THEATRE OPERATIONAL POLICY

Policy Type Clinical

Directorate Medical Director Directorate

Policy Owner Medical Director

Clinical Director, Head of Operations and

Policy Author Operational Manager for
Surgery, Women and Children’s Health

Next Author Review Date 1st May 2022

Policy Management Sub-Committee

Approving Body
9th October 2018

Version No. 1.1

Policy Valid from date 1st October 2018

Policy Valid to date: 30th October 2022

‘During the COVID19 crisis, please read the policies in conjunction with any updates
provided by National Guidance, which we are actively seeking to incorporate into
policies through the Clinical Ethics Advisory Group and where necessary other
relevant Oversight Groups’

Title: Theatre Operational Policy

Version No. 1.1 Page 1 of 26
 DOCUMENT HISTORY
(Procedural document version numbering convention will follow the following format. Whole numbers for
approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version,
e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will
be version 0.1)

Date of Version Date Director Nature of Change Ratification /

Issue No. Approved Responsible for Approval
Change
14/06/18 0.1 Medical Director New policy draft
21/06/18 0.2 Medical Director Enhancement
28/06/18 0.3 Medical Director Draft revision and
consultation
14/08/18 0.4 Medical Director Policy review Policy
Recommendations Management
Sub Committee
10/09/18 0.5 Medical Director Enhancement
13/09/18 0.6 Medical Director Final Validation
13/12/18 0.6 Medical Director Endorsement at Theatre
Steering Group
11/10/18 0.7 Medical Director Post Policy review
finalisation
9/10/18 1.0 9/10/18 Medical Director Approved at Policy
Management
Sub Committee
23/10/18 1.1 Medical Director Enhancement
16/01/19 1.1 09/10/2018 Medical Director WHO Checklist Policy
added as an Management
appendix as noted Sub Committee
at
29/01/21 1.1 09/10/2018 Medical Director 12 month blanket Quality &
policy extension Performance
due to covid 19 Committee
applied with author
review date set 6
Months prior to
Valid to Date.
22/05/21 1.1 09/10/2018 Medical Director Extended policy Corporate
uploaded and Governance
linked back with
new cover sheet

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust

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Contents Page

1 Executive Summary…………………………………………………. 4
2 Introduction….………….……………………………………………. 4
3 Definitions……………………………………………………………. 4
4 Scope…………………………………………………………………. 5
5 Purpose……………………………………………………………….. 5
6 Roles and Responsibilities………………………………………….. 6
7 Policy Detail/Course of Action………………………………………. 7
7.1 Pre-operatively……………………………………………………….. 7
7.2 Intra-operatively………………………………………………………. 8
7.3 Post-operatively………………………………………………………. 8
8 General Principles……………………………………………………. 9
8.1 Notification of cancellations made by Theatre……………………. 9
8.2 Booking of elective cases…………………………………………… 9
8.2.1 Six weeks from list date…………………………………...... 10
8.2.2 Four weeks from list date…………………………………… 10
8.2.3 Two weeks from list date……………………………………. 10
8.2.4 One week from list date……………………………………… 11
8.2.5 Three days from list date…………………………………….. 11
8.2.6 One day from list sat…………………………………………. 11
8.3 Planned changes to start/finish times…………………………….... 11
8.4 Emergency Surgery………………………………………………….. 12
8.4.1 Cases for scheduled Trauma Sessions……………………. 13
9 Ordering of supplies and consumables…………………………..... 13
9.1 Ordering for routine planned operating lists…………………… 13
9.2 Special orders, e.g. Orthopaedic revision joint surgery………… 13
9.3 Orders for sterile equipment for emergency surgery…………… 14
9.3 Return of contaminated instrument trays and equipment to HSDU 14
10 Conditions of Service……………………………………………….. 15
11 Consultation………………………………………………………….. 15
12 Training……………………………………………………………..... 15
13 Quality and Audit……………………………………………………. 16
14 Support Services……………………………………………………. 16
14.1 HSDU……………………………………………………………... 16
14.2 Porter Service……………………………………………………. 16
14.3. Laundry…………………………………………………………… 16
14.4 Pathology.………………………………………………………… 16
14.5 Pharmacy………………………………………………………… 17
14.6 Radiography……………………………………………………… 17
14.7 Security…………………………………………………………… 17
14.8 Domestic Services………………………………………………. 17
15 Monitoring Compliance and Effectiveness………………………. 17
16 Links to other Organisational Documents……………………….. 18
17 References………………………………………………………….. 18
18 Appendices…………………………………………………………. . 18
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1 Executive Summary
This is the Theatre Operational Policy for the Isle of Wight NHS Trust.

