REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
May 6, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical Center
SUBJECT
Title
Department of Anesthesia Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies and the report of the review and certification of the Department of Anesthesia Policies and Procedures Manual (included and summarized in Attachments A through D).
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manuals are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, and the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary a minimum of every one, two or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The manuals and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals will improve County government operations and provide for the safety, health, and social service needs of county residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Department of Anesthesiology Policy and Procedures Manual (Manual) contains hospital-wide policies and procedures regarding quality of patient care, and management and supervision of the Preoperative Services Unit. The Manual contains 61 policies, of which one policy is new, one with major revisions, three policies and the index have minor revisions, and 56 policies have been reviewed with no revision.
The Department of Anesthesiology completed the 2022 review of this Manual and recommends the revisions summarized in Attachment A. Update of this Manual is certified in Attachment B.
The one policy with major revisions consists of the following:
• Policy No. 650.02 v6, Moderate Sedation and Analgesia Preformed by Non-Anesthesia Providers During Procedures on Neonates, Infants and Children less than 10 years of Age - The title states this policy is in regard to neonates, infants and children 0-10, however the policy itself does not address age more than infant.
There is one new policy. The new policy added to the Manual is included in Attachment C, and consist of the following:
• Policy No. 500.30 v1, Set Up and Priming of Intravenous (IV) Fluid Warmers Lines and A-Lines for Trauma Operating Rooms (OR’s) and Emergency Cesarean Section Operating Room - This policy allows set up and priming of IV Fluid warmer lines and arterial lines in the Trauma Operating Rooms, Neuro Trauma Operating Rooms, and the Emergency C -Section Operating rooms.
There are three policies that contain minor revisions, consisting of minor grammatical revisions and specifications of acronyms. The minor revisions to the index consisted of updates to policy titles.
On April 29, 2025 (Item No. 10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on March 10, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on April 11, 2025; Finance (Jenny Yang, Administrative Analyst, 387-4884) on April 17, 2025; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387-5423) on April 18, 2025.