Document Control - northdevonhealth.nhs.uk · 1.2 Jul 14 Revision Revision of scrubs procedure 1.3 Aug 14 Revision Addition of Maintenance, Disposal of products of Conception, Checking

NDDH Operating Department Operational Policy

Theatres G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Theatres\Operating Department Operational Policy\Operating Theatre Operating Policy V1.7 09Jan17.docx V2.0 10Jul15 Page 1 of 24

Document Control

Title


Author

Author’s job title Operating Department Manager

Directorate Planned Care and Surgery

Department Operating Department

Version Date

Issued Status Comment / Changes / Approval

0.1 Dec 13 Revision Appendices added

1.0 Jan 14 Final Approved and published on Bob

1.1 Mar 14 Revision Addition of Cancelled Operation Process

1.2 Jul 14 Revision Revision of scrubs procedure

1.3 Aug 14 Revision Addition of Maintenance, Disposal of products of Conception, Checking Prosthesis, body Jewellery and wearing mask procedures.

1.4 Jul 15 Revision Changes in the uniform section and structure charts.

1.5 Jul 16 Revision Changes to Booking Emergencies.

1.6 Nov 16 Revision Changes to Booking Endoscopy Emergencies

1.7 Jan 17 Reviewed Published

Main Contact Operating Department Manager Main Theatres, Level 3 North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 322710

Lead Director Katie Cross, Lead Director of Clinical Support Services

Superseded Documents NDHT Operational Department Policy 2008

Issue Date December 2017

Review Date January 2020

Review Cycle Three years

Consulted with the following stakeholders:

Senior Theatre Staff

Approval and Review Process

Theatre User Group

Local Archive Reference G:\Theatres Local Path Theatres/Policies Filename Operating Department Operational Policy V1.6 09Jan17

Policy categories for Trust’s internal website (Bob) Theatres

Tags for Trust’s internal website (Bob) Operating, Department, Operational



CONTENTS

Document Control........................................................................................................................ 1

1. Introduction ......................................................................................................................... 3

2. Main Theatres ...................................................................................................................... 3

Theatre Philosophy ......................................................................................................................... 3

Location .......................................................................................................................................... 3

Layout of Theatres .......................................................................................................................... 3

Security ........................................................................................................................................... 5

Management .................................................................................................................................. 5

Session Times .................................................................................................................................. 5

3. Emergency Coverage ............................................................................................................ 6

How to book an emergency ............................................................................................................ 7

Opening of additional Operating Theatres out of hours ................................................................ 7

Procedure for interrupting an operating list for emergency cases. ............................................... 7

4. Staffing ................................................................................................................................ 8

Uniform ........................................................................................................................................... 8

Rosters ............................................................................................................................................ 8

Clinical Supervision ......................................................................................................................... 9

5. Education & Training ............................................................................................................ 9

6. Major Incident Plan .............................................................................................................. 9

Fire Risk Assessment and Evacuation ........................................................................................... 10

Manual Handling ........................................................................................................................... 10

Health & Safety ............................................................................................................................. 10

Patient Movement ........................................................................................................................ 10

7. Admissions Lounge ............................................................................................................. 11

8. World Health Organisation Mandatory Safety Checklist (WHO Checklist) ............................. 11

Briefing .......................................................................................................................................... 11

9. Policies Procedures Guidelines and SOPs ............................................................................. 12

10. How Paediatrics are managed ............................................................................................. 12

11. Recovery criteria ................................................................................................................ 13

12. Staff shift patterns .............................................................................................................. 14

13. Working policy/guidelines .................................................................................................. 14

14. Communication .................................................................................................................. 14

15. Procurement ...................................................................................................................... 15

Loan Equipment ............................................................................................................................ 15

16. Sterile Services ................................................................................................................... 15

17. Storage & Waste ................................................................................................................. 16

18. Patient Questionnaires ....................................................................................................... 17

19. Audits & Benchmarking ...................................................................................................... 17