The policy provides guidance and outlines the rules for the management of all
activity occurring in the Main and Day Theatres, and Minor Ops Rooms to ensure
patient safety is maintained at all times. This policy also acts as an operational guide
for those staff involved in the management of all scheduled theatre sessions i.e.
elective, trauma and emergency within the theatre suites at Isle of Wight NHS Trust.
It sets out the roles and responsibilities, processes to be followed and establishes a
number of good practice guidelines to assist staff to provide safe and efficient care to
our patients within a Theatre setting.

2 Introduction
The Trust is committed to ensuring optimal use of operating theatre capacity and
resources, maximising operating theatre performance and avoiding cancelled
operations in order to provide high quality health care to patients admitted for
surgery. The theatre services at the Isle of Wight Trust consists of two separate
areas, main theatres with a recovery area and day surgery theatre with a recovery
area leading to the day surgery ward. All professional staff must abide by standards
of professional bodies at all times to ensure patient safety.

3 Definitions
 By default, theatre sessions will be 3.5 or 5.0 hours in duration (to reflect the
consultants’ contract). The only exceptions to this will be by formal agreement in
the job planning process and signed off by the Clinical Director and reviewed on
a six monthly basis thereafter.
 Theatreman is the theatre management system in use within all theatres in the
scope of this policy.
 Start time of session: As recorded within Theatreman determined by outcome of
job planning.
 Finish time of session: As recorded within Theatreman determined by outcome of
job planning
 Theatres used for elective purposes will undertake two elective sessions per day.
(Mon-Fri) and this will be reflected in the safer staffing levels for theatre
personnel as outlined by the National Association of Peri–Operative Practitioners
and the Consultant Contract for unsocial hours working.

Main Theatres

(The WHO Checklists should start 10 minutes before the start time of the list and
the start time of the list is considered to be first contact; needle to skin)

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 o 08:30 – 12:00 AM sessions
o 08:30 – 12:45 AM sessions (Orthopaedics only)
o 13:15 – 17:30 PM sessions (Orthopaedics only)
o 13:00 – 16:30 PM sessions
o 08:30 - 16:00 All day session (including a 30 minute lunch break)

Day Surgery Theatres

(The WHO checklists should start 10 minutes before the start time of the list and
the start time of the list is considered to be first contact; needle to skin)

o 09:00-12:30 AM sessions
o 13:30-17:00 PM sessions

 Utilisation will be calculated as the sum of minutes spent anaesthetising and

operating within the scheduled start and finish time of the session, divided by the
total number of session minutes available (typically 210 or 300 or 420 minutes)
 Reports will be produced on a monthly basis and will include:

o Utilisation by consultant, specialty and theatre

o Cancellations on the day of admission or day of surgery
o Cancelled sessions
o Re-allocated sessions
o This information will be displayed electronically within main theatres
o Return to Theatre for additional surgery relating to their listed surgery

Detailed ad-hoc reports can be requested via the Theatre Co-ordinator

The Theatre User Group meeting will review the previous month’s performance as
stated in the key performance indicators (targets) and ensure these are within
agreed parameters. Deviation from these parameters will be investigated and
challenged by the relevant directorate manager and clinical leads.

As per Audit Committee definitions, the key performance indicators are:

 Planned hours of sessions used, as a percentage of planned hours of planned

sessions (i.e. elective). Target of 92.5%
 Actual run time of lists as a percentage of their session planned hours. Target
of 90%
 Patient operation hours as percentage of anaesthetic and surgical hours, for
scheduled elective session. Target of 92%
 End utilisation of original planned hours for scheduled elective sessions.
Target of 77%
 End utilisation of original planned hours for scheduled trauma sessions.
Target of 77%
 End utilisation of original planned hours for emergency surgery. Target of
60%

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 4 Scope
This policy applies to all staff working within theatres including medical and non-
medical staff groups, as well as substantive and temporary staff, including those
working on an agency and locum basis. It is the responsibility of the employing CBU
to ensure locums working in theatres with responsibility for lists are provided with a
copy of this policy. The policy covers main theatres, day theatres, and minor
procedure rooms. The dedicated Maternity theatre and endoscopy suite are
excluded.

5 Purpose
The purpose of this policy is to facilitate the appropriate surgical intervention for all
patients who require an elective or emergency procedure on a 24 hour, 365 day
basis. Facilitation will include the provision of, an appropriate environment, staff with
the required skills / knowledge and the availability of equipment that is fit for purpose
to ensure patient safety is paramount.

