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OPERATION THEATRE MANAGEMENT

PAPER-402
Ms. SUSMITA BHAUMIK
An OT is that specialised facility of the hospital
where life saving or life improving procedures are
carried out on human body by invasive methods under
strict aseptic conditions in a controlled environment
by specially trained personnel to promote healing and
cure with maximum safety, comfort and economy
Function

Operating theaters had a raised table or chair of some sort at the center
for performing operations, and were surrounded by several rows of seats
(operating theaters could be cramped or spacious) so students and other
spectators could observe the case in progress.

The surgeon wore his street clothes with an apron to protect them from
blood stains, and he operated bare-handed with unsterile instruments and
supplies. (Gut and silk sutures were sold as open strands with reusable,
hand-threaded needles; packing gauze was made of sweepings from the
floors of cotton mills.)

In contrast to today's concept of surgery as a


profession that emphasizes cleanliness and conscientiousness, at the
beginning of the 20th century the mark of a busy and successful surgeon
was the profusion of blood and fluids on his clothes.
OPERATION THEATRE
The operating theatre is based on whole system thinking and includes a whole of hospital
perspective on effective and efficient theatre utilisation.

Goals
Key elements to efficient use of operating theatres are:
• Effective management
• Good communication
• Well trained staff
• Appropriate facilities and equipment
• Operational layout that allows flow of patients.

Support services play a large part in maximising efficiency by providing:


• Pre-operative preparation and assessment
• Available beds
• Sterile theatre equipment
• Portering, cleaning and maintenance staff.

•Effective planning and scheduling systems will enable smooth patient flow thus
increasing capacity, improving patient and carer experience, improved employee
satisfaction and morale
The operation theatre complex consists of four main systems,
•Surgical support system (the environment)
•Traffic and commerce (the activities)
•Communication and information (the records)
•Administration ( the management)
ADMINISTRATION
Overview and strategy

Key elements Planning patient


Theatre pathways
Management
structure

Staffing
Postponements

Operating list
management
Trauma and
emergencies Effective use
of theatre time

Theatre design
Theatre management structure

Theatre management structure should be clearly defined with


accountability for:
•Full budgetary authority
•Adequate sessional allowance
•Information systems
•Utilisation
•Administrative, medical and nursing staff.

Day to day management should be provided by an experienced trained and skilled


theatre manager, who is responsible for clear communication, ensuring competent
staffing and suitable equipping of all theatres.
 
Suitable systems for planning activity should be available to allow allocation of
staff, and to respond safely and flexibly when changes take place to routines.
 
Policies should be developed to deal effectively with changes to operating lists.
Operating lists should be clearly posted well in advance and in suitable locations.
 
Theatre management team should regularly review utilisation, cancellations,
list overruns, late starts and waiting lists.
Planning patients pathways

Patients pathways should take into account ways to maximise


use of theatres and bed availability.
Patients admitted to pre-operative units can be transferred to
wards following surgery allowing time for discharge of previous
patients.

Integration of pre-operative assessment and day case recovery


area located adjacent to theatres provides an efficient use of
space, skilled staff and may aid patient transport to and from
theatres. This scheme also reduces time on ward rounds for
surgeons and anaesthetist as patients are in one place.
Staffing
Department should provide a system of staffing that works locally
and is acceptable to staff
•Department staffing should match clinical activity, with sufficient
cover for elective and emergencies
A lead anaesthetic consultant should be identified to support the
theatre management team and trainees
•Adequate orientation of new or locum staff should be made a
priority
•Adequate staffing should be available to cover governance
tasks of note recording and data entry.
Operating list management

• Close communication and coordination between pre-op area and theatre


using agreed procedures is essential
• A nominated person should liaise with wards and transport staff from
theatres
• A suitable holding area staffed and equipped will assist with smooth flow
• Agreement should be made for preparation and transport of patients to
and from theatres
• Policies on fasting, anticoagulation, shaving, dentures, jewellery,
appropriate underwear and removal of make-up should be developed
• Units should agree the level of training needed to escort patients to and
from theatres
• A documented system of handover and identification of patient should be
in place
• A system to book critical care beds for elective admissions should be in
place and booking confirmed before anaesthesia for surgery.
Theatre design and operational layout

Design of operating theatres is essential for maximising patient flow,


consideration needs to be made for:

• Large multi-purpose accommodation to enable increase in complexity


and equipment
• Transport routes that flow through stages of theatre care
• Internal communication IT systems that facilitate appropriate
communication and supervision.
Trauma and emergency surgery
Effective planning for emergency and trauma surgery is needed to prevent
cancellation of elective surgery.
Provision of exclusive emergency list will assist in preventing cancelled
elective surgery.
Good communication enables clinical decisions to be made rapidly, increasing
the number of surgical procedures carried out in a safe time and environment.
Time should be allowed for the Anaesthetist to assess emergency patients to
their satisfaction.