20. Infection Control ................................................................................................................ 17

21. Patients with Body Jewellery in Situ Coming into Theatre .................................................... 17

22. Procedure for Checking of Prosthesis .................................................................................. 18

23. Consent for Disposal of Products of Conception................................................................... 18



24. Theatre Maintenance ......................................................................................................... 19

Air Sampling .................................................................................................................................. 19

25. Equality Impact Assessment ................................................................................................ 20

Appendix A: PACU Discharge Criteria ......................................................................................... 21

Appendix B: Planned Care and Surgery Organisational Chart ...................................................... 22

Appendix C: Theatre Department Structure Chart ....................................................................... 23

Appendix D: Cancelled Operation Reporting Process ................................................................... 24

1. Introduction

This document sets out North Devon District Hospitals Operating Department’s Operating Policy.

2. Main Theatres

Theatre Philosophy

We believe that every patient undergoing surgery is a unique individual who has entrusted his/her safety, dignity and wellbeing into our care.

Through technological resources and the skill and expertise of theatre personnel, it is our aim to provide optimum care tuned to the individual needs of every patient.

The Theatre Manager and Deputy have overall responsibility to ensure all Health, safety and welfare issues relating to the environment, staff and patients within the Theatre Department.

Location

Main Theatres 1 to 4 are located on Level 3 in the Main Hospital building.

Day Surgery Theatres 5 and 6 are on Level 2 in the Main Hospital building

Theatres 7 and 8 are in the Ladywell Building.

Theatre 12 is a Pre-fabricated unit to the rear of the Ladywell building.

Layout of Theatres

MAIN THEATRES

In Main Theatres there are 4 operating suites each comprises an anaesthetic room, a scrub area, a preparation/store room, a sluice room and a main operating room.

A PACU with nine bays, a nurse’s station and sluice room.



A Theatre Office / Reception with IT facilities office supplies etc. This office also has the secure cupboard for holding all of the Department’s keys. Contact numbers for this office ext. 2710 and fax 01271 349129

The Theatre Manager/Deputy Theatre Manager and Theatre Management Secretary have an office. Contact number 01271 322735 or ext. 2735/5849

A third office is shared by the Recovery Manager, the Anaesthetic Support Manager and the Theatre Materials Management Person. Contact number ext. 3201

There is a Student and Staff Training room with IT facilities (x4 computers), library, TV monitor etc.

There are four Staff change areas; two male and two female.

There are two coffee / rest rooms and a small kitchenette. One rest room is a quiet room with IT facilities, the other has a television and fridge freezer facilities.

There are two large equipment stores and the main theatre stock is housed in storage units in the main theatre corridor.

There is a sterile instrument store room

Sterile Services Department (SSD) is located at the end of the theatre facilities with direct access in to the theatre department.

There is a Clinical Waste room shared between SSD and Theatres.

DAY SURGERY THEATRES

There are two Theatre Suites as per Main Theatre with a shared sluice facility.

One equipment store room

One toilet facility

A PACU with 4 bays (Known as DSU Recovery)

Coffee/rest room

THEATRES IN THE LADYWELL BUILDING

Two Theatre Suites as per main theatre

A PACU with six bays, one of which is as a separate facility for post- caesarean section mothers with baby. This is known as Recovery 2.

Two staff change areas; One male one female.

A staff rest room with kitchen facilities



A store room

A theatre office with IT facilities - contact number ext. 3705

VANGUARD MOBILE UNIT THEATRE 12

One Theatre Suite as per Main Theatre, inclusive is a 2 bay recovery area

A ward adjoins this unit leading onto the main Hospital road access. Contact number ext. 3734 and 3844

Security

All changing facilities have either key pad entry or swipe card entry.

Every member of staff is allocated a secure locker for their personal effects.

Patients should not come to Theatres with any valuables. If they do then the valuables will be stored using the Patients Property Policy (9.1 page 12).

Entrances into and out of the Department have swipe card entry with the exception of the back staircase and Recovery which are keypad entry.

