General OR - University of Colorado (UCH)

Before you start

You must have your ID badge (use it for parking, getting scrubs and getting through doors), codes for Pyxis (talk to Clark Lyda at the OR Pharmacy window for problems with Log-in), and of course EPIC (which is the same username and password as your UCD webmail. Every time you change this in one system it changes it in the other)

When in doubt, call Alyson, Aurora, the chiefs, or another resident. We have all been there and can help. Call a resident who is over at the University to give you a tour before starting.

Pre-ops can be done from home, if you haven’t already done them in the OR. This is accomplished by going to https://myapps.uchealth.org . Bookmark this page on your home computer and it will save you time in the future. Log-in using your webmail username and password. (The first time you log-in you will have to download Citrix to run EPIC. A link is posted for both Windows and Mac operating systems. Click this link and follow the instructions.) To log-in to EPIC PRD icon and log-in with your EPIC (same as webmail) username and password. Go to the OR Status or Snapboard and find your patient cases.

Phone Numbers

• AIP Charge: x85920
• AIP Charge RN: x84351
• OR Rooms: x307XX (Ex. OR 3 is 30703)
• OR Pharmacy: x86132

EPIC

Learning EPIC, the intraoperative charting system, is paramount before starting a case. If this is your first month of CA-1 year, you will have an orientation scheduled for you at the University during orientation. You be paired with another CA-1 for a couple weeks and you’ll be a pro in no time!!!

The system itself runs off the UCH OR board. To make sure this is your setting, click on the EPIC tab at the top left, find change context down towards the bottom and make sure your name is located under provider and that ZZ ANESTHESIA is below under department. Click ok and this will bring you to the Status Board setting window.

On the OR Status Board all the cases for the day will appear in order of room number; add-ons appear at the top until they are assigned to a room. For the main OR, you will want to have the AIP Intra-op Status board or AIP all areas selected. Under the location tab it will show you the areas that will appear on your status board- this tab should always show "AIP Operating Room" (which are the main ORs) and AIP Ancillary Operating Rooms which shows cases posted for EP, IR, Rad sedation, cath lab and GI in addition. Anesthesia AMC Main OR Status Board have all of the ORs for AMC.

To get you to the cases that you have been scheduled for in the EPIC system, you can select My cases direct to the left of All ORs. If you don’t see your name here, check the SnapBoard and see what room you are assigned to.

If you have any difficulties with EPIC or want to try and schedule EPIC training, please contact the chiefs directly and they can help you ASAP.

The UCH IT support number is x84000 if you need it.

If you don’t start at the U, make sure to come in and have a resident show you the ropes prior to your first day. Orient yourself with the anesthesia machine and learn where things are stored on the anesthesia carts.

Weekday Daily Workflow

• Complete pre-ops the day prior and call to discuss pertinent topics/anesthesia plan with your attending the next day. Work and personal cell phone numbers are available via SmartSheets at this link Smart Sheet Phone Roster. You will have to download and sign in via “company credentials” using your UCD email. You can also find it on the sharepoint (cupropofol.com). Plan to call your attending, but many people text first to coordinate a time.

• Preop's should include: PMH, labs, EKG, CXR, TTE etc. from EPIC. You will complete the Anesthesia pre-op evaluation note. Pertinent information can be found under Chart Review, Patient Summary, Anesthesia Records, among many others.

  • The pre-op note can be found under the Preprocedure tab, which is found at the top once you open a patient’s chart. Click on "Anesthesia Pre-Op Eval" to open note. When you select this, it will open a template that you can directly select + / - on selection under each organ system. To add procedural information of pt. history specific to the diagnosis (like for example hypertension or sleep apnea) click on the actual diagnosis and a single line box will appear that will allow you to type history that you want to include in your pre-op. Try to be as inclusive as possible for this. The next screen you will need to complete is the physical exam, which can be filled out by clicking at the top left the physical exam tab. You basically go through and click the tab that fit each portion of the physical exam. Just like on the previous history tab, you can click on each individual part of the physical exam to add handwritten notes (for example, description of a murmur heard on cardiac exam). The final tab of the three to be filled out is the anesthetic plan. Here you click the appropriate boxes for ASA status, additional case details (arterial lines, fiberoptic intubations etc.), as well as consent (that it has been done). After you are done, you will sign by clicking this button in the lower right corner.

