OPERATION THEATRE MANAGEMENT

PAPER-402Ms. 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

Theatre Management structure

Planning patient pathways

Staffing

Operating list management

Effective use of theatre time

Theatre design

Trauma and emergencies

Postponements

Key elements

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.

StaffingDepartment 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

AdmissionReceive patient to ward following operation

  Administration Processes will also need to map demonstrating process from:

Initial recording of overall patient processes should be made covering:

Allocation totheatre list

Theatre reception on day of operation

Processes

Theatre

Recovery

Home

Theatre

Recovery

Bed

Home

Bed

Theatre

HDU/ITU

Bed

Home

ICU

Theatre

ICU

Bed

Home

Theatre

ICU

Bed

Home

Process map groups

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.

Case 1

Case 2

Case 3

9.00 am 12.30pm

Process steps examplesProcesses

StepStep Time per Time per step (min)step (min)

Patient transported from wardPatient transported from ward 55Patient checked in to theatrePatient checked in to theatre 55Patient taken to anaesthetic Patient taken to anaesthetic roomroom

22

Anaesthetic givenAnaesthetic given 1010Patient positioned onto theatre Patient positioned onto theatre tabletable

55

Surgery completed Surgery completed 4040Patient taken to recovery areaPatient taken to recovery area 55Patient in post opPatient in post op 2020Patient taken to wardPatient taken to ward 55Theatre hands over patient to Theatre hands over patient to wardward

55

Process steps examples

Processes

StepStep Time per Time per stepstep

COLOURCOLOUR

Patient transported from wardPatient transported from ward 55

Patient checked in to theatrePatient checked in to theatre 55

Patient taken to anaesthetic roomPatient taken to anaesthetic room 22

Anaesthetic givenAnaesthetic given 1010

Patient positioned onto theatre tablePatient positioned onto theatre table 55

Surgery completed Surgery completed 4040

Patient taken to recovery areaPatient taken to recovery area 55

Patient in post opPatient in post op 2020

Patient taken to wardPatient taken to ward 55

Theatre hands over patient to wardTheatre hands over patient to ward 55

Build your scheduleProcesses

Use graph paper with one square per minute to sequence time scales per procedure.

1 MINUTE102 MINUTES

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.

DATA

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 PLANNING AND DESIGNING OF OPERATION THEATREOF OPERATION THEATRE

PAPER-402PAPER-402 MS.SUSMITA BHAUMIKMS.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

AND RESTINGPATIENT RECEPTION AND RECOVERY

CIRCULATION SPACE

OPERATING SUITES

THEATRE

STERILE

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 EVIRONMENTPHYSICAL EVIRONMENT

TEMPERATURETEMPERATURE HUMIDITYHUMIDITY VENTILATIONVENTILATION

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 preparationarea 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 DistributionAir Distribution

TurbulentTurbulent 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 spatialrelationships 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.

Description of the area Min. usable area in m2

Operating theatre, general 3636

Operating theatre, specific

(orthopaedics, cardiac surgery, neurosurgery)

4242

patient airlock or holding area

2020

preoperative area 1515

BASIC QUALITY REQUIREMENTS: SPATIAL NEEDS

TEMPERATURE AND HUMIDITY

Normal person at rest (unclothed) – 240-270c with relative

humidity of 50%

Body looses heat during anesthesia.

So,So,1. R.H – 45-60% recommended (adults 40% , children and infants

55%-60%)

2. In UK, 200 – 220 c with R.H. 50% to 60%

3. 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 receivingpatients 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 cleanedand biohazardous waste is disposed

OPERATION ROOM

1. Big enough for free circulation

2. 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

OPERATING ROOM

PATIENT IN

STERALIZING DEPT

STERILE PEPARATION

DISPOSAL

SCRUB

STAFF CHANGEPATIENT-OUT

OT SHOWING TRAFFIC FLOWS

NUMBER OF OPERTING SUITES

Number and type of Number and type of surgeonssurgeons

Type of hospitalsType of hospitals Hospital policy and

procedure Bed strength Number and type of

surgery patients Number of operations

per day

Time aTime allowed for staff breaks

Average time for operations

Time allowed for maintenance of OT

Expected ALOS Size of an average OT

list

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

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

Venus O.T. Lights

WORKFLOW

1. Singe corridor system

2. 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:

1. It will be without a separate anesthetic room

2. It will have shared scrub facilities between theatres

3. It will have a disposal bay or room servicing two theatres

4. 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

• Operating radiography and micrographic instruments

THANK YOU