Experienced surgical staff should prepare patients who have multiple and
complex medical problems, this can prevent cancellation at anaesthetic
assessment.

Pre-operative assessment for patients who are elderly, have multiple and
complex medical problems can benefit from a team approach between
anaesthetist, surgeon and physician.
Cancellations of surgery

It is extremely distressing and stressful to patients who are postponed


surgery, many cancellations can be prevented by assisting patient flow with
good planning in:

• Pre-operative assessment
• Increased communication

Regular review of cancellation can assist with target areas for redesign and
innovation.

Cancellation data should be collected and reviewed weekly with agreed


action plans.
It is essential for operating theatre innovation to have a skilled, trained
and committed innovation team.The team should consist of
representatives of all theatre staff groups.

Management – clinical/non clinical


Nursing – Pre op and theatres, including operating department
practitioners
Clinical – Anaesthetist/Surgeons
Administration – Admin and Portering
Processes

Initial recording of overall patient processes should be made covering:

Receive patient to
Admission
ward following operation

Administration Processes will also need to map demonstrating


process from:

Allocation to Theatre reception


theatre list on day of operation
Processes

Process map groups

Theatre Theatre Bed ICU Theatre

Recovery Recovery Theatre Theatre ICU

Home Bed HDU/ITU ICU Bed

Home Bed Bed Home

Home Home
Scheduling

The realistic building of theatre lists start in processes outside of theatre


environment, essential validation of how ‘lists’ are made needs to be
undertaken to maintain effective and efficient operating theatres.

Agreement can be made on average time per procedure to enable


effective booking of theatre lists.

Average time per operation can be agreed and used to assist building
theatre templates.
9.00 am 1 2.30pm

Case 1

Case 2

Case 3
Processes
Process steps examples

Step Time per


step (min)
Patient transported from ward 5
Patient checked in to theatre 5
Patient taken to anaesthetic 2
room
Anaesthetic given 10
Patient positioned onto theatre 5
table
Surgery completed 40
Patient taken to recovery area 5
Patient in post op 20
Patient taken to ward 5
Theatre hands over patient to 5
ward
Processes
Process steps examples
Step Time per COLOUR
step
Patient transported from ward 5
Patient checked in to theatre 5
Patient taken to anaesthetic room 2
Anaesthetic given 10
Patient positioned onto theatre table 5
Surgery completed 40
Patient taken to recovery area 5
Patient in post op 20
Patient taken to ward 5
Theatre hands over patient to ward 5
Processes
Build your schedule
Use graph paper with one square per minute to sequence time
scales per procedure.

102
1 MINUTE
MINUTES
DATA
Core data set
Suggested Measures

Late Starts (e.g. >15mins) / Early Finishes (e.g. >60mins) / Overruns (e.g. >30mins)

• Example – For ten Orthopaedic sessions with a scheduled start time of 8:30am the
sample showed four (or 40%) started >15mins late.

• Number of Major Procedures (>1hr) v Minor Procedures (<1hr) by Specialty

• Average time in theatre by specialty / procedure

• Lost time due by Cancellation reasons e.g. no beds, patient unfit

• Number of patients arriving in theatre with consents not completed by week

• Delays

• Monitor theatre delays for one week to agree on the top 10 reasons for delays. When
this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4
weeks of 10 delays have been gathered, charts will need to be produced. Time needs
to be collected against each reason(s) per day, as the top ten offenders may not
amount to the longest waste in time.
Resources
Aim: To increase the utilisation and quality of care within operating theatres.
Change Concepts

• Review operating theatre utilisation


• Scheduling
• Identify system to report delays daily via agreed criteria
• Remove delays, complexity and hand offs within administration process
• Smooth process from Emergency Department / Inpatient wards to Operating Room
and back to ward
• Review stages of Transfer from ward /Emergency Department, recovery to ward
• Review capacity and demand for emergency and elective theatre
• Review role of theatre coordinator and joint work with Pre-Operative and bed
management
• Review equipment turn around times via Central Sterilising Services Department
and booking of equipment
• Review recovery and transfer procedures – develop appropriate ‘pull’ process to
theatre/wards
PLANNING AND DESIGNING
OF OPERATION THEATRE

