What are the general guidelines for a medical procedure?

General Guidelines for Medical Procedures

Medical procedures should follow a standardized protocol that includes comprehensive documentation, proper patient preparation, appropriate monitoring, and systematic follow-up to ensure optimal patient outcomes in terms of morbidity, mortality, and quality of life. 1

Pre-Procedure Assessment and Documentation

Patient Information and History

• Document complete demographic information, including relevant factors like BMI and hand dominance 1
• Record the patient's presenting complaint, mode of presentation (ambulance, walk-in, referral) 1
• Document past medical and surgical history with relevant outcomes from previous interventions 1
• Include comprehensive medication history, allergies, psychosocial history (smoking, drug use), and family history including relevant genetic information 1

Clinical Evaluation

• Perform and document relevant physical examination findings and other significant clinical findings 1
• Create a timeline of events in the patient's history and presentation, including any delays from presentation to intervention 1
• Document all diagnostic methods used: physical exam, laboratory testing, radiological imaging, histopathology 1
• Address any diagnostic challenges encountered (access issues, financial or cultural barriers) 1
• Include differential diagnoses considered and reasoning behind them 1

Laboratory and Diagnostic Testing

Appropriate Test Selection

• Order laboratory tests based on patient's medical status, drug therapy, and nature of the proposed procedure - not routinely 2, 3
• Before percutaneous procedures, check complete blood count, prothrombin time, partial thromboplastin time, and INR 1
• For patients at high risk, consider arterial blood gas analysis if there are concerns about respiratory compromise 1

Specific Testing Guidelines

• For high-risk procedures (those involving percutaneous incision), ensure INR is less than 1.5 and platelet count is greater than 50,000/L 1
• For patients on anticoagulant therapy, follow specific guidelines: withhold clopidogrel for 5 days, continue aspirin, and withhold one dose of low molecular weight heparin before the procedure 1
• Consider performance status (using WHO, Karnofsky or ECOG scales) as part of preoperative assessment 1

Informed Consent

Essential Elements

• Provide information in a format patients can understand about expected benefits, potential burdens, risks, and alternatives 1
• For outpatient elective procedures, provide verbal and/or written information at the time of consultation 1
• Provide written information in advance with sufficient time for the patient to read, evaluate, and seek further information 1
• Document if a patient declines information, explaining potential consequences of not having complete information 1

Documentation Requirements

• Obtain and document informed consent for the procedure and for publication of case details if applicable 1
• If consent cannot be obtained from the patient directly, document why and who provided consent 1

Procedure Protocol

Pre-Intervention Considerations

• Implement patient-specific optimization measures prior to procedure (e.g., treating hypothermia, hypovolemia, sepsis) 1
• Keep patients nil per os past midnight for procedures the following day, though clear liquids may be provided up to 2 hours before to reduce risk of volume depletion 1
• Administer prophylactic antibiotics for procedures with risk of infection, typically a first-generation cephalosporin or similar agent that covers typical cutaneous organisms 1

During the Procedure

• Document the type of intervention, reasoning behind treatment choice, and any concurrent treatments (antibiotics, analgesia, VTE prophylaxis) 1
• Record detailed intervention specifics: anesthesia, patient position, equipment used, preparation, sutures, devices, surgical staging 1
• Document who performed the procedure, including their experience level and position on the learning curve for the technique 1
• Record any changes in the planned intervention with rationale 1
• For procedures requiring anesthesia, maintain proper monitoring of vital signs and ventilation 1
• For specialized procedures like tracheotomy, follow a standardized protocol including proper personnel (2 physicians, at least 1 paramedic), preparation, and specific procedural steps 1

Post-Procedure Care and Follow-up

Immediate Post-Procedure Management

• Monitor for evidence of complications or adverse events 1
• Ensure appropriate hemostasis at procedure sites 1
• Follow institution-specific protocols for removal of catheters or sheaths and continuation of anticoagulation 1

Follow-up Protocol

• Document when, where, and how the patient was followed up (imaging, tests, clinical examination) 1
• Record any specific post-operative instructions provided 1
• Document clinician-assessed and patient-reported outcomes 1
• Assess and record intervention adherence/compliance 1
• Document all complications and adverse events in detail, including how they were prevented, diagnosed, and managed 1

Special Considerations

Surgical Procedures

• For surgical procedures, ensure proper preparation of the surgical field 1
• Document blood loss, operative time, wound complications, and need for revision surgery 1
• For robot-assisted procedures, select experienced centers rather than specific techniques 1
• Do not delay critical procedures like radical cystectomy for more than 3 months as delay increases risk of progression and mortality 1

High-Risk Patients

• Patients with weight loss ≥10% or poor performance status require particularly careful assessment 1
• Patients with multiple adverse medical factors should have their management discussed at a multidisciplinary meeting 1
• For patients with comorbidities, optimize their condition before the procedure 2

Documentation and Quality Improvement

• Create a detailed procedure report including strengths, limitations, and key takeaways 1
• Document any conflicts of interest, sources of funding, and institutional review board approvals 1
• Implement a standardized care protocol to reduce complications and improve outcomes 1
• Consider using a "never events" prevention framework based on transparency, respect, accountability, continuity, and kindness 4