REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
July 27, 2021
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center Operations, Policy and Procedure Manuals (included and summarized in Attachments A through C):
1. Operative Services Policy and Procedure Manual
(Presenter: William L. Gilbert, Director, 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 the revisions 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, and will not result in the use of Discretionary General Funding (Net County Cost).
BACKGROUND INFORMATION
The ARMC Procedure Manuals and Policies are prepared in compliance with the policies and procedures of the Administrative Operations Manual, County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC requirements, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary at 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 aforementioned manual 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.
The Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration reviews all ARMC policy manuals. ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Operative Services Policy and Procedure Manual - Policy Revisions
The Operative Services policy and procedure manual contains a total of 110 policies, of which the Patient Care / Perfusion subsection includes 38 new policies and procedures addressing requirements for the cardiothoracic surgical program and Title 22 requirements. A minor change was also made to the index of the manual. ARMC completed the 2020-2021 review of the policies and recommends the revisions summarized in Attachment A, Summary of Revisions. The 38 new policies added to the manual are included in Attachment B, as listed below:
|
Policy Number |
Policy Title |
|
257.00 Issue 1 |
Cardiovascular Surgery Service Equipment and Supplies |
|
258.00 Issue 1 |
Cardiovascular Surgery Team & On-Call CVOR Team |
|
300.00 Issue 1 |
Accidental Hypothermia Guidelines |
|
301.00 Issue 1 |
Adult Pump Prime |
|
302.00 Issue 1 |
Albumin Administration |
|
303.00 Issue 1 |
General Principles of Aseptic Techniques and Standards Protocol for Perfusion Circuit |
|
304.00 Issue 1 |
Autologous Prime (RAP) |
|
305.00 Issue 1 |
Autotransfusion |
|
306.00 Issue 1 |
Breakdown and Disposal of Perfusion Circuit |
|
307.00 Issue 1 |
Cardioplegia Administration using Myocardial Protection System (MPS) |
|
308.00 Issue 1 |
Cardioplegia Setup and Priming |
|
309.00 Issue 1 |
Cardiopulmonary Support (CPS) |
|
310.00 Issue 1 |
Emergency Cardiopulmonary Bypass Preparation |
|
311.00 Issue 1 |
Emergency Initiation of Cardiopulmonary Bypass |
|
312.00 Issue 1 |
Excess Volume in Perfusion Circuit |
|
313.00 Issue 1 |
Femoral Vein to Femoral Artery Bypass Guidelines |
|
314.00 Issue 1 |
General Standards for Perfusion Services |
|
315.00 Issue 1 |
Guidelines Deep Hypothermic Circulatory Arrest (DHCA) |
|
316.00 Issue 1 |
Guidelines for Pharmacological Support |
|
317.00 Issue 1 |
High Serum Potassium Levels Guidelines during Cardioplegia Administration |
|
318.00 Issue 1 |
Initiation of Cardiopulmonary Bypass |
|
319.00 Issue 1 |
Jehovah Witness Patient on Cardiopulmonary Bypass |
|
320.00 Issue 1 |
Left Heart Bypass Guidelines |
|
321.00 Issue 1 |
Management of Adults on Cardiopulmonary Bypass |
|
323.00 Issue 1 |
Off Pump Sterility |
|
324.00 Issue 1 |
Oxygenator Change Out |
|
325.00 Issue 1 |
Perfusion Considerations for a Patient with Renal Disease |
|
326.00 Issue 1 |
Pump Standby Guidelines |
|
327.00 Issue 1 |
Re-establishment of Bypass Following Initial Termination |
|
328.00 Issue 1 |
Retrograde Cardioplegia |
|
329.00 Issue 1 |
Set Up and Priming of Centrifugal Pump for Thoracic Aneurysms |
|
330.00 Issue 1 |
Sickle Cell Anemia Patient Management on Cardiopulmonary Bypass |
|
331.00 Issue 1 |
Sucker Cardiopulmonary Bypass Guidelines |
|
332.00 Issue 1 |
Termination of Cardiopulmonary Bypass |
|
333.00 Issue 1 |
Transfusion Guidelines and Determination of Amount of Blood Needed in Cardiopulmonary Bypass Prime |
|
334.00 Issue 1 |
Treatment of Water-Blood Leak from the Heat Exchanger |
|
335.00 Issue 1 |
Volume Selection |
|
336.00 Issue 1 |
Management of Air Embolism |
On July 13, 2021 (Item No. 12), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on June 25, 2021; Finance (Yael Verduzco, Administrative Analyst, 387-5285) on July 8, 2021; and County Finance and Administration (Matthew Erickson, County Chief Financial Officer, 387-5423) on July 12, 2021.