The Main Entrance has a swipe card entry, and also a door bell for visitors to use.

Any person visiting the Department is entered into the “visitors’ book” the date and time of entry and the time of departure is recorded.

Any Company Representative or Contractor is required to have their identity checked prior to entry. Reps must check in with Procurement Department and Contractors with Estates department.

Management

The Directorate Structure is attached as Appendix A

The Operating Department Structure is attached as Appendix B

Session Times

Morning Sessions 0830 to 1230

Afternoon sessions 1330 to 1730

All day sessions 0830 to 1630

Duration of sessions are 4 hours or morning and afternoon combined 9 hours.

Private Patient sessions take place in the evenings following the NHS lists and run from approximately 1730 to 2030



Main Theatres are staffed 24 hours a day, every day of the year. Main Theatres cover all Emergency Surgery requirements.

Day Surgery currently is open Monday to Friday. Theatre session times are the same as Main Theatres.

The Day Surgery Ward Opens at 0730 and is closed at 2100 or when the last patient is discharged.

The Eye Theatre (Vanguard Theatre) with ward attached is open at 0730 and closes when the last patient is discharged. Theatre session times are 0830 to 1230 in the morning and 1400 to 1700 in the afternoon. This is the only theatre with a 3 hour session time

Theatre 7 Ladywell Building

Session times are the same as Main Theatre.

Theatre 8 Ladywell Building

Elective Caesarean Section Lists are run 4 times a week in the afternoons 1330 to 1730.

This Theatre is available for emergency caesarean sections 24 hours a day every day.

3. Emergency Coverage

Main Theatres covers all Emergency Surgery including endoscopies. Maternity emergencies which take place in Theatre 8

Orthopaedic trauma work is carried using 3 set lists per week 0830 to 1230, and two all day lists from 8.30 to 5.30. Any trauma emergencies required outside of these times are booked onto the emergency list organised by the Theatre Co-ordinator or the senior staff member on duty.

All emergency cases must be booked via the Theatre Co-ordinator or Senior Staff member on duty. There are planned CEPOD sessions on three all day and two afternoon lists each week. All endoscopy emergencies that are to be carried out in main theatres will require anaesthetic review before booking via the theatre co-ordinator.

All emergency theatres will be staffed according to AFPP Guidelines.

The Theatre Co-ordinator can be contacted on Bleep 256 or ext 3228. The Theatre Co-ordinator is available Monday to Friday 0800 to 1800. Outside of these times, theatres can be contacted on ext 2710 or 2713. When ringing from outside the hospital, telephone 01271 322710 or 01271 322713. The 256 bleep holder is available 24 hours a day.



How to book an emergency

Contact the Theatre Co-ordinator (Bleep 256) as detailed above or out of hours the senior staff member on duty.

Ensure you have the following details:

Patient name

Hospital number

Date of birth

Procedure to be performed

Surgeon name

Starvation status of the patient

The emergencies are booked and are carried out on a “first come first served basis” unless clinical need requires them to be done earlier. This decision is made by the Anaesthetist in discussion with the Surgeon.

Opening of additional Operating Theatres out of hours

Contact Bleep 256 to book the case as above. If it is essential the patient comes to theatre immediately this must be stated when booking. The senior person on shift will then implement the opening of another theatre. The consultant anaesthetist and consultant surgeon on call should both agree that the patient is of the “immediate” NCEPOD classification.

It should be established what extra staff would be needed over and above who is already on shift, and which clinical skills are required. Once the on call team has been contacted, put together, are all in place, and a team brief has been completed, then the patient can be brought to theatre.

Procedure for interrupting an operating list for emergency cases

Contact Bleep 256 to book the case as above. If it is essential the patient comes to theatre immediately this must be stated when booking. If a patient is of the “immediate” NCEPOD classification, a theatre list must stopped as soon as possible. The theatre co-ordinator will decide which one to stop according to how soon an operating theatre can be made vacant, and how suitable that theatre is.