This will be achieved by:-

 Being responsive to the individual needs of the patient. This will be supported by
appropriate and robust theatre list planning to ensure the appropriately skilled
personnel and suitable equipment is available on a patient by patient basis. This
will be monitored using theatre specific software.
 Maximum utilisation of theatre time.
 A professional and efficient Patient pathway throughout the pre and post-
operative care episode. This will include timely booking of patients to reflect
session length. Patients will be booked onto a theatre operating schedule 2-6
weeks prior to the date of surgery (see patient planning and scheduling)
 For standard procedures on all lists, patient sequencing will be fixed 24 hours
prior to surgery, unless a clinical justification case is made to the Theatre
Manager or other member of the senior theatre management team ( this will
support the patient by patient allocation of resources). No changes are to be
made to the order without this agreement.
 Delivering a high standard of patient care whilst retaining the ability to respond
quickly to changing service needs and commissioners’ requirements.
 Ensuring an efficient service is achieved through multidisciplinary co-operation
and the appropriate utilisation of available resources. For emergency and trauma
cases, session planning to prioritise patients in terms of acuity will be carried out
every morning at 07:50am with key personnel (surgical teams, anaesthetist,
theatre staff and radiology)
 Promoting an environment that is conducive to learning and development for all
grades of staff
 Recognising audit as the ‘key’ to the maintenance and development of all
standards within the department. The benchmark standard will be set and
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 monitored against national standards using all forms of technology available to
provide robust data and will be reviewed annually.

6 Roles and Responsibilities

Theatre Co-ordinator:

 Be responsible for co-ordinating the daily staff rotas, information on delays, start
time and late finished, minimising wasted resources in relation to staffing.
 Escalating to the Head of Nursing & Quality for the Care Group where safe rotas
cannot be achieved
 Co-ordinate the booking of emergency surgery and ensure the details are
accurately entered into Theatreman.
 Communicate with Consultant Surgeons and Anaesthetists to reduce delays and
avoid problems. Where problems occur, the Theatre Co-ordinator will liaise with
the Clinical Director or Consultant Anaesthetist on duty/call and agree a decision
which she/he will then communicate to those involved.
 Be responsible for overseeing the timely booking of equipment in advance of
sessions.
 Ensure Theatre policies and procedures are relevant and up-to-date, and all staff
comply with agreed policies to maintain best practice.

Team Leaders: Team Leaders for Scrub, Anaesthetics and Recovery are
responsible for leading by example, supporting and ensuring their teams comply with
the policy.

The Surgeon / Operator: is responsible for attending and participating in the Team
Brief. They have responsibility for completion of the “Time Out” and “Sign Out”
sections of the WHO checklist although they may delegate the signing to another
practitioner on their behalf as they are often scrubbed at this point on the process.
The surgeon/operator is responsible for having approved their list, including the
operating order in compliance with the timescales outlined in this policy.

The Anaesthetist: is responsible for attending and participating in the Team Brief
and the completion of the “Sign In” section of the WHO checklist although they may
delegate the signing of this section to another practitioner on their behalf Clinical
responsibility remains with the Consultant Surgeon and Consultant Anaesthetist who
are either involved with, or directly or indirectly supervising the care of the patient.
(Surgeons and Anaesthetist to have enough time in their job plans for pre-op
assessment and seen to be available at the start time of the list).

The Head of Operations/Operational Managers: are responsible for

communicating and ensuring compliance with the policy by the operational teams.

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Clinical Lead: is responsible for communication and ensuring compliance with the
policy by clinical teams (NOTE: currently post not in place. Policy to be updated
once Clinical Lead in post).

7 Aim of the service

To provide high quality efficient surgical care to all patients in a safe and professional
environment. The Operating Theatre service aims to reflect the Trust values listed
below:
 Acting professionally
 Valuing and respecting every person
 Building high trust relationships
 Commitment to quality of care
Working in partnership with others

8 Service Principles

Theatres will provide safe staffing level in line with the AfPP (Association for
Perioperative Practice) guidelines for all surgical activity. This includes 2 x Scrub
practitioners, 1x Circulator, 1 x Anaesthetic support and a recovery practitioner for
each session. By prior agreement with the Theatre Co-ordinator, the staffing of some
lists maybe substituted by specialty departmental staff with equivalent generic skills
and training and specialty skills for the procedures on the list. Where this occurs, it is
the responsibility of the surgeon/operator to ensure staff are adequately trained. This
arrangement can be terminated by the Theatre Co-ordinator at any point should
suitable evidence of training not be available.
All healthcare professionals have a duty to set a standard by which to practice. With
a focus on clinical effectiveness and evidence based care, theatre staff must be able
to demonstrate the ability to audit nursing and theatre practice. The care that is
delivered and improvements in practice must be based on evidence and best
practice.