• Should you need to update or edit any additional information, you can find your pre-op on the pre-op page at the bottom and by hovering over the area an update button will appear. Click on this button and your pre-op will appear. You can edit any portion of it and sign as you previously did to save all changes.

• If there is a recent pre-op from another procedure/surgery, you can click on the notebook with the arrow pointing right labeled "copy note", found on the upper right corner of your pre-op after you open it. This will copy all information from the previous anesthesia record, and you can update pertinent sections as needed. Remember to delete old text regarding procedure, physical exam, and plan.

• Fill out the Pre-op Orders (this should be done the night before when completing your pre op note). Nurses need official orders to start the PIVs, hang IV fluids, EKG, labs, scopolamine patch prior to case starts. The pre-op order set can be found under the order tab when you first open the pre-op page at the top (with the other tabs you frequently use on the pre-op page). The order sets can be found by searching within the box labeled "order sets". To add sets to your favorites, you can do so by right clicking over the order set and clicking "add to favorites". You want “UCHS Anesthesia Adult Pre-op.” LR is ordered for most cases in the AIP. If any labs are needed… especially a type and cross/screen, try and make sure you order those the night before.

• Other Order sets to favorite are UCHS Anesthesia PACU / Post-op, UCHS Anesthesia Intra-op Transfusion, UCHS Anesthesia Corneal Abrasion Management PACU / Post-op Orders.

• Give yourself at least 30 minutes to set-up your OR before any morning conferences:

  • Monday- Grand Rounds 6:45
  • Thursday- Cardiac lecture 6 :30 (when on Cardiac)

• Arterial lines: Pressure bags and transducers are in the Anesthesia workroom. Usually there are a couple set up for the day. You can ask the tech if there are arterial lines wet down and where to find them. You should know how to wet these down in the event that there is not a tech available to help, and you need one emergently. Have a tech or your attending show you.

• Be sure that if you need infusions, you have all the pumps you need in the room. Pumps can usually be found in each room. Extra channels are usually located in the Anesthesia workroom, or you can call one of the techs prior to your start. Prime all drips and place them on “hold”, ready to just hit run once induction is complete. Always keep an extra channel for the possibility of pressors or addition of other agents. Make sure that you change the mode to the "anesthesia mode" under the options before you set the pumps up.

• In prone cases, be sure to check that you have a prone view pillow. Ask the techs or grab one from the workroom. You will start an extra IV for most prone/spine cases that require TIVA.

• Get the patient’s narcotic bag from the Pyxis in Pre-op or from the pharmacy (It is called Narcotic Bag on the list) and includes the following controlled substances (with recent shortages the amounts below may change, always look at each bag closely!).

TIP

Typical narc bag includes:

• 1x 2mg Versed
• 2x 100mcg Fentanyl
• 1x 1mg Dilaudid
• 2x 200mg Propofol
• 1x 50 mg Ephedrine

• Other meds like Phenylephrine/Mannitol/cisatricurium/Heparin/Insulin/Precedex are in the Pyxis/refrigerator in the substerile areas between the ORs and premade phenylephrine syringes are in the pre op pyxis, sterile core, or at pharmacy (where you get your narcotic bag) or the top drawer of the anesthesia cart. You can always call the pharmacy (86132) to make up a drip for you. Remifentanil is in the pyxis, it can be made up in 1mg or 2 mg/40 ccs for the low and high concentrations. Clark Lyda, the head pharmacist, is always an excellent resource for all drug-related questions. All emergency drugs are in your cart in the OR. When adding extra narcotics or pulling out meds for a TIVA be sure to re-list the added meds you pulled out for the patient to your total on the narcotic bag. This is best accomplished with a sharpie. Example for a TIVA: get a large clear bag and write out what you pulled in regard to propofol on it. You can easily return the un-used propofols in the large bag. It also makes for easier accounting. Remi and Ketamine can be accounted for on the other narcotic tab on the narcotic bag. You can always pull out more narcotics for patient cases, just be sure to be diligent about accounting for them.

