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Statement No. 1006 - Provincial Surgery Outreach Programs

Preamble
    
      The operative procedure is only one part of the total surgical care of the patient.  Total surgical care includes establishing or confirming the diagnosis, preoperative preparation, the operative procedure, and postoperative care whether the patient is admitted or an outpatient having day surgery.  Ideally, the patient should receive all of these services from the surgeon and the anaesthesiologist to whom the patient entrusts his or her care.  
            
     Continuity of care is dependent upon physician availability.  When care is provided by a physician who is not a resident in the community, gaps in care can occur.  These gaps can be minimized through appropriate provisions for coverage.  In those hospitals where visiting surgeons and anaesthesiologists are part of a surgery outreach program, specific rules and regulations must be adopted to ensure that gaps in care associated with itinerant surgery do not occur.  Generally, a visiting surgeon is unavailable to provide regular follow-up care.  Therefore, visiting surgeons must have a working relationship with physicians practicing in the area in order to identify who will provide care when the visiting physician is not in the community.  This would include timely communication on a regular basis.  Anaesthesia services may or may not be provided by a physician practicing in the area.

  1.   Initiating a Program    

       The visiting surgeon shall submit a proposal in writing to the facility chief of staff outlining: 
   
a.  the nature of the procedures to be performed,
b. significant features of pre, intra, and postoperative care given by other health care professionals, including nursing, pharmacy, and diagnostic services.
c. a written agreement with area physician(s) to provide anaesthesia intraoperatively and to conduct preoperative anaesthesia assessments. If the anaesthesiologist is a visiting physician, his or her role is typically limited to immediate preoperative, intraoperative, and immediate postoperative care. Area physicians would conduct preoperative anaesthesia assessments.
d. a written agreement with the attending community physician(s) who will be responsible to provide postoperative care both in hospital and in the community.  The attending physician assumes all aspects of patient care unless specific arrangements are made.  The agreement also confirms that the attending community physician(s) is familiar with the surgical procedure performed, and is able to recognize and initiate treatment for complications which may occur.
e. a process that ensures availability of the visiting surgeon or back-up in an emergency including:
i. Operating surgeons must provide contact information so they can be quickly contacted when the attending community physician providing the postoperative care requires advice from an operating surgeon who has left the community.  If the operating surgeon is a member of a clinic or call group who share after hours calls, the physicians assuming call responsibility must be aware of and agree to take on the responsibility for the operating surgeon's work in the regional hospital.
ii. In the event that a patient requires admission to a higher level care facility than the regional hospital, the visiting surgeon must agree to accept responsibility for the patient, or if the visiting surgeon does not hold the necessary hospital admitting privileges, written arrangements must be in place to ensure that another surgeon with appropriate privileges will accept responsibility for the patient.
f.
confirmation from the facility manager, in consultation with the Chief of Staff, that the facilities (including physical plant, equipment, and supplies) and skill levels of the entire hospital health care team are commensurate with the care required to support the surgery to be performed. 

2.     Preoperative Care  
     Prior to slating surgery, the visiting surgeon must see and assess the patient and personally make the decision to proceed.  The assessment must include the formulation of a surgical diagnosis and the nature of the assessment and the diagnosis must be properly recorded in a hospital record. The visiting surgeon is required to obtain informed patient consent.
A preoperative anaesthesia assessment must be completed.  Anaesthesia consent must be obtained by the physician who will be providing anaesthesia.
All preoperative diagnostic work plus appropriate documentation of patient consent must be on file on the hospital record before the procedure is carried out.
 
3.   Privileges
     The visiting physicians must hold full licenses with CPSM.  Only procedures approved by the Regional Health Authority may be performed.  A list of all privileges at the facility is required to be provided annually to the Area Standards Committee (Hospitals Act Regulation).
 
4.   Audit
     The medical staff shall maintain an ongoing chart audit of all procedures performed.  Visiting surgeons and anaesthesiologists shall participate in the audit process to the extent possible.  If they attend the facility regularly, audits should be scheduled for when visiting physicians are on site.  If they attend the facility irregularly, it would be appropriate to have written communication between visiting physicians and the audit committee. The results of audits should be reported regularly to the Area Standards Committee.   Any Critical Clinical Occurrences must be reported according to the requirements of the Regional Health Authorities Act and the policy of the CPSM.  In addition, the program shall be reviewed as part of the CPSM hospital review program.
             
First Print CPP 05-91
Revision CPP 04-98
Revision EXEC 03-06
     
                A statement is a formal position of the College with which members shall comply.