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organization of OT. adult health nursing
- 1. University institute of nursing Organization and physical setup of Operation Theatre
- 2. Organization and physical setup of OperationTheatre
- 3. ā«OT is that specialized 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. ā«It is a room in a hospital equipped for the performance of surgical operations under complete aseptic conditions.
- 4. 1. Emergency Surgeries 2. Elective Surgeries 3. Major Surgeries 4. Minor Surgeries 5. Ambulatory / Daycare Surgeries Types of Operations / Surgeries
- 5. Emergency operation: It must be carried out as soon as possible after the diagnosis has been made and the patient is prepared for operation in proper way. Elective operation: It is carried out some time after the diagnosis has been made and when they suit best for the patient and the hospital
- 6. Some Advances ā« Microsurgery: surgery performed under magnification. Used most commonly for anastomosis. ā« Cryosurgery: surgery which is based on use of liquid nitrogen at a very low temperature (based on cryoablation) ā« Laproscopic Surgery: its use requires minimal incision and minimal post operative care and stay in the hospital. ā« Advantages: faster recovery, lesser pain and less scarring. ā« Bio-medical Laser : in this, there is absence of physical contact and the cutting is without mechanical pressure (scalpel) which makes the operation non-traumatic. (Light amplification by simulated emission of radiation)
- 7. Objectives ā«Promote high standard of asepsis. ā«Ensure maximum standard of safety for patient and staff from environmental, anaesthetic, radiological equipment and post operative hazards ā«Ensure optimum utilization of operation theatre and its staff. ā«Ensure comfortable treatment of patients.
- 8. OT COMPLEX ā« Operation Theatre: where surgical operations and certain diagnostic procedures are carried out. ā« Operating suite and ancillary areas, anaesthesia room, Theatre suite- O.T with room for instrument trolleys, a disposal room, a scrubbing & gowning area. ā« Operation Theatre Complex. : An unit consisting of one or more operating accommodation for the suites common with ancillary use such as changing room, rest room, receptions, transfer, pre- operative area, post-operative area and circulating space.
- 9. LOCATION OF OT ā« Accessibility to ICU, Post surgical wards, CSSD (central sterile service department) Emergency and Blood Bank ā« Access to lifts ā« Away from internal & external traffic flow ā« Future expansion ā« Ideally located on Top Floor, dust free environment & reduced bacterial load in area ā« Quiet environment: No Noise, Dust, Wind, Heat ā« Least scope of cross infection
- 10. Number of OTs Depends upon - ā« No. of Surgical beds ā« No. of surgeons ā« Scheduling of operations ā« Quantum of emergency cases ā« Out patient surgery ā« Type of hospital ā« Type of specialities ā« Number and nature of elective and emergency surgery anticipated ā« Number of operations per day ā« Expected ALOS ( average length of stay) of surgical patients ā« Expected turn over interval in OT ā« Estimated time for cleaning between operations ā« Time allowed for staff breaks ā« Amount of time reserved for emergency use
- 11. Number of OT ROOMS ā« Putsep recommends - Thumb role of 0.1 operations per bed/day is recommended - (Putsep). ā« No. of ORs should be 5% of total No. of surgical beds.
- 12. The Planning Commission Expert Committee Recommendations: a) 50 Beds: 1 Major and no Minor operating room b) 50 to 100 Beds: 1 Major and 1 Minor operating rooms. c) 300 Beds: 3 Major and 1 Minor operating rooms. d) 500 Beds: 5 Major and 2 Minor operating rooms e) 750 Beds: 8 Major and 2 Minor operating rooms. f) 1000 Beds: 10 Major and 2 Minor operating rooms. Americans: 1 OT for 25 beds. Europeans: 1 OT for 50 beds.