The objectives of the theatre training are:

 To ensure that a standard of care is delivered to each individual that is equitable

and fair and safe.
 To identify the standards of care to be delivered to patients through all the areas
within the operating theatres i.e. Anaesthetic room, Operating Theatres and the
Recovery Unit.
 Where practice needs additional clarity, a Standard Operating Procedure will be
written. Staff will sign to say they have read and are familiar with these.
 To enable auditing of professional practice through all areas.
 To ensure all staff are aware of standards of care to be delivered to patients
whilst in the Operating Theatre Department.
 To provide information to all staff.
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 8.1 Pre-operatively
 All patients are seen immediately prior to surgery by the anaesthetic and surgical
medical staff either in the ward or Theatre Admission Area. It is not acceptable to
do this in the theatre reception area unless an emergency.
 All patients have consent for their operation discussed and signed before they
come to theatre in line with Trust policy.
 No patient will be accepted into theatre without a signed consent form and pre-
operative check list. Should the planned procedure the surgeon wishes to carry
out, vary from that that the patient has been consented for, the consent form
must be amended and re-signed.
 Patients will either walk to theatre accompanied by a member of staff or be
transferred on a trolley or a bed accompanied by both a member of staff and a
porter according to the standard operating procedure for patients being
transported to theatres.
 A team brief will be conducted and documented before each theatre list.
 Theatre staff must ensure relevant equipment is available. If equipment is not
available, the surgeon should be informed before anaesthesia commences. See
theatre sessions 8.2 Intra operatively
 Patients must not be left unattended in the Anaesthetic Room.
 All patients will undergo a “sign in” from the Surgical Safety Checklist completed
and documentation filed in the patient’s notes, as part of their Peri-operative care
provision.

8.2 Intra-operatively

 All patients will undergo a “time out” and “sign out” from the Surgical Safety
Checklist completed and documentation filled in the patient notes, as part of their
Peri-operative care provision.
 All staff must practice Asepsis at all times.
 All staff must follow Trust policies and procedures for assessing, manging and
reporting risks, ensure that any incidents are dealt with swiftly and effectively and
reported to their line manager, in order that further action can be taken where
necessary.
 Patients and instrument trays are tracked within Theatre. It is the
responsibility of the surgeon/operator to ensure that the theatre practitioner
verifies that the instruments & swabs counts are correct, including items such
as finger tourniquets and throat packs, and that sharps have been correctly
disposed of
 Specimens will be dealt with according to IOC Guidelines.

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8.3 Post-operatively
 All patients that require post anaesthetic care will be recovered by a trained
Recovery practitioner.
 The anaesthetic team will give a clear handover that will include patient
identification, the operation performed, any patient alerts or allergies and specific
post op instructions.
 The send team will give a clear handover to include; identification, local
anaesthetic, operation performed, wound closure, drains as appropriate and
dressings.
 The recovery team will assess the patient’s condition to meet the unit’s discharge
criteria. For day case surgery, criteria led-discharge will be the default practice.

9 General Principles
All day/all day plus evening sessions using the same theatre team, including surgeon
and anaesthetist are particularly efficient. Wherever possible, weekly half day
sessions should be consolidated into fortnightly full day lists. There should be
provision for meal and comfort breaks however, and overall operating time should
not be in excess of the planned session time.

9.1 Notification of cancellations made by Theatres

In exceptional circumstances it may be necessary for Theatres to cancel theatre
sessions. Such a decision would only be taken if absolutely necessary, for reasons
such as theatre equipment failure, unplanned theatre maintenance, major work to
theatres etc. In the event of a serious incident/never event/death in theatres, the
remainder of the list will be stood down.

The Theatre Co-ordinator (in conjunction with the Clinical Director and Business Unit
staff) will make a decision regarding which session should be cancelled following
escalation to the Head of Operations, Deputy Director of Acute Services or the
Director of Acute Services. The decision to cancel for non-clinical reasons may not
be made by the consultant without consultation as above. This decision will be
sensitive to the current situation regarding waiting lists/times, cases booked on lists
(i.e. cancer patients), previous cancellations and skill mix of anaesthetists/theatre
teams available.

9.2 Booking of elective cases

When planning elective theatre sessions it is the responsibility of the Consultant to
whom the session belongs to ensure that, as far as is reasonably practicable,
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allocated operating session times are not exceeded, in order to effectively utilise
theatre resources. PAAU (Pre-Assessment & Admissions Unit) will use informed
booked in order to fill lists to their allocated session length.

PAAU will fill lists first based on indicated clinical priority and thereafter in waiting list
date order. They will be responsible for ensuring across the operating day that there
is an appropriate gender mix, given the constraints of day surgery, and that total day
surgery unit or inpatient ward capacity is not exceeded.