Once the team brief has taken place and equipment prepared, then the patient can be sent for.



4. Staffing

There is an annual review of staffing requirement for all areas of the Operating Department Service. This review is made according to service requirement and in line with recommendation on Staffing in Theatres by the Association for Perioperative Practitioners.

Uniform

Everyone is issued with “scrubs”.

There is an ample supply of clean scrubs in various sizes in every theatre change area.

Clean uniform is to be worn every day and changed as often as need determines.

Theatre scrubs worn by Clinical Staff outside of Theatres must be changed on re-entering the Theatre Department.

Personal theatre hoodies are available to purchase and are to be worn outside of clinical areas. Individuals must ensure these are clean at all times.

Personal shoes are ordered for every individual and cleanliness of these is the responsibility of every individual. Staff can wear / purchase their own footwear providing it meets the requirement for safety and cleanliness.

Personal protective equipment is available for all staff and it is the responsibility of every staff member to ensure that they wear the appropriate equipment as and when needed according to the Trust’s Infection Control policy and the Trusts Health and Safety policy.

Face masks should be worn where appropriate except for orthopaedics, where masks must be worn at all times.

Hair must be covered and a variety of disposable head covering is available.

Please refer to the Trust’s Uniform Policy.

A selection of masks, visors and goggles are available for visitors.

Rosters

The Trust has the MAPS staff rostering system.

Rosters are compiled approximately 6 weeks in advance according to the needs of the service and the competency and experience of the staff.



The Department operates “on call” arrangements to cover all eventualities and specialist services. There is always a senior member of staff on call, to support more junior colleagues and to refer to for advice.

Clinical Supervision

The Trust is committed to ensuring all staff receives Clinical Supervision. This takes place at least 6 weekly. In Theatres this is recorded on the spread-sheet on the Theatres’ G Drive.

Following any organ retrieval, an unexpected death during surgery or unexpected poor patient outcome following surgery, a staff debrief will take place.

5. Education & Training

Regular visits from the Clinical Development Facilitator take place and staff have access to discuss any issues or training needs.

Theatres have an Education Facilitator. This person co-ordinates Operating Department training programmes in conjunction with Plymouth and Oxford Brookes University.

A 12 month preceptorship programme is in place for newly-qualified staff.

There is an “in house” accredited Anaesthetic course for Registered Nurses that is 6 months in duration and takes place as and when required. This course is also open to external applicants.

The Department has an Education / Training room with IT services and a small library.

Access to a simulation facility is available to staff; booking via the Education Facilitator.

All staff are responsible for keeping their own Professional Portfolio and Safety Clinical Skills passport up to date.

Band 5 staff have a competency booklet issued to them and this is completed in every speciality area by the senior staff member and a mentor. The in-house training programme is estimated to take approximately 1 year but is guided by the needs of the individual.

6. Major Incident Plan

The Trust’s Major Incident policy is in place.



Staff contact numbers are recorded on appointment and changed as needed. Staff are responsible for notifying the Theatre Manager of any changes to contact details. This is reviewed by the Theatre Management Secretary.

Staff skills competencies are noted and call out time in relation to distance from the hospital.

Staff on duty are expected to stay and staff rostered for duties later are not the first to be called as they will need to relieve those on duty.

Fire Risk Assessment and Evacuation

The Trust’s Fire Safety Policy is in place and is reviewed annually or more often if there are changes to theatre layout/new works etc.

Every area of the Theatre Department has a Fire Safety Log book.

Every area of the Department has individual evacuation plans, displayed on the wall in each area.

Manual Handling

The Trust’s Manual Handling policy is in place.

Theatres have several bariatric tables. All tables in theatres are documented on a chart giving location and weight-bearing load / x-ray facility

Power assisted leg supports / stirrups are available including a pair for bariatric use.

There is an AirPal System available to assist in the lateral movement of patients. This is stored in the Main Theatres.