- 14. ā« Basic activities involved in the Act of Surgery ā« Supporting Procedures ā« Administrative Procedure ā« Clerical Procedures ā« Housekeeping Procedures
- 15. Basic activities involved in surgery ā« Reception and identification of patient ā« Pre-operating supervision of patient ā« Transfer of patient to OT table ā« Administration of Anaesthesia ā« Intubation ā« Positioning ā« Preparation of operative area ā« Draping of patient ā« Patient / Attendantās Consentā« Wound sewn up and dressed ā« Drapes removed and bagged ā« Extubation ā« Transfer of patients from operation table to trolley or bed to recovery room ā« Post operative supervision of patient
- 16. Supportive procedures ā«Staff changing to operating room garments and shoes ā«Putting on cap, gloves and apron ā«Aseptic washing of hands ā«Gowning ā«Laying out, checking and re-checking the no. of instruments
- 17. Administrative procedures ā« Preparation of operation lists, duty schedules ā« Requisition of patient ā« Notification to wards of time for patient transport to and fro the surgical department ā« Distribution of messages ā« Requisition of records, equipment and material ā« Contacts with other departments, lab, workshops and supplies ā« Ascertain availability of doctors and supporting staff
- 18. Clerical procedures ā«Preparation of operation records ā«Preparation of operation room records ā«Filing ā«Statistical interpretation of operation room Hou re s c e o k rd e s eping procedures ā«Collection of used instruments ā«Collection of used materials and soiled surgical instruments, dressings and underlays ā«Cleaning of operation rooms and other areas in the surgical department ā«Disposal or incineration of refuse
- 19. ZONING in OTs ā« Minimises risk of hospital infection in the operating room ā« Minimises unproductive movement of staff, supplies and patients ā« Ensures smooth work flow ā« Reduces hazards in the operation suites ā« Ensures proper positioning of the equipment ā« Ensures optimum utilization of the operation suites ā« There should be movement from one clean area to another without having to pass through dirty areas. ā« Soiled linen & wastes should be removed without passing through highly clean areas.
- 20. Types of ZONES ā«Protective Zone ā«Clean Zone ā«Sterile Zone ā«Disposal Zone
- 21. Protective Zone This includes entrance for patients, staff & supplies where normal hospital standards of cleanliness applies & where normal everyday clothes are worn. ā« Reception ā« Waiting room ā« Changing room ā« Store room ā« Autoclave/TSSU ā« Trolley Bay ā« Control area of electricity
- 22. Clean Zone This is the main area of the OT where all patients, staff should undergo complete changing of clothes before entering. ā« Pre-operating room ā« Recovery room ā« Theatre work room ā« Plaster room ā« X-ray unit with dark room ā« Sisters work room ā« Staff work room ā« Anaesthesia Store
- 23. Sterile / Aseptic Zone This is the inner zone, where conditions are as near sterile as possible. It applies to 2 rooms in a suite, the theatre & theatre supply room. All staffs who might handle the exposed instruments, must be scrubbed & gowned. ā« Operating Room ā« Scrub Room ā« Anaesthesia Room ā« Instant instrument sterilization ā« Instrument trolley area
- 24. Disposal Zone This is where all exposed instruments (used or unused), pathological specimens, lotions, suction jars, soiled linen are passed from the theatre to disposal corridor & returned for changing, sterilizing or any other necessary procedure. ā« Dirty wash up room ā« Disposal Corridor ā« Janitorās Closet
- 25. Maintenance of OT and Aseptic Standards
- 26. Maintenance of OT and Aseptic Standard ā« One day in a week should be given for maintenance of OT ā« Swabs should be taken away from areas of OT ā« Air-conditioning of OT should be checked regularly ā« Filters should be properly maintained ā« Spare bulbs should be kept in stock in OT department ā« Adequate pressure should be maintained all the time ā« Operating staff having infection should not be permitted in OT ā« Sterilisation of mobile equipment and operation table should be ensured
- 27. POLICY ON CLEANING TECHNIQUE ā« Preparatory Cleaning ā« Operative Cleaning ā« Intermediate Cleaning ā« Terminal Cleaning
- 28. Preparatory Cleaning ā«An hour before the beginning operation, a damp dusting with of the first detergent or disinfectant. ā¢ Every morning OT is to be cleaned and carbolized before starting of first case. ā¢ All equipment OT tables, walls and floors have to be cleaned and carbolized using 1% hypochlorite solution. Check the concentration of available hypochlorite, dilute accordingly. ā«Example: Hypochlorite solution (available 4% solution of sodium hypochlorite: dilute 1 in 4, to 250ml of 4% sodium hypochlorite add 750ml of
- 29. Operative Cleaning ā«Areas contaminated by organic debris such as blood & sputum, during the operation should receive immediate cleaning. An in use dilution of phenolic detergent germicide or other broad operation germicide.
