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Operation Theater Policies and Procedures Manual
Operation Theater Policies and Procedures Manual
by date
Dr Prakash Kini
Document
Sakamma ( Group Medical Dr K.P.Das New Policy &
.No. HWP- 10.1 28st of
( OT Director), (Group Procedure
3/13, points April 2013
Incharge) Dr Raghavendra Hallur Advisor)
V- 1.0
(Asst Quality Manager)
The operation theatre also called as operating room (OR) is a very important
high risk area in the hospital; It is also a high cost area which demands its
proper utilization.
Infection control practices and Quality Assurance activities of the OT have a
vital role in the quality of services provided in the hospital.
Operating theatre complex is one of the important high risk areas in the
hospital.
The complex involves the patient receiving zone, the preoperative area,
operative rooms, the dirty corridor, the clean and dirty utility rooms.
3. Sterile zone:
zone this area covers the operating room/
sterile linen storage area
4 P URPOSE
5 SCOPE
6 RESPONSIBLITY
Qualification of staff:
staff
1.1.4. The site for all procedures that involve incisions, percutaneous
punctures, or insertion of instruments must be marked taking into
consideration
• Surface, spine level, specific digit or lesion to be
operated on
• Laterality. For procedures involving laterality of organs,
but where the decision or approach may be from the
mid-line or natural orifice, the site must be marked and
a note made of the laterality
1.1.5. All site markings must be made in conjunction with checks made
on the patient’s diagnostic imaging results i.e. X-rays, scans,
electronic imaging or other appropriate test results, ensuring these
match the patient’s medical notes and identity band.
a. Prior to the transfer of the patient the ward nurse informs the OT nurse
about the patient details and confirms the scheduled time for surgery
forty five minutes prior to the scheduled time of surgery.
b. The ward nurse prior to the transfer of the patient ensures that the
nurse’s preoperative checklist is dully filled and all the patient details as
required by the surgeons are arranged in the proper order.
c. The patient is identified by at least two identification parameters.
d. The patient is transferred to the OT as per the hospital’s transfer policy.
To ensure eliminate the risks endangering the lives and well being of
the surgical patients the WHO surgical Safety checklist has to be
followed to ensure that the team follows a few critical steps for its
effectiveness.
Ideally the surgeon should be present during this phase as the surgeon
may have a clearer idea of anticipated blood loss, allergies, or other
complicating patient factors
Before skin incision, each team member should introduce himself or
herself by name and role. If already partway through the operative day
together, the team can simply confirm that everyone in the room is
known to each other.
The team should confirm out loud that they are performing the correct
operation on the correct patient and site and then verbally review with
one another, in turn, the critical elements of their plans for the
operation, using the Checklist for guidance.
The team should also confirm that prophylactic antibiotics have been
administered within the previous 60 minutes and that essential imaging
is displayed, as appropriate.
Before leaving the operating room, the team should review the
operation that was performed, completion of sponge and instrument
counts and the labeling of any surgical specimens obtained. It should
also review any equipment malfunctions or issues that need to be
addressed.
Finally, the team should discuss key plans and concerns regarding
postoperative management and recovery before moving the patient
from the operating room.
3. When the patient is fully conscious and follows the command, the
patient is shifted to the concerned ward, with written order of the
anaesthesiologist in the recovery room vitals chart
4. When the patient is deemed fit for discharge from the recovery room,
the recovery nurse should confirm with the ward nurse for the bed and
start shifting of patient.
7.12.1 Definition
7.12.2 Purpose
The role of the recovery nurse is to ensure that the patient is protecting their
airway, breathing freely and perfusing adequately (airway, breathing and
circulation).
The recovery nurse should also monitor the patient’s pain as the anaesthetic
wears off and ensure that there are no early complications developing, such
as bleeding from the wound or loss of distal circulation and/or sensation.
