Cardiovascular Operating Room Circulate/Scrub (CVO Checklist

WORK SETTING EXPERIENCE

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Inpatient Acute Care Facility
Trauma Center
Academic/Teaching Facility
Outpatient Care Facility
Long term care/Skilled Nursing
Clinic/Ambulatory
Home Health Setting

GENERAL SKILLS EXPERIENCE

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Awareness of HCAHPS
Cardiac arrest / adult CPR
Cardiac arrest / infant-child CPR
Advanced directives
Patient / family teaching
Lift / transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care / palliative care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medication administration
Diabetic management in the OR
National Patient Safety Goals
Accurate patient identification
Effective communication
Time out protocol
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Monitoring conscious sedation
Sedation / Anesthesia
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers

CARDIAC EXPERIENCE: CIRCULATE

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
DaVinci Procedures
Aortic Valve Replacement
Mitral Valve Repair/Replacement
Multiple Valve Transposition
Coronary Artery By Pass
Pericardial Window
Septal Defects
Ventricular aneurysm repair
Intra-Aortic Ballon insertion
Bring Back Heart
Aortic Arch Replacement
Aortic Valve Conduit
Thoraco Approach Mid-Cab
Heartport or Similar CABG
Mechanical Heart/ LVAD
Chamberlain Procedure
Femoral Artery Cannulation
Gastric Artery Harvest
Endoscopic Vein Harvest
Saphenous Vein Harvest
AICD Insertion
Radial Vein Harvest
Pacemaker Insertion
AV Shunt
Femoral-Popliteal By-Pass Graf
Thrombectomy
Abdominal Aortic Aneurysm
Carotid Endarterectomy
Pediatric Hearts
Tetrology of Fallot
Organ procurement

CARDIAC EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
DaVinci Procedures
Aortic Valve Replacement
Mitral Valve Repair/Replacement
Multiple Valve Transposition
Coronary Artery By Pass
Pericardial Window
Septal Defects
Ventricular aneurysm repair
Intra-Aortic Ballon insertion
Bring Back Heart
Aortic Arch Replacement
Thoraco Approach Mid-Cab
Heartport or Similar CABG
Mechanical Heart/ LVAD
Chamberlain Procedure
Femoral Artery Cannulation
Gastric Artery Harvest
Endoscopic Vein Harvest
Saphenous Vein Harvest
AICD Insertion
Radial Vein Harvest
Pacemaker Insertion
AV Shunt
Femoral-Popliteal By-Pass Graf
Thrombectomy
Abdominal Aortic Aneurysm
Carotid Endarterectomy
Pediatric Hearts
Tetrology of Fallot
Organ procurement

VASCULAR EXPERIENCE: CIRCULATE

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Carotid Endarterectomy
Abdominal Aoric Aneurysm
Femoral-Popliteal By-Pass Graft (Insitu)
AV Shunt
Portacath, Tesio, Hickman
Femoral-Popliteal By-Pass Graft (Graph)
Thrombecomy
Pacemaker Insertion
Arterial Stenting
Subclavian/Carotid By-Pass
Intra-Operative Angioplasty

VASCULAR EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Carotid Endarterectomy
Abdominal Aoric Aneurysm
Femoral-Popliteal By-Pass Graft (Insitu)
AV Shunt
Portacath, Tesio, Hickman
Femoral-Popliteal By-Pass Graft (Graph)
Thrombecomy
Pacemaker Insertion
Arterial Stenting
Subclavian/Carotid By-Pass
Intra-Operative Angioplasty

THORACIC CARDIOVASCULAR EXPERIENCE: CIRCULATE

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Abdominal Aortic Aneurysm
Aortic-Femoral Bypass Graft
Thoracotomy
Thoracoscopy
Mediastinoscopy
Lobectomy
Carotid Endarterectomy
AV Shunt/Graft

THORACIC CARDIOVASCULAR EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Abdominal Aortic Aneurysm
Aortic-Femoral Bypass Graft
Thoracotomy
Thoracoscopy
Mediastinoscopy
Lobectomy
Carotid Endarterectomy
AV Shunt/Graft

CIRCULATE/SCRUB: AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Newborn / neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (ages 2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescent (ages 13-21 years)
Young adult (ages 22-39 years)
Adult (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)

MEDICATION ADMINISTRATION:

Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision 3) Able to function independently *
Preparation and administration of emergency (ACLS) medications
Inotropic: (digoxin, dopamine, epinephrine)
Antiarrhythmics
Beta Blockers
Fibrinolytics
Antianginals (isordil/nitrates)
Antihypertensives
Antilipemic: statins
Anticoagulation medications
Diuretics