West Los Angeles Veterans Administration Healthcare Center - Orthopaedic Surgery
Surgery scheduling. Patients scheduled for surgery in the clinic should be booked for surgery when appropriate. Discuss the case with the attending staff surgeon. Patients who will require medical clearance prior to surgery should not be booked before they have been cleared. Give the name of the patient to the Case manager (Angie Majaducon). Send a consult to the patient's Primary care provider to request for clearance. Document in CPRS why medical clearance is needed. A patient ready to be booked for surgery should be scheduled in DHCP and recorded in the "Ortho OR Book" in the clinic. Notify the case manager of every case scheduled.
Surgical patients with non-orthopaedic problems. If there is another problem that needs to be addressed by another service it is helpful to contact them in advance of the surgery. Recent examples have included patients who needed management of anticoagulation, Greenfield filter placement, urology assistance in placing catheter due to history of stricture or prior surgery, management of ongoing use of steroids, etc. Back to Top
Autologous blood donation. The request should be signed, dated and witnessed. The patient should schedule donation with the blood bank. Back to Top
Special Surgical Instrumentation. In requesting surgery, special instrumentation must be indicated. Request special instrumentation by completing an OR resource form and submit it to case manager.
All implants, surgical supplies, and instrument trays have to be in SPD 48 hours prior to surgery to comply with Veterans Administration requirements for sterility testing. Please request implants and equipment loans to allow for this requirement. Back to Top
Arthroplasty cases, special requirements. Order sufficient specific orthopaedic x-rays that will be needed for surgical planning. Consider the need to assess leg lengths, alignment, and for templating. An internal rotation AP hip x-ray is helpful for hip arthroplasty surgery planning. The patient should be referred to PM&RS, Physical Therapy, and Occupational Therapy, for PRE-OP teaching and evaluation. Dental and urological needs should be addressed, and treatment completed prior to surgery. Patients should see their dentist once surgery is being considered so that all dental work is completed and healed prior to surgery. Patients with metal allergy or sensitivity may not be candidates for use of cobalt chromium prostheses, and titanium or ceramic components may be a better choice. The patient must have sufficient help and satisfactory living conditions arranged for the recovery period. It would not be safe to perform an arthroplasty patient on a homeless person with no place to go after discharge, or on someone who lived alone and would be unable to care for himself. The patient should be instructed to be NPO, to discontinue NSAIDS or aspirin, discontinue herbals and supplements, change DM management etc. as medically indicated. Consider the ongoing medications in light of need to be NPO. Medical team involvement is sometimes helpful with these questions. Patients with marked deformity, such as a valgus knee alignment, 20 degrees or more of knee varus, patients who are younger than 65 years old, patients who have complex accompanying deficit such as prior knee fusion, patellectomy, or disruption of the extensor mechanism are appropriate for a staff subspecialist (such as Dr. Bert Thomas) to be the attending physician. Dr. Eric Johnson is available for complex hip arthroplasty revision surgery. Back to Top
Spinal fusion surgery and ACL reconstruction surgery. The patient should be referred to PM&RS, Physical Therapy, and Occupational Therapy, for pre-op teaching and evaluation. Patients whose brace and equipment needs can be anticipated in advance should have these items ordered from prosthetics at the time the case is scheduled, to request they be available at the time of surgery. Back to Top
Spinal surgery requiring the use of the microscope. The orthopaedic service has priority for use of the scope on the 2nd and 4th Friday each month, the neurosurgery service on the 1st, 3rd, and 5th Friday each month. Please schedule your cases accordingly. Back to Top
Arthroplasty Surgery and post-op PT. After elective arthroplasty surgery the PT and OT can begin on POD#1 if there is a progress note with documentation of the need for therapy, and weight bearing status that is printed to the PT printer, NE158. There are two Saturday inpatient PT slots reserved for patients who have had orthopaedic surgery. Back to Top
Arthroplasty Surgery, Hip Fracture, and other patients who have been ordered DVT prophylaxis with Coumadin, who are discharged prior to completion of their course and who cannot have their INR monitored after discharge, should be switched to Lovenox 30mg injected BID. (Typically patients who live outside of the area of our VA lab cannot get daily INR and daily dosing). Back to Top
Day Surgery and PT. If PT is notified in advance of outpatient surgeries, a therapist can be available for crutch training, etc. when needed. Back to Top
Procedures requiring informed consent. These include arthrocentesis, all central lines, and of course surgical procedures. The VA policy is available at http://vha22cfp1/GlaPoliciesMXv2/code/Documents/Public/00-EI-04/00-EI-04.htm. Back to Top
Case Manager. Angie Majaducon is the outpatient orthopaedic case manager. The chief resident should keep her informed of surgeries scheduled and cancelled. Ask for the procedure for add on, urgent, and inpatient surgery. The case manager can help expedite scheduling of surgery. Cherrie Katayama is the inpatient orthopaedic case manager. She can help coordinate delivery of braces and equipment, and with discharge planning. Back to Top
Operative note. Operative notes should be dictated the day of surgery, and a brief chart note also written. Please select the title ”OPERATIVE <ORTHOPEDIC OPERATIVE NOTE>" in CPRS. Please record the dictation confirmation # in the log book in the OR and in your brief chart note. Back to Top
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