Patient’s Name PIN

Patient Identifier Sticker

Date of Birth Age Sex

ADDENDUM FOR SIGN IN PHASE OF PERIOPERATIVE AND PERIPROCEDURAL

FLOWSHEETS DURING COVID-19 PANDEMIC
Patient Safety
SIGN IN

□ Patient wears acceptable face mask

□ Patient signed the Consent for Elective Surgery/ Proce- Check Anesthesia Preparation Checklist (for possible intuba-
dure during Pandemic tion), check equipment:
□ Patient is confirmed COVID-19 □ Facemask + Bag-Valve-Mask + HEPA filter
□ YES □ NO □ Oropharyngeal airway
□ Screening test done: □ Yankauer Suction
□ Videolaryngoscope
□ RT-PCR Test result checked □ N/A □ Bougie
Result: _______________
Date Done: _______________ □ ETT x 2
□ Serological / Rapid Test □ N/A □ EtCO2 confirmatory method
Result: ______________ □ Prepare required drugs which will be brought inside the room
Date Done: ______________ □ Induction agents
□ Chest X-ray result checked □ N/A □ Emergency (hemodynamic support)
Result:_____________
Date Done: _______________ □ Maintenance (sedation, hemodynamic support)
□ Confirm which supplies & drugs will remain outside the
□ Validated Health Declaration Form
room
□ Others:____________________________ □ Prepare how you will dispose of used items (2x bags: clean
and dirty contaminated bags)
□ Available tray for contaminated items
□ Ensure that only identified and screened essential per-
sonnel are inside the OR/DR/Procedure Area before □ Other requested item:
the start of the procedure. ______________________________
_______________________
□ All surgical/healthcare team in the OR/procedure
room remove personal items (pens, mobile phones,
ID badges) prior to wearing of PPE.
□ Properly don required PPE for confirmed/probable/
suspected COVID-19 patient:
□ Shoe/leg covers Anesthesia Induction □ N/A
□ Cover all (bunny suit) Prepare
Appropriate mask type: □ Apply standard ASA monitors
□ Tie-on Type Surgical Face Mask
□ N95 Mask □ Check for working IV access
□ FFP3 Mask □ Ensure HEPA Filter is between anesthesia bag & bag-
□ PAPR (properly checked for function) valve mask/ anesthesia circuit bag
□ Level 3 Gown
□ Bouffant Head Cover Preoxygenate
□ Eye Protection (Goggles/Face Shield) □ Optimize position
□ Double Gloves □ 5min or until target EtO2 reached (as defined by airway
□ Buddy/mirror check
team)
Perform RSI
□ Rapid administration of induction drugs and flush
Ensure availability of facility/medical equipment/ If difficulty intubating, follow difficult airway plan below:
instrument:
□ Connect ETT to anesthesia circuit
□ PPE Donning and Doffing Area □ Inflate cuff BEFORE applying PPV
□ OR Theater □ Confirm intubation via EtCO2 (avoid auscultation)
□ Procedure Room □ Secure ETT
□ Negative Pressure
□ Isolation Room
□ HEPA Filter (if required)
□ Notification sign on door
□ Remove non-essential equipment
□ Patient’s chart placed outside the room
□ Waste bins for contaminated items __________________________
□ Availability of medical equipment/ instrument Performing Physician
□ E-cart: □ Regular □ COVID-19 dedicated Signature over Printed Name/Date & Time
□ A-Cart: □ Regular □ COVID-19 dedicated
□ Ventilator: □ Regular □ COVID-19 dedicated
□ Aerosol Box with clear impermeable (plastic)
disposable drape ____________________________
□ Alcohol/disinfecting solution Circulating Nurse/Healthcare Professional
□ Others:____________________________
Signature over Printed Name / Date & Time

*IF with anesthesia/sedation

If patient is for possible intubation, the following shall be ____________________________
observed to reduce exposure: Anesthesiologist
□ Only necessary personnel in the OR during intuba-
tion: Signature over Printed Name/ Date & Time
Maximum of three (3) personnel inside the OR
Theater:
- 1st intubator (Anesthesiologist or Airway Team
Member)
- 2nd intubator (if required)
- 1 RN
- 1 Runner (outside the room)
□ N/A

SLMC-IPC-5-170 (October 9, 2020)