OPERATING THEATRE DESIGN AND ADMINISTRATION

This section will briefly deal with the design, layout, work flow and administrative responsibilities of the Operating Theatre (OT) Manager. The OT team works closely together with the surgeons, nurses and OT technicians. Therefore the work and relaxation areas for staff are well demarcated yet accessible from the outside if required.

There is a separate clean area for the entry of surgical instruments and other equipment, and there is a demarcated area for used or soiled surgical instruments to be rinsed before sending to the Central Sterile Services Department (CSSD). The layout accommodates the arrival of patients and the recovery area post operatively.

1.1 Layout and Design

Theatre managers, infection control team, surgeons and anaesthesiologists are involved in the planning of the theatre design/layout. The operating theatre suite is a purposely built independent complex located away from the main flow of traffic but it is in an area easily accessible to the critical care, surgical and maternity wards and the supporting service departments, e.g. CSSD, laboratory and X-ray departments. The operating theatre should has an independent air handling unit with controlled ventilation such that the lay-up room and the OT table is under positive pressure and has the most Air Changes per Hour (ACH) i.e. 20-24. The traffic within the operating suite is controlled. It only allows access to staff, patients and equipment from different entrances and exits. There is no thoroughfare through the OT.

1.1.1 Walls and Ceilings

All surface materials are hard, nonporous, fire resistant, waterproof, stain proof, seamless and easy to clean. In addition the corners of the walls and the floor are coved (round) and smooth for easy cleaning. Washable paint for the walls is present in OT complex 2 and metallic sheet coated walls are present in OT complex 1 both of them withstand a daily washing programme. Tiles are not used in walls. . The walls and ceiling are used to mount essential devices and equipment to reduce crowding of the floor area. Thus these walls are solid and robust enough to carry the weight of equipment. The ceiling has pendulum devices for outlets for oxygen and other medical gases and vacuum. There is no scavenging system in OT. There are multiple electric outlets on the walls and on pendulum for purpose of electronic devices in OT.

1.1.2 Floors

Floors are smooth, without cracks and breaks, made of materials that reduce static and does not endanger the safety of personnel. The surface of the floor provides a path of moderate electrical conductivity between all persons and equipment making contact with the floor to prevent the accumulation of dangerous electrostatic charges. The floor coverings are as per the recommendations and are easy to clean. The floor covering is curved up the wall to 2.5 cm, thus ensuring that edges are coved and easier to clean than right angled floors. The floor surface is suitably hard, nonporous and appropriate for frequent cleaning and there are no cracks. The floors have a nonslip surface, to prevent staff from slipping and injuring themselves. When floors are being cleaned, a warning sign “wet floor” are put up to warn the personnel.

1.1.3 Doors

Sliding doors are used in OT complex 2 and swing doors (self-closing) are used in the OT Complex 1. This is essential during an operation because the microbial count in the air rises every time doors swing open from either direction. There is a clear glass viewing window in the door to prevent frequent opening and closing of the door. Entrances of the OT doors have air curtains to balance the airflows at various places.

1.1.4 Lighting

Most OT lights are white fluorescent as they cast minimal shadow. Lighting is evenly distributed throughout the room. The anaesthesiologist also has sufficient light.

The overhead operating light:

1. Is near daylight in colour and free of shadow
2. Gives contrast to the depth and relationship of all anatomic structures. The light is equipped with an intensity control mechanism. The surgeon may ask for more light when needed therefore a reserve light is available (e.g. a mobile operation light).
3. Is freely adjustable to any position or angle. Overhead operating lights are ceiling mounted on mobile fixtures. It can be positioned so that light is directed into a single incision or two concurrent operative sites.
4. Is spark-proof where anaesthetic gases are used.
5. Produces minimum heat to prevent injury to exposed tissues, to ensure the comfort of the sterile team, and to minimize airborne micro-organisms.
6. Can be easily cleaned.

Tracks recessed within the ceiling virtually eliminate dust accumulation. Operation theatre has a generator back up in case of power failure. In case one of the bulbs is not working, it is replaced as soon as possible, to provide sufficient lighting at all times during an operation.

1.1.5 Ventilation

The ventilating system in the OT is mechanical ventilation, supplied from an independent air handling unit (AHU) which ensures a controlled, filtered, clean air supply. Air changes and circulation provide fresh air and prevent accumulation of anaesthetic gases in the room.

1.1.5.1 Types of Operating Theatres

We have a central air conditioning in all the theatres. Ventilation in all OTs is the ultra-clean or laminar flow OT. Here, 80% of extremely clean air is re-circulated via a canopy above the operating area, and this unidirectional airflow can be up to 300 m/s (meters per second) forming a curtain of air. . Wall mounted or floor standing air conditioners are not used for providing clean air in a sterile environment as they only cool the air and are strongly discouraged. The filters clog up easily with dust which comes in directly from the outside and need frequent changing. They do not remove stale air from the OT which increases the risk of infection.