Realistic scheduling of procedures can assist in avoiding cancellation of operations

due to lack of theatre time or impact on other theatre users. Consultants are
responsible for checking their theatre lists prior to final submission. Thrice weekly
huddles are in place to review theatre bookings and escalate any issues.
Consultants are also responsible for ensuring that any particular requirements, for
example, loan equipment, are communicated in advance of the list.

Efficient use of theatre capacity, time and resources relies upon effective
communication and co-ordination of theatre cases. This will be achieved by
implementing procedures for notifying theatres of forthcoming cases with as much
notice as possible which also allows for planning skill mix and required equipment, or
planning for special circumstances i.e. allergies, infections.

9.2.1 Six weeks from list date

Surgeons who plan not to utilise their operating list are to ensure that they have
notified theatres six weeks prior to the list date to ensure a theatre and anaesthetic
team can be reallocated. The cancellation of the list will need to be confirmed by the
Operational Manager for the area who will have counter-signed leave applications. A
list is not to be stood down without this second confirmation.

Direct instructions to PAAU to cancel lists or to not fill them with less than six weeks’
notice will need confirmation from the Head of Operations.

9.2.2 Four weeks from list date

Four weeks prior to planned list date for routine elective work, if the list has not been
held by the operating surgeon who usually occupies that session, the session may
be offered to other surgical specialities as a funded session that is available for
utilisation.

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9.2.3 Two weeks from list date
All routine lists will be booked to 85% within Theatreman two weeks prior to planned
date for surgery. Specialist or limited items must be identified at the time of listing to
enable theatres and other services to plan resource availability and identify conflicts
for resolution as they arise.

Examples of these resources may be:

 Anaesthetic cover
 Radiography
 Critical care/ HDU/ITU bed
 Loan Equipment
 Implants
 Patient BMI
 Known allergies

(This list is not exhaustive)

Equipment booking requests must be emailed to the theatre team and a printout
recorded in the theatre diary held at Theatre Reception for Main Theatres and
recorded in the order book in Day Surgery theatres.

The following details must be recorded: -

 Consultant
 Date and time of planned procedure
 Procedure to be performed
 Time and date when booking made

Where specialist or limited resource requirements are not identified at the two
week time frame access to that resource cannot be guaranteed.

At the two week time fence where lists have been held but have no patients added
into Theatreman, the list will be considered vacant and all supporting resource will be
reallocated and the list cancelled.

9.2.4 One week from list date

One week prior to the planned list date the theatre list for routine lists (i.e. list that do
not have a two week access requirement) will be locked and no further patients will
be added unless a sound clinical justification for late addition is made to the Theatre
Management Team and Clinical Director for Theatres. Where lists are not filled to

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85%, the operating surgeon will be notified and requested to add patients to the list.
Any remaining time will be reallocated for emergency or urgent cases.

9.2.5 Three days from list date

Seventy two hours prior to surgery all cases must be listed in Theatreman and
Consultant should have ordered the list and staggered the admission times where
appropriate and signed off the list. The operator/surgeon and anaesthetist are
responsible for ensuring that patients have been correctly listed as either day cases
or inpatients. Failure to do so, risks on the day cancellations to surgery.

9.2.6 One day from list date

At 3pm on the day prior to surgery, all lists will be locked for order of content and
theatres will send for the patient at the top of the operating schedule at 0800hrs on
the day of the list. Changes to the list on the day should only be for clinical reasons
and must be agreed by the Theatre Co-ordinator. The Theatre Co-ordinator will be
required to report these on a weekly basis.

9.3 Planned changes to start/finish times

Where it is anticipated that the complexity of the procedure(s) or the nature of the
operative case(s) will result in a longer than scheduled operating time it is the
responsibility of both the Consultant surgeon and Anaesthetist to liaise with the
Theatre Co-ordinator to discuss the potential for an early start/late finish and the
organisation of appropriate resources

 If patients are brought forward on the list and require an inpatient bed, the
Surgical Manager or the Day must be informed prior to anaesthetic commencing
to ensure the patient can be accommodated at an earlier time and to avoid
delays in recovery.
 Where theatre sessions overrun due to factors outside theatres control, time will
be deducted from the speciality’s total annual hours – Business Units may
reallocate this loss of time within the Business Units’ allocation of funded lists but
must notify theatres of any reallocation.
 Where theatre sessions are planned and scheduled to reflect appropriate
planned utilisation (85 – 92%) and the session overruns due to clinical
complications of surgery, theatres will support the list to its conclusion.
 Theatre session utilisation will be reviewed on a monthly basis, where sessions
are underutilised (i.e. less than 85%) session allocation will be reduced by
speciality with 8 weeks’ notice.