The recovery unit nurse should apply defined criteria to assess the fitness of
the patient to be discharged from the recovery area.
a. Purpose:
Purpose
Surgical attire provides a barrier between personnel and patient and
patient and personnel, through which contamination may pass. Surgical
attire also provides protection for personnel against exposure to
infectious micro-organisms and hazardous materials.
b. Policy
i. All personnel entering the clean zone of the OT complex should be in
operating room attire.
ii. Attire which is soiled or wet shall be changed.
iii. All reusable attire shall be laundered after each use, by a laundry
facility approved and monitored by Hospital.
iv. OT attire shall be stored in an enclosed cupboard. All head and facial
hair is to be covered while in the restricted areas of the surgical suite.
v. The surgical cap or hood is to be clean, free of lint and confine the hair.
The surgical cap or hood should be changed daily. .
vi. Dedicated slippers should be worn in the restricted areas
vii. Shoe covers shall be worn if it is anticipated that splashes or spills will
occur.
viii. Masks shall be worn at all times in the surgical suites and other areas
where open sterile supplies or scrubbed personnel are located. Masks
shall cover the nose and mouth and shall be discarded whenever
removed.
ix. Personal jewellery worn in the surgical suites shall be limited to the
following:
• Necklace - One small single chain
• Earrings - Small studs. All other earrings worn are to be
contained within a cap at all times.
• No rings will be allowed.
x. All jewellery (rings and watches) is to be removed prior to hand
washing. All other jewellery shall be totally confined within scrub attire
or removed.
xi. Fingernails shall be kept short and trimmed
Keep nails short and pay attention to them when washing your hands –
most microbes on hands come from beneath the fingernails.
Do not wear artificial nails or nail polish.
Remove all jewellery (rings, watches, bracelets) before entering the
operating room suite.
Wash hands and arms up to elbows with a non-medicated soap before
entering the operating room area or if hands are visibly soiled.
Clean subungual areas with a nail file. Nailbrushes should not be used
as they may damage the skin and encourage shedding of cells.
Nailbrushes, if used, must be sterile and used only once.
Start timing. Scrub each side of each finger, between the fingers, and
the back and front of the hand for two minutes.
Proceed to scrub the arms, keeping the hand higher than the arm at all
times. this helps to avoid recontamination of the hands by water from
the elbows and prevents bacteria-laden soap and water from
contaminating the hands.
Wash each side of the arm from wrist to the elbow for one minute.
Repeat the process on the other hand and arm, keeping hands above
elbows at all times. If the hand touches anything except the brush at
any time, the scrub must be lengthened by one minute for the area that
has been contaminated.
Rinse hands and arms by passing them through the water in one
direction only, from fingertips to elbow. Do not move the arm back and
forth through the water.
Proceed to the operating room suite holding hands above elbows. At
all times during the scrub procedure, care should be taken not to
splash water onto surgical attire.
Once in the operating room suite, hands and arms should be dried
using a sterile towel and aseptic technique before putting on gown and
gloves.
8.2.4 GLOVEING AND GOWNING:
Procedure:
• Hands must be washed thoroughly before gowning
• Pick up the gown holding it well away from the trolley and your own
body.
• Hold the neck band and unroll until the sleeves are seen.
• Slide both hands and arms into the sleeves at the same time.
• The floor nurse / assistant slides her hands under the gown at the
shoulder and pulls out and fastens all the back tapes.
• Cover the back with the back flap with the help of the scrub nurse.
Remember:
• Do not keep the hands lower than the waist line.
• Do not keep the hands near ones neck or shoulder.
• Do not touch the back of the gown.
Removal of Gown at the end of the Procedure
• The circulating nurse will unfasten the gown.
• The gown is carefully removed by the scrub nurse leaving the gloves
on.
• The gown with the inside folded out is placed in the appropriate bin.