ProTurn equipment is available for positioning patients into the prone position (face down)

Mainly Pat slides and slide sheets are used for positioning patients in Theatres.

Health & Safety

Risk assessments for the Department are on BOB and are reviewed annually

Patient Movement

When patients are going to Theatres for surgery, if they are able they will walk escorted by a Theatre member of staff or a member of the ward staff.

If patients have any walking difficulty then they can go to Theatres in a wheelchair.

Obviously those patients unable to walk or in pain will be taken to Theatre on their bed.



Following surgery, patients will be returned to their ward area from the Recovery area on a trolley or on a bed, accompanied by a Registered Theatre Practitioner.

7. Admissions Lounge

The Admissions Lounge receives patients booked for surgery on the day of their operation. This unit is located on Level 4 of the Main Hospital block. It is open from 0730 until the last patient is taken to theatre.

There are 2 bays with examination couches and armchairs; one for female patients and one for male patients.

It is in this area that patients will be seen by their surgeons and their anaesthetists prior to surgery.

This area is staffed by a Registered Nurse and two Support staff. If the area is busy, sometimes two nurses will be allocated.

8. World Health Organisation Mandatory Safety Checklist (WHO Checklist)

Briefing

Briefing at the start of every operating list and every emergency case is part of the WHO safety check process. This allows Surgeons and anaesthetists to identify any specific requirements and discuss the procedure to be performed. Theatre Staff have the opportunity to discuss any issues regarding the running of the list, equipment issues etc. with everyone involved.

Sign In: This takes place in the anaesthetic room. Many checks are made including confirmation of the patient’s identity, the site and side of procedure to be performed, patient’s allergy status.

Time out: This takes place in the Operating Room with the whole surgical team. Aspects regarding the patient and the particular procedure to be performed are discussed and preparations checked.

Sign Out: This takes place in the Operating Room with the surgical team. Aspects that have arisen during the procedure, post-surgical instructions for the recovery team, any specimens taken are confirmed. The surgical instrument, swab and needle check is confirmed as correct.

The above checks are recorded as having taken place on the TheatreMan IT management system.

THE STOP BEFORE YOU BLOCK



A STOP moment must take place immediately before inserting the block needle, this can be instigated by any member of the anaesthetic team (Anaesthetist, Anaesthetic Nurse or Operating Department Practitioner).

This involves,

● Visualising the surgical arrow indicating site of surgery

● Asking the patient to confirm the side of surgery (if conscious)

● Double checking the consent form for operative site and side.

De-briefing

De-briefing is just as important to ensure on-going smooth running of the Department. It supports staff, gives praise where due to encourage staff and raise any area that could be improved for the future. This information is discussed as learning points and shared at staff meetings.

We carry out a minimum of 20 random Quality audits each month which are sent to the Quality and Safety Team for the Trust. This provides assurance to the Board of Directors that the WHO safety checks are carried out effectively.

9. Policies Procedures Guidelines and SOPs

Theatre practice is guided nationally by “The Association for Perioperative Practitioners”. This Trust uses their “Standards and Recommendations for Safe Perioperative Practice” publication on which to base theatre policies procedures, guidelines and SOP’s. Local variances are added to these and reviewed as necessary. These recommendations are used in the practical training of all Perioperative practitioners and in the university programmes for ODP training.

The latest publication is 2011

Prior publications were in 1998, 2004 and 2007.

Evidence of these are to be found on BOB

10. How Paediatrics are managed

Paediatric patients are as a rule placed first on any operating list. If there is a list of paediatric cases they will be placed in order of youngest first.

Any variance to the above rule will be made by the consultant and will be for clinical need.

Paediatric patients are escorted into the anaesthetic room by one of their parents / carers.



Post-surgery as soon as the paediatric patient is awake, their parent or carer is called from the ward to be with them in the recovery area.

There is a play room for children in the Day Surgery unit.

In Day Surgery the paediatric cases are separated from the adults into a separate bay and when it is possible, any with learning difficulties will be given a single room with their carer.