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 All other theatres will be allocated on a session by session basis ( up to 6 weeks
in advance) taking account of each specialities individual requirements e.g. ultra
clean, microscopes
 If additional theatre sessions are required by the specialities and the above
theatres are not available, the next most appropriate theatre available will be
allocated for use.

9.4 Emergency surgery

The use of emergency operating time will be co-ordinated by the Theatre Co-
ordinator or, out of hours, a senior member of Theatre staff under the guidance of
the Clinical Director, and Operational Managers for Theatres. Case mix and priority
of patients on lists will be decided based on the clinical needs of patients and
NCEPOD (National Confidential Enquiry into Patient Outcomes and Death)
recommendations. Consideration of vacant lists to be converted to NCEPOD lists
within hours identified a week in advance.

When a patient requires emergency or trauma surgery they will be listed in

Theatreman by;

i) Theatre staff who have appropriate access following training, and who abide
by the access policy.
NOTE; where access guidelines are not adhered to, access rights will be
removed until a period of retraining has been completed.
ii) The Theatre Co-ordinator will be responsible for ensuring a member of
Theatres staff enters patient information into Theatreman and the list will be
ordered by clinical priority as outlined below.

All patients requiring emergency surgery must have a management plan to reflect
fitness for emergency surgery at time of listing and availability of a surgeon to carry
out the procedure as soon as a slot becomes available. It is the responsibility of the
surgeon listing the patient to ensure appropriate instructions regarding fasting and
prophylaxis are given to the ward to ensure patient safety.

Requests for emergency operating slots will only be supported if the appropriate
minimum information is provided and a surgeon is planned to be available. Where a
patient requires immediate lifesaving surgery, this will be made available
retrospectively. Patients requiring emergency surgery will be called to theatre in
order of clinical priority which will be identified collaboratively by the operating
surgeon, attending anaesthetist and theatre co-ordinator or deputy.

9.4.1 Cases for scheduled Trauma sessions

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It is acknowledged that there is a lesser degree of control over planning of scheduled
Trauma sessions when compared to elective sessions. However effective
communication and co-ordination of Trauma cases is still required and therefore
when planning scheduled Trauma sessions it is the responsibility of the Consultant
on-call to ensure that, as far as is reasonably practicable, allocated operating
session times are not exceeded.

Notification of Trauma cases to theatres will be via the Trauma theatre list. Due to
airflow considerations, Trauma lists are held in Theatres 3 or 4.

Orthopaedic trauma lists will have one image intensifier allocated without the
requirement of booking for each individual list. However, if trauma cases are being
operated upon at other times, e.g. during vacant morning sessions, there will be a
requirement to book the Image Intensifier as for other specialties and ensure there
are no clashes.

10 Ordering of supplies and consumables

It is imperative that the adequate volumes of stock are held so that surgical efficiency
is not compromised by item unavailability, while maintaining a cost effective level of
stock on hand.

10.1 Ordering for routine planned operating lists

Sets of sterile instruments, drapes and gown packs will be stored in the main theatre
sterile store and individual theatre prep rooms.
On receiving the operating list the Team Leader will check the availability of the
required numbers of instrument sets, drapes and gowns plus any special
requirements.

Requests to stores for extra equipment will be made directly to the Department,
giving as much notice as possible.

10.2 Special orders, e.g. Orthopaedic revision joint surgery

Orders for the sterilisation of trays and instruments on loan or hired to support
specialist surgery will be notified to HSDU (Hospital Sterilisation and
Decontamination Unit) giving as much notice as possible prior to the date of the
planned surgery.

10.3 Orders for sterile equipment for emergency surgery

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Orders for sterile equipment for emergency surgery will be checked as described in
8.1 and 8.2 above. In addition to the above, trolleys containing sterile equipment for
each specialty and/or surgeon will be kept in the theatre department.

Theatre staff will be responsible for restocking and replacing equipment used from
specialist trolleys; these will be checked on a daily basis.

Specialty trolleys will be located in the theatre prep rooms appropriate to the
particular specialty but will follow the surgeon if he/she operates in a different area,
e.g. emergency theatre, or day surgery theatre.

10.4 Return of contaminated instrument trays and equipment to

HSDU
In order to ensure equipment is promptly decontaminated and available for use, at
the end of a case all instrument trays and specials should be loaded on to a trolley
and taken immediately to one of the dirty HSDU caddies. (Contaminated equipment
must not be parked in theatre exit bays or left in dirty utility rooms).

It is the responsibility of the operator/surgeon to ensure any defective equipment is

identified and therefore placed in the quarantine process.