• The gloves are then removed by holding the inside of the cuff and
placed in appropriate container
8.2.5 Standard Precautions
1. HIV
2. Hepatitis B
3. Hepatitis C
4. MRSA
5. VRSA
6. VRE
7. Gas Gangrene
8. Any Multi Drug Resistant Pathogen
Infectious cases should be posted at the end of the day after all
surgeries
For infected cases universal precautions should be taken
Before procedure minimize the things present inside, keep the things
and trolley outside if it is not necessary.
Use disposal packs and gowns.
Use goggles to protect the eyes.
Shoe cover to avoid dripping of body fluids and blood.
Double gloves should be used
Needles should be handled very cautiously.
After the case the OT should be carbolized and Fogged as per the
protocol.
Handling of Linen:
All the infected linens should be put in a separate yellow colour bag and be
labelled as Infectious
aerosols. Fold the linen away from the person and fold into a bundle
Pack the linen into double yellow bags and label as infected and sent to
the laundry.
Wash bed pans with detergent and water dry then wipe with 1%
Wipe all IV poles, suction machines, beds, pillows, cots, switch boards,
door
handles, trolleys,telephone handles etc with 2% bacillocid
Wash the toilets and hand wash sinks with soap and water
Mop the floor with detergent and water followed by bacillocid special at
2%dilution.
8.2.9.1 Schedule :
Fogging will be done every week preferably at the end of all cases on
Saturday.
The OT should be thoroughly scrubbed before fogging.
8.2.9.2 Disinfectant
8.2.9.3 Dilution:
Scrubbing:
o Send all linen for washing
o Wipe OT table, mattress,telephones ,ac grills, lights,
monitors with 2%bacillocid
o Wash (clean) and dry all furniture and equipment suction
wall cupboards).
o Wipe the doors and window panels with damp and dry
cloth to remove dust
o Scrub the floor with a hard brush
o Wipe the walls with 2% bacillocid solution.
o Mop the floor with 2% bacillocid solution.
o HVAC pre filters should cleaned by the people arranged by
maintenance
8.2.9.5 Fogging:
• Surface of OT table
• Overhead Lights
• Monitor Screen
• A/C Grill
• Warmer
• Humidifier Water
1. Two Blood Agar plates should be kept exposed for 1Hour, One
at the centre of the room and the other at any one corner of
the room.
2. After Exposure the lid should be closed and sealed with
8.2.9.8 Document:
Formula-
Formula- Number of unplanned return to OT/ Number of surgeries
performed X 100
Formula:
Formula: Number of surgical site Infections in a given month/ Number
of surgeries performed in that month X 100
Theatre complex should be absolutely clean at all items. Dust should not
Operating rooms are cleaned daily and the entire theatre complex is cleaned
light reflectors, other light fittings, slabs etc with soap solution. This should
the service corridor (behind the theatre) and place them in trolleys to be
taken for sorting. The dirty linen is then sent to the laundry. Use gloves while
9.3 Instruments
Used instruments are cleaned immediately by the scrub nurse and the
are then sent for sterilization in the CSSD. The instruments are sent in the
instrument tray for autoclaving. They are then packed and re-autoclaved
before use.
9.4 Environment
Wipe used equipment, furniture, OR table etc., with detergent and water. If
The same procedures as mentioned above are followed and in addition the
with 2 % bacillocid
• Wash floor and wet mop with liquid soap and then remove water and wet
• Clean doors, hinges, facings, glass inserts and rinse with a cloth
• Stainless steel surfaces – clean with detergent, rinse & clean with warm
water.
• Wash (clean) and dry all furniture and equipment (OT table, suction
holders, foot & sitting stools, Mayo stands, IV poles, basin stands, X-ray
view boxes, hamper stands, all tables in the room, holes to oxygen
solution
Before spraying the area is swept and the area is mopped with clean water.
Evenly does the spray close the room and allow it to dry for 1 hour. After 1
hour mop the floor with plain water with a clean mop cloth.
9.6 HVAC maintenance:
HVAC pre filters should cleaned by the people arranged by maintenance
routinely
• Urgent repairs should be carried out at the end of the days list