- 30. Intermediate Cleaning ā« General clean up OT room for the next patientās instruments should be placed directly into perforated trays for processing in a washer sterilizer, or may be covered for transportation to the CSSD for terminal sterilization. ā« Furniture - cleaned with germicide ā« Floor - wet vacuuming is the method of choice. If wet mop is used, then a fresh one must be used each time & no buckets at all. ā¢ Collect waste materials, sharps, sponges and soiled linen separately in colour coded bags according to hospital waste disposal protocol. ā¢ After removing the blood from the floor and other spillage areas (as per hospital protocol) disinfect and
- 31. Terminal Cleaning ā« At the end of dayās schedule a vigorous cleaning of the OT table etc. ā¢ Clean the O.T. area, after removing all the used material & other items to be discarded. ā¢ Mop with 1% sodium hypochloride solution , dilute as mentioned earlier. ā¢ After mopping the floor carbolize the OT walls, floor, tabletops and equipments except where contraindicated (marked āXā: in red). ā¢ Bacilocid spray ā« Fumigation: Fumigation in gas proof enclosure with 40% formula for 8 hours and then neutralized with a gauge
- 32. FUMIGATION Area that requires fumigation: ā¢Operation Theatre complex and Intensive Care areas ā¢Cardiac Cath Lab, Endoscopy Lab, Bronchoscopy Lab ā¢Special cases as advised by Infection Control Committee Method Of Fumigation By OT care machine using formaldehyde solution Solution used: Formalin 40% - 500ml clean water (for Thousand cubic B /f e e fe otr )e Fumigation 1) Remove all articles likely to be damaged by fumigation 2) Remove any containers with Hypo-chlorite solutions 3) Wash OT properly 4) Fumigate
- 33. METHOD ā¢Send note to maintenance to TURN A/c off (Very important) ā¢Check OT care machine ā¢Put the solution in OT care machine (Formalin 40% 500 ml, water 100 ml) ā¢Put the machine inside the OT (wire and switch outside the OT) ā¢Seal the OT properly ā¢Put on the machine for Ā½ hour. ā¢Keep the OT sealed for 10-12 hours ā¢Turn the A/c on and exhaust the fumes ā¢Remaining fumes if any may be neutralized with ammonia ā¢Cleaning, carbolization & bacilloacid spray should be carried
- 34. Cleaning of entire OT on weekends (Saturday Evening) ā¢Remove all equipment, OT tables, anesthesia machine, and heart lung machine, Ventilator etc. ā¢Wash each OT thoroughly with detergent and water paying special attention to the corner of OTs. ā¢Dry the OT and walls with dry duster and carbolize properly with 1% hypochloride ā¢Carbolize all the equipment and place them properly in the OT. ā¢Close the OT and to not allow anybody to enter unless there is a surgical case.
- 35. Planning of OTs
- 36. General Considerations ā« OT unit needs specialised services, such as piped suction and medical gases, electric supply, heating, air-conditioning, ventilation and efficient lift services. OT requires more height (above 4.2 meters) Dedicated (AHU) Air Handling Unit for 100% fresh air for each OT. ā« Minimum area for general operating room is 40 sq m ā« Cardio-vascular, Neuro-surgery, Orthopeadic and other procedures which require additional equipment needs minimum area of 60 sq m.
- 37. Grouping of Operation Theatres. 1. Maximum flexibility in use 2. Easy expansion 3. Simplifies theatre staffing 4. Easy & economical maintenance 5. Improved cleaning and better sterilization 6. Minimises infection & cross-infection 7. Minimizes cancellation of operating schedule 8. Improves utilisation of operating suites 9. Flexibility in allocation of operating suites
- 38. OT CONSTRUCTION ā« Floor Flooring - Vinyl floors, Antistatic to minimize danger of static electricity Earthing for electrical installation - laying flat copper strips 6ft deep in the floor. Minimum conductivity-1ohm, maximum-10 ohm. Floor corners and edges rounded to facilitate cleaning . ā« Walls - plain, free of glare, easily cleaned & impervious ā« Doors: sliding doors, wide for passage of pt trolleys & equipments . ā« Ceiling: False roofing not preferred. ā« Paint colour: Light & non reflecting
- 39. Light ā«Most important component of OT ā«Central field of operation should be 2000-3000 candela per sqm. ā«The floor around surgical table should be 200-300 candela per sqm and walls 300-500 candela per m sq. ā«The colour composition should be such that anaesthestist will be able to see the colour changes of the patient skin. ā«General light luminance may vary from 500 lux to 2000 lux ā«Operating Light: ā¢ Easy maintainability repair and maintenance ā¢ Fitting be directly flexible ā¢ Control accurate and quick ā¢ Shadowless ā¢ Heat radiation small
- 40. Power Outlet ā« OT require electro-medical equipment for life support and for performing surgery. For using these equipments power outlets at convenient location are needed. ā« Sparkless electrical outlets at least 5 ft. from the floor, . ā« 4 power outlet should be provided on every wall of OT ā« Near Anaesthetist, 6 power outlets should be provided ā« All these outlets should be on UPS ā« Power outlet should also be located at one meter above the floor level.