11 Conditions of service
All staff and users will adhere to Trust Policies and guidelines all times. All staff and
users will adhere to local theatre policies to promote the provision of a seamless
service and the achievement of utilisation target and ensure patient safety.

Where clinically appropriate all basket and trolley cases will be scheduled through
the Day Surgery Unit without exception. Theatres will support specialities to expand
the basket and trolley of cases.

If there is a requirement to add a procedure description to the theatre management

software it must go through the correct approval process to review implications to
service delivery.

If there is any change in practice that will have equipment (instrumentation, critical
resource or consumable) implications that may have influence reference costs this
must be supported by a business plan that has gone through the correct approval
process and identifies the funding stream for capital or revenue expenditure. The
business plan must also identify the lead time for equipment acquisition and training
that informs the planned implementation date.

The introduction of new surgical techniques or equipment must go through the

Clinical Effectiveness Committee. Such techniques or equipment will not be
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approved for use until the Theatre Co-ordinator has confirmed that all theatre staff
are suitably trained and competent to support.

12 Consultation
All documents including major revisions of existing policies will require consultation;
policies should describe the level of consultation undertaken in relation to new, or
revised, documentation and will be dependent upon:

 The type of document;

 The impact that its introduction will have.

NB the document should include the most recent consultation not consultation on
previous versions.

Any significant dissent against a Policy that is flagged during the Consultation
process should be highlighted to the Lead Director and documented in the meeting’s
minutes.

13 Training

This Theatre Operational Policy does not have a mandatory training requirement or
any other training needs.

14. Quality and Audit

 The Quality Risk and Safety for the Surgery, Women and Children Care Group
meeting provides a forum for ensuring safety and quality standards in clinical
practice.
 Clinical incidents will be processed and reviewed in DATIX in line with Trust
policy.
 The WHO (World Health Organisation) and NatSSips/LocSSIPs checklists will be
audited in accordance with the NPSA (National Patient Safety Agency).
 Health and Safety and COSHH standards will be managed in line with trust
policy.
 Infection Prevention and Control are in line with Trust Policy, Clean Hospital and
Saving Lives. There are identified Infection Control Link Nurses.

15. SUPPORT SERVICES

Theatres interface with a range of support services and co-operative working
relationships and effective communication is essential to maintain safety and quality
standards and meet the expectations of staff and users of the service.

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15.1 HSDU
A routine two hourly collection and delivery service is in place to maintain throughput
and flow of equipment. Emergency provisions are supplied within agreed timescales
in line with service level agreement.

15.2 Porter Service

A dedicated porter service is available in line with Service Level Agreement with ISS
and in consultation with Support Services.

15.3 Laundry
A daily delivery of theatre scrubs and linen will be provided on a receive and return
basis

15.4 Pathology

Collection of specimens will be twice daily at 13:00 and 16:30 approximately. Urgent
specimens will be sent immediately following operation. There are specific
arrangements for Breast Specimens.
 Specimen containers will be routinely ordered and additional stock can be
requested daily at the specimen collection point.
 Any large formalin containers are stored with specimen containers and
associated spill kits. Replacements will be provided upon request.
 The blood fridge is located in Pathology

15.5 Pharmacy

 Pharmacy ordering and deliveries will be on a daily basis

 Flammable items will be stored in the appropriate manner
 Anaesthetic volatile agents will be stored in locked cupboards in the
anaesthetic rooms.
 Pharmacy items stored in Anaesthetic Rooms or Recovery will be in locked
cupboards.
 There are lockable fridges in each Anaesthetic Room and Recovery for drugs
which need to be stored at lower temperatures.

15.6 Radiography
There is both an in hours and out of hours radiology service. Advance notice should
be given to radiology to avoid delays
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15.7 Security
Digital or swipe security locks are provided on all external doors. Security alarms are
fitted to all Theatre Suite entrance doors. Main Theatres have several panic alarms.

15.8 Domestic Services

Domestic services are supplied via Service Level Agreement
Soiled linen and clinical waste will be removed as required from the disposal rooms
by the ISS Portering Service.

16 Monitoring Compliance and Effectiveness

The Trust will maintain a full reporting suite against the theatre utilisation targets.
These will be displayed on the intranet and in the department. The electronic
information will be real-time and populated from information entered into
Theatreman.

Compliance with the WHO checklist will be monitored through observational audits
on six week cycles. The information will go to the Quality Risk and Safety for the
Surgery, Women and Children Care Group.

17 Links to other Organisational Documents

Include all relevant documents that should be read in conjunction with the document
e.g. legal, guidelines etc.

