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Essential Duties:

RNFA STANDARDIZED PROCEDURE

I. Standard

The RN First Assistant renders direct patient care as part of the perioperative role by assisting the surgeon in the surgical treatment of the patient. The responsibility of functioning as first assistant must

be based on documented knowledge and skills acquired after 73pecialized preparation and formal instruction.

II. Policy

A. The safety and welfare of the patient should be given primary consideration in the selection of a first assistant in surgery. In the absence of a qualified physician, the registered nurse who possesses appropriate knowledge and technical skills is the best qualified non-physician to serve as the first assistant.

B. The RNFA practices under the direct supervision of the surgeon during the surgical intervention.

C. The RNFA must perform only as first assistant and not concurrently as scrub nurse.

D. Only in extreme emergencies should an RNFA be expected to assist on procedures that present an unusual hazard to life.

E. The RNFA must adhere to the policies of the institution and must remain within the scope of practice as stated by the Nursing Practice Act of the State of California.

F. The RNFA may perform technical functions:

1. Assist with the positioning, prepping and draping of the patient or perform these independently, if so directed by the surgeon.

2. Provide retraction by:

a. Closely observing the operative field at all times.

b. Demonstrating stamina for sustained retraction.

c. Retaining manually controlled retractors in the position set by the surgeon with regard to surrounding tissue.

d. Managing all instruments in the operative field to prevent obstruction of the surgeons view.

e. Anticipating retraction needs with knowledge of the surgeonspreferences and anatomical structures.

3. Provide hemostasis by:

a. Applying electrocautery tip to clamps or vessels in a safe and knowledgeable manner as directed by the surgeon.

b. Sponging and utilizing pressure as necessary.

c. Utilizing suctioning techniques.

d. Applying clamps on superficial vessels and the tying off, electrocoagulation of them as directed by the surgeon.

e. Placing suture ligatures in the muscle, subcutaneous, and skin layers.

f. Placing hemoclips on bleeders as directed by the surgeon.

4. Perform knot tying by:

a. Having knowledge of the basic techniques.

b. Tying knots firmly to avoid slipping.

c. Avoiding undue friction to prevent fraying of suture.

d. Carrying knot down to the tissue with the tip of the index finger and laying the strands flat.

e. Approximating tissue rather than pulling tightly to prevent tissue necrosis.

5. Provide closure of layers by:

a. Correctly approximating the layers under the direction of the surgeon.

b. Demonstrating a knowledge of different types of closure.

c. Correctly approximating skin edges when utilizing skin staples.

6. Assist the surgeon at the completion of the procedure by:

a. Affixing and stabilizing all drains.

b. Cleaning the wound and applying the dressing.

c. Assist with applying casts or plaster splints.

NOTE: The above specifications are general guidelines and do not reflect all duties in all specialty areas. Therefore, they should not preclude the performance of other duties which, in the judgment of the surgeon, can be successfully accomplished by the RN First Assistant. However, the RN First Assistant must know his/her limitations and may refuse to perform those functions for which he/she has not been prepared or which he/she does not feel capable of performing.

STANDARDIZED PROCEDURE

Procedure: Intraoperative Retracting

Personnel: Registered Nurse First Assistants

Purpose: To direct the RNFA in providing retraction of the surgical field

Desired Outcome: Adequate surgical exposure without subsequent tissue/organ compromise.

Supportive Data: Selection and placement of an appropriate retraction instrument will assist the surgeon by providing exposure and optimum visualization of the surgical site.

Process: The RNFA will assist the surgeon by providing intraoperative retraction using the following measures:

1. Retracting tissues or organs by the use of the hand.

2. Placing and holding surgical retractors.

3. Packing sponges or laporotomy pads into body cavities to hold tissues and organs out of the operative field.

4. Managing all instruments in the operative field to prevent obstruction of the surgeons view.

STANDARDIZED PROCEDURE

Procedure: Intraoperative Hemostasis

Personnel: Registered Nurse First Assistants

Purpose: To direct the RNFA in providing Hemostasis of the surgical field.

Desired Outcome: Minimal blood loss during surgery.

Supportive Data: Providing a dry operative field promotes adequate visual assessment and access to the surgical site. Effective hemostasis is essential to carry out surgery in a time-efficient manner and to prevent excessive blood loss.

Process: The RNFA will assist the surgeon by providing intraoperative hemostasis using the following measures:

1. Aspiration of blood and other fluids from the operative site, as directed by the surgeon.

2. Sponging the wound or other area of dissection, as directed by the surgeon.

3. Using hemostasis or other surgical instruments to clamp bleeding tissue, as directed by the surgeon.

4. Using sutures to tie off clamped blood vessels or other tissue, as directed by the surgeon.

5. Using electrocautery or other surgical device to cauterize tissue, or surgical instruments clamped to tissue.

6. Place hemoclip, or other ligating devices on vessels or tissue, as directed by the surgeon.

STANDARDIZED PROCEDURE

Procedure: Intraoperative Tissue Manipulation

Personnel: Registered Nurse First Assistants

Purpose: To direct the RNFA in the manipulation of tissue and use of surgical instruments during a surgical procedure.