- 41. Air-conditioning and Ventilation ā« Construction of OT should be made in a way that it could be fitted with modern air-conditioning system. ā« Height of 4.2 m is needed in OT, coz air-conditioning duct, laminar flow and high efficiency filter takes 1 m space above false ceiling. ā« Grill for return air-duct should be located 30 cm above floor level. Minimum of 2 return ducts should be provided in the OT ā« Vertical laminar flow is preferred in OT, which is the most advanced A/c technology today, which is a unidirectional air flow through high efficiency particulate filters. ā¢ The laminar flow system maintains an air change of 10- 20/hour in the OT & supplies 100% fresh filtered air through HEPA filers which flows in 2 directions in high velocity, vertically down wards or horizontally. ā« Positive pressure in the OT room should be maintained to eliminate risk of infection.
- 42. Scrub Station ā« It is provided near the entry room of the OT ā« One scrub room per Operation room should be provided. ā« The working height of scrub station is 96 cm with water source 10 cm higher ā« If possible gowning area should also be provided ā« It is better to have photo electric cell operated wash basin, so that there is no body contact
- 43. PERSONNEL MANAGEMENT IN OTs ā« By convention, OTs all over the world are under the overall charge of the anaesthesiologist. ā« OT is a area which needs certain qualities from its personnel such as, stamina for long standing hours, emotional stability to cope with the stressful environment, good team spirit, stable health and respect the patientās right for privacy. ā« Surgeon ā« Anaesthetist ā« Assistant ā« Scrub nurse ā« Circulating nurse ā« Anaesthetist nurse Further there are assistants to help: Radiographer, Technicians, Disposal staff
- 44. Equipments Mobile Equipments ā« Anaesthetic apparatus ā« Anaesthetic table ā« X-ray equipment ā« Diathermy equipment ā« Electrical suction apparatus ā« Pulse monitor ā« Ventilator ā« Monitor-cum- defribrilator ā« Heart lung machine Fixed Equipments ā« Operating Table ā« Wall intercom station, nurse call system, wall clock ā« Tele. at circulation nurse work area ā« Film illuminator at foot end of operating table ā« Sx light, ceiling mounted over the centre of the operating table. ā« Video cameras for observation on ceiling tracks.
- 45. INSTRUMENT STERILIZING POLICY ā« CSSD - can be located anywhere in the hospital to facilitate utilization by other areas , preferably close to OT as they are the main user. ā« TSSU -This system is seldom used. Located within the operating deptt. to facilitate maximum utilization, flow of instruments, supervision of sterilization by nursing staff. However, on economic & efficiency grounds 2 sterilizing units in one hosp is difficult. ā« Sterilization unit between 2 OTs -This is practiced in small setup, where the autoclave is kept between 2 OT suites.
- 46. Computerization in OT without complete ā« Modern OT is incomplete computerization. has become a necessity for the ā« HIS ā OT Module ā« Computerization following: - Maintaining pts records so as to avoid stacks of record keeping. - For telecommunication with the various wards & support areas so as to fasten the supporting works in OT. - For teaching purposes the functions in the OT can be directly telecasted in to the students room or doctors room so that doctor can visualize the procedure sitting outside the OT room.
- 49. Operating list management ā¢ Close communication and coordination between pre-op area and theatre using agreed procedures is essential ā¢ A nominated person should liaise with wards and transport staff from theatres ā¢ A suitable holding area staffed and equipped will assist with smooth flow ā¢ Agreement should be made for preparation and transport of patients to and from theatres ā¢ Policies on fasting, anticoagulation, shaving, dentures, jewellery, appropriate underwear and removal of make-up should be developed ā¢ Units should agree the level of training needed to escort patients to and from theatres ā¢ A documented system of handover and identification of patient should be in place
- 50. Effectiveuseoftheatretime ā« It is important that all theatre lists start and finish at the agreed time. ā« Realistic scheduling of theatres will prevent cancellations ā« All day theatre lists have proven efficient, within the synchronising of surgical and anaesthetic time and staffing ā« Good time keeping principles should be adopted and monitored by the theatre management team ā« Pro-active re-allocation of cancelled theatre lists.