 PAPER-402
 MS.SUSMITA BHAUMIK
OBJECTIVES OF PLANNING
 Promote high standards of asepis
 Ensure maximum standard of safety
 Optimum utilisation of OT and staff time
 Optimize working conditions
 Patient and staff comfort in terms of thermal, acoustic and lighting
requirements
 Allow flexibility
 Facilities coordinated services
 Minimize maintenance
 Ensures functional separation of spaces
 Provide a smoothing environment
 Regulate the flow of traffic
DESIGN PARAMETERS (OPTIMAL RELATIONSHIP BETWEEN
VARIOUS FUNCTIONAL ZONES)

CIRCULATION SPACE

STAFF CHANGING
PATIENT RECEPTION
AND RESTING AND RECOVERY

CIRCULATION SPACE

THEATRE
STERILE
OPERATING SUITES
SUPPLY

CIRCULATION SPACE
DESIGN PARAMETERS
 Avoidance of unrelated hospital traffic flow
 Convenient functional flow between related departments like
ICU,ITU ETC
 Avoidance of outdoor noise
 Provision for future expansion
 Sliding doors
 Desirable floors to be smooth and non-slippery
 Ceilings to be painted with washable paints
 Taps in scrub room should be knee/elbow operated /infrared operated.
 Provisions of high speed autoclaves
 Essential pharmaceutical storage
 X-ray films illuminators
 Emergency communicators that can be activated without the use of
hand
 Toilets
PHYSICAL EVIRONMENT

 TEMPERATURE
 HUMIDITY
 VENTILATION
Areas with higher hygienic requirements for air quality.

Areas with high clean-air requirements include the operating theatre, any
sterile preparation and pre-operative areas,
sterile storage, the anesthesia and equipment storerooms and the
entrances and the exits. The highest clean-air requirements apply to the
operation area and the sterile preparation area.

With respect to air treatment, the operating theatre and a number of


adjacent areas have to comply with the provisions of the working
conditions policy regulation.
From a technical point of view, the protective effect of the air
surrounding the patient, operation team and instrument table, can be
achieved by installing a large Laminar Air Flow (LAF) device
(plenum).
This LAF device with a downflow has a surface area of 8 to 9 m2
(e.g. square or octagonal 3 x 3m, rectangular 2.8 x 3.2m).

The air velocity from the downflow plenum is 24 to 30 cm/sec and


flow temperature from the LAF device is 1 to 2°C lower than the
ambient air.
There are also possible solutions and satisfactory results in
environmental control using special LAF devices in which the supplied
air has different speeds and temperatures and which also improved the
thermal comfort of the surgical team.
In order to be able to safeguard the requisite air quality in the
operating theatre, a very large air flow is necessary. A re-
circulation downflow system can be installed for this purpose. Part
of the air from the down flow system is recirculated via fans to
the HEPA filter. (HIGH EFFICIENCY PARTICULATE AIR)

In order to be able to evaluate whether the air system, the air flow
profiles are correctly functioning, a CFD calculation is
recommended at the design stage. This also makes it possible to
ascertain whether, at a specific internal heat load, the selected
diffused air temperature and the selected air velocity will not lead to
an excessively high level of cooling in the operating theatre. This
will also reveal at an early stage any short-circuiting between air
supplied from the plenum and the site of the intake openings for air
recirculation
Assuming that the air from the HEPA filter is sterile, the only
possible emission source will be the operation team, the OT staff,
the patient, the material used and the equipment.

With respect to the sterile preparation


area with direct access to the operating theatres, a higher pressure is
recommended compared to all rooms adjacent to this area.

POSSILE AIR CLEALIESS:


The desired germ level of less than 10 colony forming units (CFU)
per m3
Air Distribution

 Turbulent or mixing air distribution system


 Downward displacement piston system
 Unidirectional air flow system (laminar flow)
Basic quality requirements for the technical facilities are:

• The surgical department has to be equipped with a mechanical


ventilation system.

•The operating theatre has to be equipped with a laminar downflow


system with a large air plenum (8 to 9 m2). Under working conditions
with operation lights switched on and the presence of the operation
team, the air supply and blast air profile are chosen in such a way that
the air does not pass through any sources of contamination before
flowing into the operation area or over the instrument table.

•There must be no windows that can be opened and outside walls


must be completely sealed.
The most important basic quality requirements concerning spatial
relationships are:

 The surgical department is independent of traffic flows in the


rest of the hospital; through traffic is not permitted through this
department.
 Airlocks physically seal a surgical department from the rest of
the hospital.
 Staff working in the operating theatre complex can move from
one ‘clean’ area to another without needing to pass through ‘non-
clean’ areas.
BASIC QUALITY REQUIREMENTS: SPATIAL NEEDS

Description of the area Min. usable area in m2

Operating theatre, general 36

Operating theatre, specific 42


(orthopaedics, cardiac surgery,
neurosurgery)

patient airlock or holding 20


area

preoperative area 15
TEMPERATURE AND HUMIDITY
 Normal person at rest (unclothed) – 240-270c with relative
humidity of 50%
 Body looses heat during anesthesia.