Adolescents (12-18 year olds) are separated into male and female areas.

Portable DVD players and films are available for children to use in the department to keep them occupied whilst waiting for their operation or during their recovery period.

11. Recovery criteria

Accommodation and facilities

Main theatre recovery

• Nine fully equipped patient bays (inc 2 set up for paediatrics) • Four bays have the capacity for taking HDU/ICU patients • One sluice room • One central office station • One recovery manager’s office situated in the theatre complex • Staff rest room, toilets and changing facilities shared with theatre

Recovery 2 (Ladywell)

• Five fully equipped patient bays • One fully equipped obstetric bay • One central office station • Staff rest room, toilets, changing facilities and sluice room shared with theatre Day Surgery recovery

• 4 fully equipped patient bays • A nurses work station and other essential equipment



12. Staff shift patterns

Recovery shift patterns are complex due to the nature of the workload. The shifts are staggered throughout the day to ensure there is enough staff coverage for all lists. The rota is produced electronically but generally full time staff work either 4 long days (3x 9 1/2 hours and 1x 9 hour shift) or 4 ½ days (4x 8 hours and 1x 5 ½ hour shift). This varies for part time staff.

Main theatre recovery provides a 24 hour service. Staffing is calculated using the Association for Perioperative Practice (AFPP) guidelines, to cover the needs of the service.

13. Working policy/guidelines

Following general, epidural or spinal anaesthesia, all patients should be recovered in a specially designated area which complies with the standards and recommendations laid down by the AAGBI (2002).

All patients must be observed on a one-to-one basis by an anaesthetist or an appropriately trained recovery practitioner until they have regained airway control and cardiovascular stability and are able to communicate.

No fewer than two staff should be present when there is a patient in the recovery room who does not fulfil the criteria for discharge to the ward. Overnight, the second person is one of the theatre team.

All patients must meet the Recovery Discharge Criteria before return to the wards (see appendix A).

14. Communication

There are weekly staff meetings lead by the Theatre Manager or Deputy Theatre Manager for raising current issues and providing staff with a venue to raise issues themselves. Minutes are taken and made available in a communication folder for anyone who was unable to attend.

Senior staff meetings are also held weekly. Issues raised from the “all” staff meeting are discussed. Other topics covered include theatre utilisation, equipment, staffing, risk assessments, incident reports, complaints, national and local changes requirements etc. Minutes are taken from this meeting.

There is a Communication Diary in the Main Theatre office. This records visitors to the Department, changes in lists staffing issues etc.

In the coffee rooms topical issues and other items of interest are posted. Also the training and education reports for all staff



15. Procurement

We have a Materials Management person in theatres who manages ordering of stock which does not come from Logistics. He rotates stock and checks on expiry dates and keeps the storage areas clean. Supplies from Logistics (NHS supplies) are topped up on a daily basis, Monday-Friday, via a central store and this service is run by the Procurement department.

There is a Peninsula Theatre Users Group, of which the Theatre Manage/ Deputy are members. This group is run by the Peninsula Alliance and large contracts are managed via the Peninsula Alliance negotiating with this group. Contracts such as orthopaedic implants and operation drape packs fall in to this remit.

Theatre Management and senior staff work closely with the local procurement team. There is a procurement buyer that is designated for Theatres and along with the theatre management will be responsible for looking at new products, reviewing new contracts and delivering on departmental CIPs.

Loan Equipment

Any equipment that is brought in on loan has to be agreed by the Theatre Manager/Deputy. It must be identified for a specific procedure and a specific patient on a specific day and be requested by a specific clinician. The cost of the hire charge, the carriage charge and any implants must be known prior to agreeing the loan.

The equipment must come in the day prior to being required so that every item can be listed for traceability, and decontaminated, packed & sterilised according to required standards for Sterile Services. Information on decontamination instructions, dismantling of instruments etc must accompany the loan equipment. There must also be a certificate of decontamination from the previous users of the equipment.