- 51. SCHEDULING ā« The realistic building of theatre lists start in processes outside of theatre environment, essential validation of how ālistsā are made needs to be undertaken to maintain effective and efficient operating theatres. ā« Agreement can be made on average time per procedure to enable effective booking of theatre lists. ā« Average time per operation can be agreed and used to assist building theatre templates.
- 55. During the theatre allocated time, a theatre may be in one of the following states: ā«A patient undergoing an operating procedure ā«A patient may be administered anaesthesia ā«The theatre being cleaned or set up ā«The theatre may be unused The theatre could be unused due to one of the following reasons: ā«Delay in starting the first case ā«Delay between cases ā«End of scheduled list
- 56. Operation Theatre Utilisation ā« The efficiency of an operating theatre is commonly expressed in terms of theatre utilisation, and is a frequently quoted performance indicator. ā« There is no universally accepted or consistent descriptor of theatre utilisation. Therefore benchmarking and improving theatre utilisation and resource allocation within the health system is extremely difficult. ā«Theatre utilisation = Theatre used time Theatre allocated time The theatre allocated time is a period for which the theatre is adequately staffed and scheduled for given service or clinician.
- 57. Improving theatre utilization is a key performance target for hospital in terms of ensuring : ā«Timely surgical intervention for patients. ā«Reduce length of stay. ā«Increase activity and income. ā«Improved productivity and value for money from the services provided.
- 58. FACTSā¦.. ā« OTs generate 42% of a hospitalās revenue. ā« The average OR runs at only 68% capacity. ā« The average OR starts on time only 27% of time. ā« The average patient out to patient in time is 31.5 minutes (standard- 15 minutes) ā« O.Ts are choked by paperwork. (nurses fill in average of 15 pieces of paper per patient.)
- 59. KEY PERFORMANE INDICATORS ā« O.T. Utilization: depends upon ā«No. of cases canceled or delayed ā«Doctor or Anesthetist availability ā«Patient canceling the process ā«Lab /radiology reports not available on time ā«Bills /advances not paid ā«Consent not taken ā«CSSD not functioning or not making instruments available on time ā«O.T. equipments non functioning ā«First procedure prolonged ā«Attendants not properly communicated about the procedure ā« Clean-up & set-up time ā« Performance data of surgeon ā« Number of Minor and Major cases
- 60. Studies on OT Utilization Preoperative phase ā« Delay in assembling of OT team in the OT complex (sequencing) - Due to different OPD hours - Due to heavy OPD. - Tight scheduling of doctors. ā« Delay in supplies. Operative phase ā« Sequencing of equipment ā« Standardization of procedures. ā« Specific surgeons for specific procedures. ā« Trained staff. Post operative phase ā« OT preparation ā« Availability of beds in ICU and ā« Time motion study low /on- time starts ā« Process flow charts ā« Root cause analysis
- 61. Studies on Equipment Management USE COEEFICIENT=M/N*100 M= Maximun No of Hours the Equipment is used in a day N =Maximum No of Hours The Equipment can be used in a day Down time analysis to reduce down time. CHECKLIST FOR DOWNTIME MANAGEMENT ā« S.No. ā« Name of equipment ā« Warranty period ā« Date of breakdown ā« Date of repair ā« Cost incurred
- 62. HISTORY SHEET 1. Name of equipment 2: Date of purchase 3: Cost of equipment 4: Name and address of supplier 5: Date of purchase 6: Date of installation 7: Department where installed 8: Environmental control* 9: Spare parts inventory 10: Technical manual/circuit diagrams/literature 11: After sales service arrangement 12: Guarantee period 13: Warranty period 14: Life of equipment 15: Depreciation per year 16: Charges of tests** 17: Use coefficient*** 18: Down time up time 19: Cost of maintenance 20: Date of condemnation 21: Date of replacement (*) Proper environment control in terms of temperature, lighting and ventilation should be ensured and recorded, whenever applicable. (**)whenever applicable. (***) should be applied to assess the utilization of equipment. RESOURCE UTILIZATION (MACHINE)
- 63. Stores Audit and Analysis STORES AND SUPPLY CHAIN MANAGEMENT ā« Standard products selection /usage ā« Proper forecasting and need assessment (bulk purchases ) ā« Limited no of vendors ( purchases discounts, Quality assured) ā« Reorder levels estimation ā« Proper usage analysis ā« Just in time
- 64. Thanks