Section R432-100-16 - Surgical Services(1) The licensee shall integrate surgical services provided by the hospital with other departments or services of the hospital and specify in writing the relationship, objective, and scope of each surgical service. (a) A person appointed and authorized by the administrator shall provide administrative direction of surgical services.(b) A member of the medical staff shall provide medical direction of surgical services.(c) A qualified registered nurse shall supervise the provision of surgical nursing care.(d) A qualified registered nurse shall direct and supervise the operating room suites. The supervisor shall have authority and responsibility for:(i) assuring that the planned procedure is within the scope of privileges granted to the physician;(ii) maintaining the operating room register; and(iii) other administrative functions, including serving on patient care committees.(e) The licensee shall establish a policy governing the use of obstetrical delivery and operating rooms to ensure that any patient with parturition imminent, or with an obstetrical emergency requiring immediate medical intervention to preserve the health and life of the mother or her infant, is given priority over other obstetrical and non-emergent surgical procedures.(f) A qualified surgical assistant shall assist as needed in operations in accordance with hospital bylaws.(g) A surgical technician or licensed practical nurse may serve as a scrub nurse under the direct supervision of a registered nurse, but may not function as a circulation nurse in the operating rooms, unless the scrub nurse is a registered nurse.(h) An outpatient surgical patient may not be routinely admitted to the hospital as an inpatient. The licensee shall complete a systematic review process to evaluate patients who require hospitalization after outpatient surgery.(2) The licensee shall establish, control and consistently monitor a safe operating room environment that complies with: (a) surgical equipment including suction facilities and instruments is provided and maintained in good condition to assure safe and aseptic treatment of any surgical cases;(b) traffic in and out of the operating room is controlled and there is no through traffic;(c) there is a scavenging system for evacuation of anesthetic waste gasses; and(d) the following equipment shall be available to the operating suite:(iii) a ventilation support system;(vi) equipment for cardiopulmonary resuscitation.(3) The administration of anesthetics shall conform to the requirements of the Anesthesia Services of Rule R432-100.(4) Removal of surgical specimens shall conform with the requirements of Laboratory and Pathology Services, Section R432-100-24.Utah Admin. Code R432-100-16
Amended by Utah State Bulletin Number 2016-5, effective 2/10/2016Amended by Utah State Bulletin Number 2023-14, effective 7/6/2023