Desired Outcome: No tissue damage due to improper handling, or use of surgical instruments.

Supportive Data: Proper handling of tissue & selection and use of surgical instruments is essential to proper treatment of tissue and rapid healing of the surgical site.

Process: The RNFA will use surgical instruments & suture material to manipulate tissue, as directed by the surgeon, to:

1. Expose & retract tissue.

2. Clamp & sever tissue.

3. Grasp & fixate tissue with screws, staples, and other devices.

4. Drill, ream, and modify tissue.

5. Cauterize and approximate tissue.

PROCEDURE FOR THE RNFA IN THE EVENT THE SURGEON BECOMES INCAPACITATED

OR NEEDS TO LEAVE FOR AN EMERGENCY DURING SURGERY

1. In the event the operating surgeon, during surgery, becomes incapacitated or needs to leave the OR due to an emergency, the responsibility of the RNFA is to:

a. Maintain hemostasis, according to the approved standardized procedure.

b. Keep the surgical site moistened, as necessary, according to the type of surgery.

c. Maintain the integrity of the sterile field.

d. Remain scrubbed in appropriate attire (gown, mask, gloves, cap).

e. Remain at the field while a replacement surgeon is being located.

2. The RN circulator will initiate the procedure for obtaining a surgeon in an emergency.

Standardized Procedure for the Registered Nurse First Assistant

I. PURPOSE:

This standardized procedure will provide guidelines for the registered nurse assisting the surgeon in the first assistant role.

II. POLICY STATEMENT:

The RNFA may function in the expanded role, provided in this standardized procedure, which is approved by the Interdisciplinary Practice Committee. This role requires the direct supervision of the sponsoring primary surgeon.

III. GENERAL GUIDELINES:

A. The RNFA will assist the surgeon by providing intraoperative retraction giving exposure and optimum visualization of the surgical site as directed by the surgeon.

1. Retracting tissue or organs by the use of the hand, closely observing the operative field at all times.

2. Placing or holding surgical retractors in the position set by the surgeon with regard to surrounding tissue.

3. Packing sponges into body cavities to hold tissue or organs out of the operative field.

4. Managing all instruments in the operative field to prevent obstruction of the surgeons views.

B. The RNFA will assist the surgeon by providing intraoperative hemostasis promoting adequate visual assessment and access to the surgical site as directed by the surgeon.

1. Aspiration of blood and other fluids from the operative site using suctioning techniques.

2. Sponging the wound and utilizing pressure as directed.

3. Placing hemostats on other instruments to clamp tissue or bleeding vessels.

4. Applying electrocautery tip to clamps or vessels as directed.

5. Placing suture ligatures on vessels or tissue as directed.

6. Perform knot tying firmly to avoid slipping.

C. The RNFA will use surgical instruments to perform dissection or manipulate tissue as directed by the surgeon.

1. Dissects only those layers required to provide exposure to the operative area as directed.

2. Dissect only the superficial tissue of lower extremity veins during cardiac or vascular surgery as directed.

3. Grasps and fixates tissue with staples or screws.

4. Drills and modifies bone tissue as directed.

C. The RNFA will suture tissue and insure hemostasis or wound alignment as directed by surgeon.

1. Approximating tissue layers as directed to avoid excess tension or tissue necrosis.

2. Uses suture, staples, skin clips or other devices to correctly approximate tissue.

IV. REQUIREMENTS FOR RN PRIVILEGED IN THEIR EXPANDED ROLE:

A. Will meet all requirements of the hospital Non-physician/Non-Employee Policy.

B. Certified in basic Cardiopulmonary life support.

C. Nationally certified operating room nurse through the Association of Operating Room Nurses (AORN).

D. Minimum of three (3) years of operating room experience in both the scrub and circulating roles.

D. Proof of successful completion of a structured RNFA course and completionof 20 hours or 10 cases of proctoring by the sponsoring surgeon.

F. Will receive approval from the surgical sub-specialty of the sponsoring physician.

G. Will be evaluated by the hospital staff for compliance to OR policies and by the sponsoring surgeon annually.

V. DEVELOPMENT AND APPROVAL OF STANDARDIZED PROCEDURE:

A. This policy will be developed and approved by authorized representatives of administration, medicine, and nursing.

B. This standardized procedure will be reviewed and approved every three years.

Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.

• 3-years recent (within the past 5 years) full-time equivalent experience in the operating room, including both the scrub and circulating roles.


• Nationally certified operating room nurse through the Association of Operating Room Nurses (AORN) or an accredited program.


• Successful completion of a structured RNFA course and completion of 20 hours or 10 cases of proctoring by the sponsoring surgeon.

• Registered Nurse License (California)

• Basic Life Support

• Advanced Cardiac Life Support

• N/A