6 Colo. Code Regs. § 1011-1-20-15
Current through Register Vol. 47, No. 11, June 10, 2024
Section 6 CCR 1011-1-20-15 - SURGICAL AND PROCEDURAL SERVICES15.1 A qualified person designated by the administrator shall be responsible for the daily functioning and maintenance of the surgical and/or procedure room(s).15.2 Surgical Site Identification: Each center shall develop a standardized method to ensure all patients are appropriately identified, all pertinent information is obtained, the surgery and surgical site are confirmed, and a surgical team time out is conducted prior to an incision being made.(A) At a minimum, all surgical sites involving laterality, multiple structures (i.e., fingers, toes, lesions) or multiple levels (i.e., spine) shall be marked. (1) The marking shall be made by an individual that is familiar with the patient and is involved with the patient's procedure such as the surgeon or a licensed individual who performs duties in collaboration with the surgeon (ie, registered nurse, advance practice nurse or physician assistant).(2) Whenever possible, the marking shall involve the patient and take place when the patient is awake and aware.(B) The surgical time out shall include, at a minimum, unanimous confirmation by the entire surgical team of the following factors: (1) Patient identity using two patient identifiers;(3) Identification of correct site or side.15.3 Scrub Area: The scrub area shall be adjacent to the operating room to permit immediate access to the room after scrubbing. The scrub area shall be no more than 10 feet from the entrance to the operating room. Scrub sink(s) with electronic sensors, knee or foot controls shall be installed in the scrub area.15.4 Clean-up Facilities: Clean and soiled utility rooms shall be arranged and provided with equipment necessary for proper patient care and for the processing of soiled equipment, including a decontamination or sterilization system that is appropriate to the procedures being performed, and storage cabinets and work counters with sinks. Equipment for sterilizing instruments and supplies shall be conveniently located and of adequate capacity for the workload. Records shall be maintained to assure quality control, including date, time and temperature of each batch of sterilized supplies and equipment.15.5 Staff Dressing Rooms: Separate staff dressing rooms shall be provided for men and women; each containing a toilet, hand-sink, and clothing storage. For centers with five or less surgical and/or procedure rooms, unisex dressing rooms are acceptable. Showers shall be provided where there is more than minimal possibility of exposure to blood or body fluids and secretions.15.6 Environmental Services Room: A separate room or equivalent space shall be provided exclusively for the surgical and/or procedure rooms. It shall be equipped with shelves for supplies, mop clip boards, and a wall or floor-mounted mop sink. A hand washing sink with soap and sanitary hand washing facilities will be available nearby. There shall be room also for a waste container, drum of disinfectant detergent, mop carts and buckets, etc.