1.1.6 Air Flows

In the OT there is always a positive pressure which enters the OT suite in the preparation or layup room, to ensure safety of the surgical instruments when the trolleys are being laid up for surgical procedures. The Layup and OTs have the highest positive air pressure which flows outwards to the scrub areas, and sub-sterile rooms. Positive pressure forces air out of the room. Air-conditioning units may be a source of micro-organisms that pass through the filters. These are changed at regular intervals to prevent this and the ducts must be cleaned regularly according to the manufacturer’s recommendations.

1.1.7 Temperature and Humidity

The temperature is maintained at 21 +/- 3 degrees Celsius inside the OT all the time with corresponding relative humidity between 50 to 60%. Appropriate devices to monitor and display these conditions inside the OT are installed. Moisture provides a relatively conductive medium, allowing static to leak to earth as fast as it is generated. Sparks form more readily with low humidity and fires are a potential hazard.

1.1.8 Gas Scavenging System for Anaesthetic Explosive Gases

There is no gas scavenging system in OT. . Page

1.2Administration in the Operating Theatre

1.2.1 The Operating List

The nurse in charge of the OT has the sole responsibility of managing all the activities of the OT. The activities include among others the theatre lists and communication with the surgeons in case of changes in the operation list. The nurse in charge of the OT has given all the necessary support to correctly execute his/her responsibilities regarding theatre activities. There is a written operation list for all elective cases. This helps the OT staff to adequately prepare for the surgical procedures.

The following is followed:

 The operation list is sent by 3 pm on the day before the operation.

 The operation list is handed in physically and NOT telephonically.

 The name and designation of the Doctor who compiled the theatre list is be clearly indicated.

 The surgeon discusses the operation list in co-operation with the OT nursein-charge and OT in charge (HOD/professor anaesthesia).

 The operation list does not exceed the permitted time allocated to it. Note: this does not refer to the time during an operation of an individual patient)

 The operation list is put on a notice board near the patient’s admission/ entrance to the OT.

1.2.1.1 Facts that are taken into consideration when operations are booked

 The age of the patient plays an important role, for example an infant or a small child is not placed at the end of a list. The same applies to the elderly person.

 Types of operations – major operations e.g. laparotomy are always booked at the beginning of the operation list.

 A diagnosed abscess or in case of doubt/uncertainty, the operation is preferably done at the end of the slate.

 Emergency cases such as acute abdomen and caesarean section should always be considered a priority.

 Patients with a state of disease such as Diabetes Mellitus are not starved for long periods as they patient may become comatose.

 Abbreviations are avoided e.g. D&C (dilatation and curettage) as abbreviations may cause confusion to personnel. 

1.2.1.2 Particulars that Appear on the Operating List

 The time, day, and date when the operation will be performed.

 Full names, surname, gender, age as well as the form of address e.g. Mr. Mrs or Miss.

 The name of the ward in which the patient lies, as well as the sex e.g. male or female.

 A clear description of the type of operation to be performed. When an operation is to be performed on an extremity, or inguinal hernia repair, it is clearly indicated which side e.g. left or right, and it is checked with the patient as well. This is important to prevent an operation being performed on the wrong side or the wrong operation.

 The scheduled sequence for the operations appears on the list. If the surgeon decides to do a patient earlier or later on the scheduled list or cancel an operation, the OT nurse is informs the nurse in the particular ward of the change on the operating list immediately.

 The name of the surgeon appears on the operation list.  It is indicated whether it is major or minor case.

1.2.2 The Registers Used in the Operating Theatres

Different registers are used in the OT, namely:

1. Operation registers

2. Register regarding abortions and pregnancy residues

3. Poison drug register

4. Specimen register for biopsies

5. Death register

1.2.2.1 Operating Register

Every operation done in the OT, whether under general or local anaesthesia, is recorded in the operation register. The operating register is a legal document, so are the operating slips, and both are stored in the section for enquiry as well as for statistical purposes for at least five years. . All the information and particulars of the patient which appear on the operating slip are complete and in detail and are recorded in the operating register:

 The patient’s full names and surname

 Registration number and age

 Ward in which the patient is admitted

 Full description of the operation performed

 Initials and surname of anaesthesiologist

 Type of anaesthesia given

 Name of scrub nurse, as well as the amount of specimens sent to the laboratory

 Indicate whether the patient is male or female

 Indicate whether the patient underwent major or minor surgery

 Duration of the operation It is every nurse’s responsibility to record his/her operation slips of the day’s operations, for which s/he acted as scrub nurse, in the operating register and to sign next to it.