 Who Safety Check List

 Infection Control Policies
 Dress Code and Uniform Policy
 Departmental SOPs

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18 References

Audit Commission Operating Department Review of National Findings. Available at:

http://webarchive.nationalarchives.gov.uk/20100806215628/http://www.audit-
commission.gov.uk/SiteCollectionDocuments/AuditCommissionReports/NationalStud
ies/TheatresAHP.pdf

19 Appendices

Appendix A - WHO Surgical Safety Checklist

Appendix B – Financial and Resourcing Impact Assessment on Policy Implementation

Appendix C - Equality Impact Assessment (EIA) Screening Tool

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Title: Theatre Operational Policy
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 Appendix B

Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either
a positive or negative impact on resources. Therefore this form should not be
completed where the resources are already deployed and the introduction of this
policy will have no further resourcing impact.

Document
Theatres Operational Policy
title

Totals WTE Recurring Non

£ Recurring £
Manpower Costs N/A N/A N/A
Training Staff N/A N/A N/A
Equipment & Provision of resources N/A N/A N/A

Summary of Impact: No financial or manpower implications

Risk Management Issues:

Benefits / Savings to the organisation:

Equality Impact Assessment

 Has this been appropriately carried out? YES/

 Are there any reported equality issues? NO

If “YES” please specify:

Use additional sheets if necessary.

Please include all associated costs where an impact on implementing this policy has
been considered. A checklist is included for guidance but is not comprehensive so
please ensure you have thought through the impact on staffing, training and
equipment carefully and that ALL aspects are covered.

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 WTE Recurring £ Non-
Recurring £
18 Manpower
19.4 Operational running costs

Totals:

Staff Training Impact Recurring £ Non-

Recurring £

Totals:

Recurring £ * Non-Recurring
£*
20 Equipment and Provision of Resources
Accommodation / facilities needed
Building alterations (extensions/new)
IT Hardware / software / licences
Medical equipment
Stationery / publicity
Travel costs
Utilities e.g. telephones
Process change
Rolling replacement of equipment
Equipment maintenance
Marketing – booklets/posters/handouts, etc

Totals:

 Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:
Funding / costs have been agreed and are in place:
Signature of appropriate Executive or Associate Director:

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 Appendix C

Equality Impact Assessment (EIA) Screening Tool

Document Title: Theatre Operational Policy

This document outlines the required standards for all activity

Purpose of document
occurring in the Main and Day Theatres, and Minor Ops Rooms
All staff who work in theatres and who support the scheduling of
Target Audience
work through theatres

Person or Committee undertaken

Theatres Steering Group
the Equality Impact Assessment

1. To be completed and attached to all procedural/policy documents created within

individual services.

2. Does the document have, or have the potential to deliver differential outcomes or affect
in an adverse way any of the groups listed below?

If no confirm underneath in relevant section the data and/or research which provides
evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework,
Commissioning Intentions, etc.

If yes please detail underneath in relevant section and provide priority rating and
determine if full EIA is required.

Positive Negative
Reasons
Impact Impact

Gender Men No differential impact

Women No differential impact

Asian or
Asian British No differential impact
People
Black or
Black British No differential impact
People
Race Chinese
No differential impact
people
People of
No differential impact
Mixed Race
White people
(including No differential impact
Irish people)
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 People with
Physical
Disabilities,
Learning No differential impact
Disabilities or
Mental
Health Issues
Transgender No differential impact
Sexual
Orienta Lesbian, Gay
tion men and No differential impact
bisexual
Children
No differential impact

Older People
No differential impact
Age (60+)
Younger
People (17 to No differential impact
25 yrs)
Faith Group No differential impact

Pregnancy &
No differential impact
Maternity
Equal Opportunities
and/or improved No differential impact
relations

Notes:
Faith groups cover a wide range of groupings, the most common of which are Buddhist,
Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and
collectively when considering positive and negative impacts.
The categories used in the race section refer to those used in the 2001 Census.
Consideration should be given to the specific communities within the broad categories such
as Bangladeshi people and the needs of other communities that do not appear as separate
categories in the Census, for example, Polish.

3. Level of Impact
If you have indicated that there is a negative impact, is that impact:
YES NO
Legal (it is not discriminatory under anti-discriminatory
law)
Intended

If the negative impact is possibly discriminatory and not intended and/or of high impact then
please complete a thorough assessment after completing the rest of this form.

3.1 Could you minimise or remove any negative impact that is of low significance? Explain
how below:

3.2 Could you improve the strategy, function or policy positive impact? Explain how below:

3.3 If there is no evidence that this strategy, function or policy promotes equality of

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 opportunity or improves relations – could it be adapted so it does? How? If not why not?

Scheduled for Full Impact Assessment Date:

Name of persons/group completing the full
assessment.
Date Initial Screening completed

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