Perioperative Protocol



Scope and Target Population

The protocol describes appropriate evaluation for operative procedures for adult and pediatric patients. Pediatric patients for whom this protocol is intended are those between the ages of 2 and 15 years. Patients over age 15 are considered adults for the purposes of this protocol.

Emergent and urgent procedures are outside the scope of this protocol, but the topics of this protocol may still apply.


  1. Increase the percentage of patients age two years and older with complete preoperative history and physical examination obtained prior to undergoing elective, non-high-risk surgery and no diagnostic tests performed without clinical indications.
  2. Increase the percentage of patients age two years and older undergoing elective, non-high-risk surgery who receive appropriate management of stable comorbidities prior to procedure.
  3. Decrease the percentage of patients age two years and older who have canceled or delayed elective, non-high-risk surgical procedures due to incomplete preoperative basic health assessment and ineffective communication between clinicians.
  4. Eliminate the wrong surgical procedure or surgery performed on the wrong body part, or on the wrong patient.
  5. Eliminate unintentionally retained foreign objects during a surgical procedure.
  6. Minimize the rate of wound infections in surgical patients.
  7. Improve the adherence to the key components of the Perioperative protocol.

Clinical Highlights

  • Provide a comprehensive preoperative basic health assessment for all patients undergoing a diagnostic or therapeutic procedure as defined in the protocol.
  • Most laboratory and diagnostic tests including electrocardiograms are not necessary with routine procedures unless a specific indication is present.
  • Patient education and instruction strongly influence perioperative outcomes (e.g., medication management, apnea screening, nicotine cessation and surgical site infection).
  • Preoperative verification process includes patient identification, procedure(s), site(s), laterality and level. This process is confirmed by source documents, consent form, medical record and discussion with the patient. Additional verification must occur at designated points in the perioperative period.
  • All procedure sites – including level, position, laterality, multiple sites/digits in the same anatomic location – and bilateral procedures will be marked with the surgeon’s initials. The surgeon should follow the preoperative verification process prior to marking the sites. Surgeon initials must be visible at time of incision. Note: An anatomical diagram shall be used to identify surgical site(s) that are not visible through the surgical drape.
  • A Time-Out will be performed just prior to the start of the procedure (after the surgeon has scrubbed and gowned), with active verbal confirmation by all the professionals involved in the care of the patient. A repeat Time-Out will be performed for multiple procedures or position changes. An intraoperative pause shall be performed for all procedures that involve level, implants and/or laterality after an orifice or midline entry.
  • A pre-procedure briefing will be conducted. The purpose of the briefing is to present the plan for the procedure and confirm with the team members what will be needed during the procedure and when it will be needed.
  • When a hand-off is required, a structured process should be followed.
  • A Hard Stop will occur when either the verification process is incomplete and/or a discrepancy is identified. The procedure will not proceed until the discrepancy is resolved.
  • Baseline counts should be effectively and reliably performed for all countable items.
  • Imaging is required if the final count is unable to be reconciled.