Section 250.1305  Visitors in Operating Room

a)         No lay visitor shall be given access to the operating rooms during surgery.

b)         Only individuals in the categories authorized herein and individuals authorized in accordance with hospital policy shall be allowed access to the operating rooms during surgery. Individuals authorized herein shall be members of the medical staff, persons covered by Section 250.310(a)(14), persons employed by the hospital and assigned to the operating room, and persons participating in residency or clinical training programs approved by the Department of Financial and Professional Regulation under the Medical Practice Act of 1987.

c)         Where hospital policy approved by the Governing Board permits other persons to be in attendance in the operating room during surgery, the policy shall provide for the screening of such persons to ensure the necessity of their presence, such as documentation that they have appropriate licensure, qualifications or competence and that the person performing the procedure, the patient's attending physician and the chairman of the department of surgery in departmentalized hospitals have agreed to allow such access. These individuals shall follow the requirements set forth in Section 250.1300.

d)         The presence of a parent or guardian, or other designated individual selected by a child's parent or guardian, may be allowed in the operating room during the induction of anesthesia on an individual who is 12 years of age or younger and for a mentally disabled adult, at the discretion of the hospital if the hospital has first adopted a policy on the matter, approved by the Governing Board. The policy shall include, but not be limited to, the following conditions:

1)         Written consent of the parent, guardian or other designated individual, the anesthesia provider, and the physician performing the surgery;

2)         Notation in the patient's medical record of the presence of the additional person in the operating room during the induction of anesthesia;

3)         Application of safeguards against the introduction of infection or other hazards by the parent, guardian or other designated individual, including orientation, education and training of the person prior to performance of the procedure; this shall include, at a minimum, specifics regarding the procedure and what can be expected, basic infection control practices expected of the person, and instruction that the person must leave the operating room after the induction of anesthesia is completed;

4)         Requirements that the parent, guardian, or other designated individual wear a mask, cover all head and facial hair and don hospital laundered scrub attire or a single-use coverall suit designed to totally cover outside apparel;

5)         Provision of at least one additional staff person in the operating room assigned to oversee, supervise and assist the parent, guardian or other designated individual for the period of time the parent, guardian or other designated individual is present; and

6)         If, at any point during the induction of the anesthesia, the physician performing the surgery or the attending anesthesia provider determines that the parent, guardian or other designated individual poses a threat to the safe completion of the induction of the anesthesia, he or she may require the parent, guardian or other designated individual to leave the operating room.

(Source:  Amended at 34 Ill. Reg. 19031, effective November 17, 2010)