• Make sure you get EPIC loaded up in the OR before you head to pre-op; you will want your intra-op screen for the case going into the OR up. Having this up will also allow you to click the next buttons easily as soon as you enter the room with the patient. Under the intraprocedural tab you will want to make sure you do the following prior to your patient arriving.

• Make sure your anesthesia machine is connected to the correct workstation in EPIC. If you look at the top right of each monitor where the vitals are displayed, each will have a label with UCH OR then a two-letter state or AMCANES and a number. On the top left of the strip’s buttons located at the left of the intra-op record is button called “Device. Once you click this button, the correct label should be displayed. If not, then search for it in this window and add it. Once added correctly it should appear to the left.

• You also want to select you and your attendings names under “Staff” so that it auto logs when you click anesthesia start once the patient arrives.

Lastly, make sure that you select a “Macro” to load commonly used medications. “General” under public is a good one.

Before you leave the room, write you and your attending name and number on the board so the circulator can get ahold of you if needed.

Arrive in Pre-op around 6:45-7:00 (8:00 on Mondays).

Find your patient. (The EPIC screens in pre-op show the bay number and you can find it under the patient’s name in their chart.)

Complete pre-op H&P in EPIC while talking with the patient or once you get back to the room. Nurses chart vitals in the patient EPIC chart and you can see them on the main pre-op page. If not just ask and they can help you.

Consent the patient. (Check with attending about type of anesthesia first). The consent is found at the front of the chart or at the nurse’s station.

Start IV if not done already (rare). Try to put in 18 gauge or larger. PIV kits can be found at the bedside and IV fluids primed and ready to go are found around the Pre-op front desk. If you need anything else, just ask!

Verify antibiotics and that they are on the bed, taped to the fluids, or on the way to the OR. The primary team is supposed to order, but they often forget (ortho) so check with surgical team or just draw up Ancef to be prepared.

The circulator will get the patient and bring them to the room. Make sure you are ready by 0720 at the latest. It’s a good idea to call you attending once the circulator leaves so, they can get there in time.

Once the patient rolls in the room, click “Start anesthesia,” Patient in Room,” and “Immediate Reassessment”. This will start the charting once vitals are collected as you start the case.

If your vitals don’t move over or you forget to click these buttons, you can still collect vitals by validating the vitals located in each monitor…. they save them, thankfully! By clicking on the "Mon Caps" button again, your monitor will be displayed at the left. Click on the monitor and a chart of your vitals will appear. Click the upper left corner of this chart and it will highlight all the vitals within the box in yellow. Click "validate" to add these to the patient record (alternatively, you can go through and highlight them individually and drag the yellow area over vitals you want included). I recommend playing with this feature as a lot of times the vitals feature of EPIC is down, and you can manually add vitals into the record this way (instead of manually entering them).

Put on monitors. Start BP. Start pre-oxygenating.

Call your attending to tell them you are in the OR if they are not there. Have all the induction drugs ready to go, even plugged into the IV line. Do not push the sedative drugs yet, however titrating in fentanyl will allow it to work by the time you are ready to start induction.

Your attending will come in for the induction.... have fun!!

After induction, begin charting. Everything is charted in EPIC through buttons located on the left of the record. They are all pretty self-explanatory. Go through each and chart the specifics of each case. Meds is probably the most crucial along with the intubation. Common meds can be charted through a macro. You can also input meds manually as well through the meds tab. Gtts for TIVAs are under infusions. You just need to familiarize yourself with all these functions prior to starting a case.

Make sure you complete the PACU orders before going to PACU (can be done any time in the case). Use the macro you favorited earlier.