Training staff on the use of the loan equipment must be carried out by the company supplying the equipment. This often involves the company representative coming on the day of surgery to work with the respective operating team. It is important to ensure that patient consent is obtained to have the representative in the theatre at the time of surgery.

16. Sterile Services

The Sterile Services Department is on site at NDDH; it complies with BSEN ISO 13485:2012 and required CE markings. There is a service level agreement contract between Theatres and the CSSD department, and regular meetings looking at compliance, new equipment, and supplies etc take place bi-monthly.



17. Storage & Waste

We have new storage facilities in the Department which consist of clear-fronted enclosed cupboards with pull-out shelving in easy-clean plastic. . There is a Logistics top-up service managed by the Procurement service for supplies from the NHS supplies depot in Bridgewater.

The materials management person for Theatres manages all other supplies.

Linen and surgical scrubs are collected separately but both into clear plastic bags labelled “Sunlight Laundry” and sent to Sunlight Laundry. The bags are collected from the Clinical Waste room. Fresh linen is distributed to Theatres via Sodexo on a top-up system.

There is an “in house” laundry service for special slide sheets used in manual handling movement, which is also collected in clear plastic bags but sent to Bideford Hospital for laundering.

Theatre waste is divided into the following colour coded bags:

Clear - domestic waste e.g. paper towels, empty packets.

Tiger Stripe – waste suitable for landfill e.g. swabs, soiled Theatre waste, giving sets with “normal” fluids.

Orange – treatable clinical waste e.g. heavily soiled or infected Theatre waste

Yellow – incineration, recognisable anatomical waste. There are specific limb bins available which, when sealed, must be taken down to the marked bin available in the clinical waste compound on level 0 at NDDH

Fluid/Irrigation waste – containers are placed in orange bags within the disposal boxes.

The bags are labelled with the date, the signature of the person who disposed of the waste the theatre/area from which it came and the case number.

Waste is collected in clinical waste rooms. Plastic bags are placed in the large yellow wheelie bins, these bins are labelled to contain to contain the correct waste stream, Cardboard is flat packed and put in to cages, fluid/Irrigation boxes and full sharps bins are stored in the second waste room. The porters remove the waste twice a day from these rooms.

Sharps are disposed of in yellow-topped plastic sharp containers which have secure closable lids. These also must be dated, signed and the area from which they came noted on the side of the container. Clinical waste containers are similar to the sharps containers, but have a purple lid.



Recycling waste is carried out in the kitchen area for food waste, plastic bottles, cans, glass etc.

There is a trust policy on waste.

18. Patient Questionnaires

There is a patient questionnaire that is undertaken on an ad hoc basis with patients before they are discharged to home.

The results to be analysed following every 50 questionnaires completed; feedback given to staff on the results, action plans drawn up as required, to be reviewed on an annual basis.

19. Audits & Benchmarking

We audit paperwork completion and standards in Theatres on a weekly basis using the Meridian audit tool.

National Benchmarking is carried out with membership to the National Patient Advisory group which meets quarterly in London. Topics covered include sickness absence management, theatre utilisation, cancellations on the day of surgery etc.

We also participate in a national trust staff survey

Many audits are carried out on theatre utilisation, cancellations, start and finishing times of surgery etc. by utilising data capture by the TheatreMan management system.

A Dashboard of these key indicators from TheatreMan is shared monthly with the Executive team.

20. Infection Control

There is a Trust-wide Infection Control policy which Theatres work to.

Sterile techniques are employed for all surgical procedures according to AfPP (Association for Perioperative Practitioners) Guidelines and Recommendations.

21. Patients with Body Jewellery in Situ Coming into Theatre

Patients wearing body jewellery should ideally remove this prior to surgery and this should be noted in the patient Healthcare records.

If the patient cannot or will not remove the jewellery, the anaesthetists and surgeons must be made aware the patient has jewellery in place.