The scrub nurse who counted the swabs mandatorily signs the register daily before s/he goes off duty. The monthly statistics are kept up to date Every new month’s operations are started on a new page with the relevant month written on top of the page. These slips are kept in the section and in a special storing or filling area. If a patient goes into cardiac arrest in the theatre or dies on the operating table, this information is recorded in red in the operation register.

1.2.2.2. Register regarding Abortions and Pregnancy Residues

Operations like abortion or the removal of pregnancy residues are separately recorded with the particulars of such an operation. There is a special register for the purpose of abortions and the removal of pregnancy residues. . PThe register and other relevant documents are kept for at least five years.

The register has the following information:

 Name and surname of patient

 Registration number

 Age/ marital status/ nationality

 Name and surname of the doctor who referred the patient

 Name of the assistant surgeon if applicable

 Description of the operation being performed

 Name and surname of the anaesthesiologist

 Type of anaesthesia used Monthly statistics are kept up to date.

The special form for the notification of the operation pertaining to an abortion and the removal of pregnancy residues is completed in duplicate. The original forms on a monthly basis are sent to the medical superintendent’s office for cognizance. The duplicate remains in the theatre and are filed.

1.2.2.3 Poison drug Register

A variety of medicines are used in the theatre, especially for the administering of anaesthesia. We maintain a strict control of all the different medicines, as well as proper recording into registers. Schedule 3 and 4 and Schedule 4 medicines are not stored in the same poison cupboard, but in separate cupboards, which are clearly marked “Poison Schedule 5”.

 The poison cupboards are in a proper place and must be wall-mounted

 The poison cupboards have a double lock and the keys are kept by the nurse in charge

 The keys are not be given to any unauthorized person or left in drawers The poison drug register is checked once a week by the nurse in-charge /pharmacist of that section. This register is kept for at least five years.

1.2.2.4 Specimen Register for biopsies

For efficient control over specimens, there is a book/ register in which all specimens are recorded, with the same information as on the label. A space is made available for the signature of the person who recorded the specimen into the book/ register, as well as the signature of the person who received the specimen at the laboratory.

 The specimen are clearly marked with the following information on the label: o The name and surname of the patient o The registration number o The ward in which the patient is placed o The type of specimen o The name of the operation o The date and time when the specimen was taken o The required laboratory test o The name of the surgeon

 At the end of the day’s operating schedule the nurse checks all specimens with the entries in the book/ register

 A reliable person, for example the porter, then takes the specimens and the book/ register to the laboratory and the person who receives them at the laboratory signs the specimen book in the space provided for this purpose

 In the space provided on the operating slip it is recorded that the specimen was sent to the laboratory. This information is also recorded in the operation register

 Every specimen carries the correct information to prevent a mix-up of specimen which may lead to a faulty diagnosis and treatment

1.2.2.5 Death Register

There is no separate death register for OTs. Operation register is used to enter the event of death with red ink.

12 1.3. Visitors to the Operating Theatre

1.3.1 Introduction

The main objective of medical staff of OTs remains the creation of a safe environment, conducive to healing, and the protection of patient privacy and integrity. Allowing unauthorized people into this environment will violate this responsibility. The anaesthetized patient depends on the care giver to protect him/her against such intrusion of privacy, not authorized by him/her. 1.3.2 Definition Visitors to the OT include all people not forming part of the medical and nursing team allocated to the specific procedure at the allocated time.

1.3.2.1 Objectives

 To protect the patients privacy;

 To restrain the entering of unauthorized people into the OT;

 To ensure that the patient has given informed consent for the presence of the visitor;

 To establish a guideline for visitors to the OT.

2.3.2.2 Recommendations regarding Visitors to the Operating Theatre

Medical representatives are only allowed into the OT if they are there to demonstrate operating equipment, medical devices or loan instruments. All medical representatives (for example sales representatives of medical equipment/devices and pharmaceutical products) report to the theatre manager for permission to enter the OT.

a) Medical representatives enter the sterile field only after they have gowned and gloved correctly under the supervision of scrub nurse

b) The medical representatives enter the OT on the scrub nurse instructions after the patient has been cleaned and draped

c) The medical representatives are informed of areas where they may enter and attend to the procedure.

d) Medical representatives guides and advises the scrub nurse and surgeon on use, assembling and sequence of use of instruments and implants but does not work directly with the patient

e) Family members are not allowed to watch or be present at any surgical procedure

f) A mentor accompanies medical students and the level of study is determined prior to entering the OT

1.3.2.3. During a Caesarean Section

If the father requests to be present during the procedure: At present we do not allow father to enter OT during caesarean section

1.3.2.4. Parents

 Parents accompanies young children only till OT waiting area

 Parents do not enter the OT