So,
 R.H – 45-60% recommended (adults 40% , children and infants
55%-60%)
 In UK, 200 – 220 c with R.H. 50% to 60%
 In US, 210 -24.50 c with R.H 50-60%
Other basic quality requirements

The following basic quality requirements apply to the use of equipment, operational
reliability of installations and finish in a surgical department:
 Health risks to staff such as exposure to microbiological and chemical
Contamination, and lasers and ionizing radiation can be avoided as far as
possible by drawing up guidelines and protocols.

 Operational reliability of the technical installations and an optimal indoor


environment for both patients and staff form the basis for the design
and maintenance of the mechanical engineering and electro technical installations.

 The finish of floors, walls and ceilings must be smooth, flawless or closed.

Corners and transitions between floors and walls will be rounded to prevent
accumulation of dirt. The different areas should be constructed and furnished in such
a way as to allow effective cleaning and if necessary disinfection with commonly
used cleaning agents and permitted disinfectants.
ZONING IN OT
CONSISTS of 4 zones

A. OUTERZONE - Areas for receiving


patients messengers,toilets,administrative Function

B. RESTRICTED ZONE OR CLEAN ZONE –

- Changing room
- Patient transfer area
- Stores room
- Nursing staff room
-Anaesthetist room
- Recovery room
C. ASEPTIC ZONE –

•Scrub area
•Preparation room,
•Operation theatre,
•Area for instrument packing and
sterilization.

D. DISPOSAL ZONE

Area where used equipment are cleaned


and biohazardous waste is disposed
OPERATION ROOM

3. Big enough for free circulation


4. Two openings (optional)
Towards scrub area
Towards sterile area
3.Openings fitted with swing doors.
4.Marble or polished stone flooring
5.Glaze tiled walls
6.No false ceiling
OT SHOWING TRAFFIC FLOWS
DISPOSAL

STERALIZING
DEPT

STERILE
SCRUB
PEPARATION

OPERATING ROOM

STAFF
PATIENT-OUT CHANGE

PATIENT IN
NUMBER OF OPERTING
SUITES
 Number and type of  Time allowed
a for staff
surgeons breaks
 Type of hospitals  Average time for
 Hospital policy and operations
procedure  Time allowed for
 Bed strength maintenance of OT
 Number and type of  Expected ALOS
surgery patients  Size of an average OT
 Number of operations list
per day
1. According to Rao committee

-One operation theatre for 50 surgical beds

2. American pattern

One operation theatre for 25 surgical beds

3. European countries

One operation theatre for 50 surgical beds


LOCATION

GROUND FLOOR/ TOP FLOOR/ ANYWHERE IN


THE HOSPITAL
LIGHTING IN OT
O.T. Light

Hospital furniture is important aspect owing to its specialized


design. This furniture has certain functions needed to support
patients who have decreased mobility. In such cases the specialized
design of hospital furniture serves the need of providing the required
support.

Operation theatre (OT) light comes with the following features:

• perfect
• comfortable
• Lights brilliant
• Exclusive design
• Trouble free
• Mounting is economic
Venus O.T. Lights
Shadow less Ceiling Operating light
combination that provides the superior
performance for all kinds if surgeries.
Compact, Light weight and sealed dome
made of aluminium consists of glass
diachronic reflector to provide cool, bright
and homogenous illumination.

OT Lights are made to spot light the


operation table area. They illuminate the area
to the right level of brightness with effective
heat absorbing and color correcting provided
for cool, white and brilliant light field for
operational convenience
WORKFLOW
2. Singe corridor system

4. Double corridor system

• disposal traffic

• Patient and disposal traffic

• Patient and staff traffic


EQUIPMENT PLANNING
The most efficient type of operating suite in terms of maximum utilisation of resources as
well as the most cost-effective, will display the following characteristics:
2. It will be without a separate anesthetic room
3. It will have shared scrub facilities between theatres
4. It will have a disposal bay or room servicing two theatres
5. It will have a centrally located supply room servicing a no. of theatres
FURNITURES & GADGETS
• Special fixtures: anesthesia cabinet, instrument storage cabinet, scrub station, x-ray
viewing, writing board, inter-communication.
• Special furniture: instrument trolley, bowl stand, infusion stand, step stair, disposal bag
holder, stool, endoscopes,
• CCTV
• Assembly tables, sterilization equipments, patient monitoring and resuscitation
equipments
• Medical gases
• Anesthesia equipments
THANK YOU