THEATRE OPERATIONAL POLICY - iow.nhs.uk

Title: Theatre Operational Policy Version No. 1.1 Page 1 of 26

THEATRE OPERATIONAL POLICY

Policy Type Clinical

Directorate

Medical Director Directorate

Policy Owner

Medical Director

Policy Author

Clinical Director, Head of Operations and Operational Manager for Surgery, Women and Children’s Health

Next Author Review Date

1st May 2022

Approving Body

Policy Management Sub-Committee 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’


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 Issue

Version No.

Date Approved

Director Responsible for

Change

Nature of Change Ratification / Approval

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 Recommendations

Policy Management Sub Committee


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


16/01/19 1.1 09/10/2018 Medical Director WHO Checklist added as an appendix as noted at

Policy Management Sub Committee

29/01/21 1.1 09/10/2018 Medical Director 12 month blanket policy extension due to covid 19 applied with author review date set 6 Months prior to Valid to Date.

Quality & Performance Committee

22/05/21 1.1 09/10/2018 Medical Director Extended policy uploaded and linked back with new cover sheet

Corporate Governance

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


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


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)


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%


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


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.


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.


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.


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,


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.


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


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.


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


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


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


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.


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


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


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/NationalStudies/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

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





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 title

Theatres Operational Policy

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.


18 Manpower

WTE Recurring £ Non-Recurring £

19.4 Operational running costs

Totals:

Staff Training Impact Recurring £ Non-Recurring £

Totals:

20 Equipment and Provision of Resources

Recurring £ * Non-Recurring £ *

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:


Appendix C

Equality Impact Assessment (EIA) Screening Tool

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.

Gender

Positive Impact

Negative Impact

Reasons

Men No differential impact

Women No differential impact

Race

Asian or Asian British People

No differential impact

Black or Black British People


Chinese people


People of Mixed Race


White people (including Irish people)


Document Title: Theatre Operational Policy

Purpose of document This document outlines the required standards for all activity occurring in the Main and Day Theatres, and Minor Ops Rooms

Target Audience All staff who work in theatres and who support the scheduling of work through theatres

Person or Committee undertaken the Equality Impact Assessment

Theatres Steering Group


People with Physical Disabilities, Learning Disabilities or Mental Health Issues


Sexual Orientation

Transgender No differential impact

Lesbian, Gay men and bisexual


Age

Children


Older People (60+)


Younger People (17 to 25 yrs)


Faith Group No differential impact

Pregnancy & Maternity


Equal Opportunities and/or improved 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


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