Click the appropriate events as/time to roughly when it happens. Make sure that they make sense and tell the right story. Some of these are metrics tracked by the hospital so getting them close does matter.

You’ll get attending specific instructions for what to call them for. If they don’t, then ask!

Call attending prior to extubation, no exceptions. If they don’t show up immediately or give you a time frame, then make sure to call again!

After you extubate, fill out the extubation tab/LMA removed, then click “out of room” as the last thing you do before you leave to PACU. It’s after “patient transported with oxygen.”

Transport to PACU. Remember to look at epic (under the patient names) or ask the OR circulator the PACU bay # you are going to before leaving the room. If you forget, this can also be found on a whiteboard just inside the main PACU entrance. Complete Post-op note, and give brief report to PACU RN: Anesthetic type, drugs, drips, complications, IVF totals, UOP, and special orders.

Chart any meds given in PACU and fill in EBL / Urine output if you haven’t. Remember to click “Anesthesia Stop” which you will find under your post op note. This is an audited metric because it ties into how we are paid, so get it close to accurate.

Write your totals on narcotic bag; make sure they match EPIC totals.

No needles! Only blue caps!!!! Drop it off at the pharmacy window if possible. Otherwise, there are metal box next to the Pyxis in Pre-op or next and the pharmacy window. Put your name and patient names/sticker. Get meds for the next case. (If you have quick cases, you may want to pull out multiple narcotics first thing in the morning).

Usually will get “coffee” (15min. morning around 9am), lunch (30min. 1100-1300), and “tea” (15min. afternoon around 1500) break.

The OR schedule with anesthesia assignments comes out around 2-3pm. It is emailed to us as a PDF, but you can also find your cases from the main Epic page by clicking My Cases. However, it will show up in the Snapboard first (typically around 1100/1200) Look up patients for the next day and call your attending the night before to discuss plans. Try to do this as early as possible and definitely before 2000. Try to see all inpatients the night before and have the consent signed.

Weekday Hours

R1: This means overnight call: 3pm-7am. You will finish all the late cases for the day and all the emergency overnight cases.

12 hour: Normal am-7pm: Start with the first cases of the day and you are in house until 7pm. Res-OR: You usually finish and can leave after you have finished your cases, or about 3-5p. If you finish early, always check with the charge anesthesia attending to see if you are needed elsewhere.

Call Nights/Weekend Call

On weekday call nights, arrive ready to start a case at 3pm. Check OR board and/or with Anes Charge (85920) to see where you’re needed (usually your name will be written in red on the main OR White board to tell you your assignment when you arrive). Keep your pager/Cell on during the day; they may need you to come in a little early if they are very busy (rarely, if ever, happens).

Weekend call is a 12-hour shift, 7am-7pm.

Call Room

Located on the 2nd floor between AOP and AIP. Room # 2016. Code is 5889#. We just got new stuff (Nespresso, Pillows, Mattress topper, etc) for the call room so please keep it nice!

Pagers (Trauma activation and Code pager)

When on call, you will carry a code/airway pager as well as a trauma activation pager (see below). Codes (See Section “What to do at a code”): Your responsibility is the “A” of the ABCs. Get to the head of the bed, assess need for airway intervention. It’s OK to push RTs, RNs, and other residents out of the way. Before intubation remember “VISA” V-ventilator or ambu-bag ready? I- patent IV functioning?, S- suction ready?, A- airway tools available? Always remember to grab the Airway Box prior to heading to the code location.

Airway Bag Locations:

1. main OR anesthesia charge station
2. in PACU
3. in STICU located at main nursing pod
4. CTICU by the signout roomYou will carry the trauma pager when on call at UCH as well
5. Resident workroom (aka the K-Hole)

If you are not in a case, you should go down to the ED for all trauma activations as we are a Level 1 Trauma center. The ED owns the airway, and we just stand by the door to help if needed. Your secondary objective is to determine if the case will rush up to the OR.

You should not start carrying this pager until after January, so ask your attending if you are unsure.