic involves injecting a single dose of the anesthetic medication into the subarachnoid space, which surrounds the spinal cord. The injection is made into the lower back, below the end of the spinal cord, and causes numbness in the lower body. In some situations, such as a prolonged procedure, continuous spinal anesthesia may be used. A thin catheter (hollow tube) is left in place in the subarachnoid space for additional injections of the anesthetic agent, which ensures numbness during the length of the procedure.

Anesthesia • Epidural anesthetic. The epidural anesthetic is similar to a spinal anesthetic and is commonly used for surgery of the lower limbs and during labor and childbirth. • Method of induction: This type of anesthesia involves continually infusing an anesthetic medication through a thin catheter (hollow tube). The catheter is placed into the space that surrounds the spinal cord in the lower back (just outside the subarachnoid space), causing numbness in the lower body.

Surgical instruments • A wide variety of instruments are available for surgery, including saws, drills, hammers, clamps, tubes ( available in any hardware store- just kidding). Surgeons also use needles, knives, suture material, and lasers. Some examples of surgical instruments are:

Instruments • Aspirator-suctions fluids or gas • Catheter- tubular instrument inserted into body cavity • Clamp-used for griping, supporting or compressing an organ or vessel • Curette-spoon-shaped instrument for scraping & removing tissue • Dilator- enlarges an opening

Instruments • Forceps- instrument with two blades and a handle for pulling or compressing • Hemostat- stops the flow of blood • Retractor- pulls back the edge of a wound • Scalpel- a knife • Tenaculum-a hook like instrument for seizing & holding • Laser- an instrument that uses a beam of light instead of a scalpel

Sutures • When asking for a suture generally three pieces of information are included; suture size, suture type and suture needle. • For example- "Give me a 4-0 Vicryl on a PS-2“ • 4-0 (pronounced 4-oh) refers to the size of the suture fiber. Vicryl is the type of suture. And finally a PS-2 is the type of needle the suture is attached to.

Suture size • 10-0Typically used in the most delicate surgeries. Common in both Ophthalmic (eye)9-0 surgery and for repairing small damaged nerves often due to lacerations in the hand 8-0.7-0 Used for repairing small vessels and arteries or for delicate facial plastic surgery.6-0 Common for use in vascular graft sewing such a carotid endarterectomy.5-0 Used for larger vessel repair such as an Abdominal Aortic Aneurysm or skin closure 4-0

Suture size • 3-0 Skin closure when there is a lot of tension on the tissue, closure of muscle layers2-0 or repair of bowel in general surgery.0 For closing of the fascia layer in abdominal surgery, the joint capsule in knee and1 hip surgery or deep layers in back surgery.2 For repair of tendons or other high tension structures in large orthopedic surgeries 5.

Suture types Absorbable Non-absorbable • VicrylRapide – 2 weeksUndyed Monocryl – 3 weeksDyed Monocryl – 4 weeksCoated Vicryl – 4 ½ weeksPDS – 9 weeksPanacryl – 70 weeks • Nylon (Ethilon), Gortex, Silk, Fiberwire, Ethibond, Prolene and Steel are all example of non absorbable suture. When used on the skin, these sutures will be removed however when used in the body they will be retained inside the tissue.

Basic simple suture technique Interrupted: tie off each one Continuous ; like basting

Surgical slating • Depending on the facility, surgical slating may be performed by a Unit Clerk, Slating Clerk, and Admission, Clerk or nurse. • This may be your job • Simply put it is the same idea as scheduling using defined parameters • In order to be effective the clerk must be well train, knowledgeable in medical terminology, and possess good management skills & common sense

You will need to know • the number of O.R. theatres • equipment available for certain procedures • the doctor’s O.R. privileges • type and length of procedures • available slate time • the doctor’s clinical and vocational schedule • special needs of the patient • any additional needed equipment

Types of slating • There are two major types of O.R. slating systems: block and non-block. The block appears to be the most popular. In this system “blocks” of time in a day are assigned to specific surgical specialties. For example urological procedures may be given the time frame of Monday and Tuesday mornings only from 0700-1230. The urologist would then schedule his or her clinic hours around this slating schedule.

Non-block • Non- block slating is a first -come, first- served method of scheduling. There are no definitions to specific blocks of O.R. time. A master slate for the non-block system would simply show the column and row titles (theatre number and weekday). If a doctor had O.R. privileges at a hospital using this type of scheduling they would likely arrange the O.R. time around their clinic schedule.

The slate • Is a form that goes to each unit • The unit clerk checks for the name of any of their patients who are going for surgery • Information on the form varies but usually includes- start & end time, procedure, surgeon name , admission diagnosis, patient name, patient location • Other information is at the facility’s discretion

Scramble time • Scramble time or emergency time is open to any surgical specialty on a first-come first-served basis. It is similar to non-block. A hospital using the block system may in fact have some blocks specified as scramble time. Many facilities have a policy that if a specialty block is not booked within a certain time frame the block will revert to scramble. A hospital that uses non-block will usually try to fill available O.R. time with patients from the waiting list. Although time consuming it is cost-effective.

Scramble time • Remember most patients in Canada do not pay up front for procedures, but payment must be made. It is beneficial for the hospital to always be using the available facilities. Please bear in mind that scramble time would not be used for major surgeries, unless they were indicated as emergencies and appropriate time blocks were booked. Often an emergency procedure will "bump" an elective one out of its block.

To schedule patients from the wait list the clerk would: • determine the amount of available time • determine the gender of available beds on the Post-op unit • select the appropriate patient • contact doctors, patients to determine availability • If patient or doctor were unavailable, the clerk would repeat the process until the time block is filled.

Practice • Review the sample schedules • Review the patients • Review the slate schedule • Decide where you would schedule the patients

time slot- start time and end time • patient name • patient location- room and bed • surgeon name • procedure slated • admissions diagnosis

ASSESSMENT • you will be asked questions from the material on this PowerPoint & from chapter 13 in the transcription text • You will be given 1) a list of patients 2) a surgery template 3) slating forms • You will have to use the template to slate the patients. • You will not use any other resources • Any missing information, miss-scheduled patients will result in a mark of F

Basic registration Procedures