Patients who have a tongue piercing in situ need to discuss their options with the anaesthetist before the commencement of any anaesthetic

The operating team must be informed of any patients arriving in theatre with jewellery in situ, so decisions can be made prior to the commencement of anaesthetics regarding taping or removing the items prior to the procedure.

Any jewellery removed within the operating department must be recorded in the Patient’ Property Book and the items returned to the patient before they return to the ward.

Any infected pierced site must be cleaned with saline solution, where possible the use of Chlorhexadine should be avoided.

22. Procedure for Checking of Prosthesis

A scrub nurse will ascertain and confirm any requested Prosthesis and size from the operating surgeon. Any ophthalmology procedures will have had the lens implant size predetermined and stated in the patient’s notes.

The scrub nurse requests the circulating nurse/ODP to bring the Prosthesis into theatre. The identifying label on the Prosthesis will be confirmed and verbalise the details on the label i.e. “This is a Left Total Knee Femoral Implant Size 75mm”

The Sterilisation date is checked, the expiry date and the integrity of the packaging. If the information is correct the packaging is opened.

All Prosthesis have accompanying information labels with an implant number, size, sterilisation date and method, and expiry date along with the description of the implant, one of these labels is inserted into the patients notes and dated, the other label is inserted into the specialist theatre Implant order book for stock purposes.

23. Consent for Disposal of Products of Conception

The consent forms for disposal of remains for patients undergoing an Evacuation of Retained Products of Conception (ERPC) or Laparoscopic Ectopic Operation.

If a specimen needs to be sent to Histology during a procedure the consent form needs to go with the Histology form and the specimen.

If ‘Application for Cremation’ form needs to be completed this should be done by the operating surgeon.

• The White Copy should be sent to Histology • The Yellow Copy should be placed into the patients notes • The Pink copy is retained in the book.



A ‘Permission for Cremation’ form is available, if this is required it will have been completed by the Petter Ward nurse and signed by the mother.

In this case it is the White copy is sent to Histology, the Yellow copy should be held in the patient’s notes and the White copy is attached with the application and histology form and sent to Histology.

24. Theatre Maintenance

Each theatre is closed on an annual basis for maintenance which includes the testing and checking of ventilation systems and changing filters. At this time, any defects will be amended such as flooring, paintwork etc., as well as any lighting changes that are required.

Air Sampling

Air sampling in theatres takes place on an annual basis.

Programme:

Prior to closure;

• organise Sodexo to provide a cleaning team for the appropriate date

• organise plates from Path Lab for collection on Day 1 of the Maintenance.

Day 1

• Collect 2 plates from the Pathology Lab and store in fridge nearest to the Theatre that is undergoing maintenance

• Close and clear the Theatre at the end of the day’s operating list

• Notify Facilities that the Theatre has finished the day’s operating and Maintenance will commence that evening.

Day 2

• Theatre closed for maintenance work

• Once Facilities have finished their work ensure that the ventilation system is switched on

• Theatre staff to clean high walls and ventilation grills

• Contact Sodexo cleaning team who will scrub floors during the evening



Day 3

Prior to anyone entering theatre and with the ventilation left on all night, the air sampling should take place.

• Take one of each type of plate and write on theatre number, date and time of sample on the lid • Perform the air sampling procedure as per instructions of the machine • Place the plates in a plastic bag and take to Path Lab on Level 1 and place in the incubator • A Microbiology form needs to be sent with the plates

Day 4

• Theatre to remain closed while Sodexo clean all areas • Theatre to be restocked ready for use

Day 5

• Results from Plates will be phoned through by Path Lab to the Theatre Manager. Discrepancies will be discussed with Dr Richards of the Infection Control Team.

25. Equality Impact Assessment

Group Positive Impact

Negative Impact

No Impact

Comment

Age X

Disability X

Gender X

Gender Reassignment X

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment), marriage and civil partnership

X

Pregnancy X

Maternity and Breastfeeding

X

Race (ethnic origin) X

Religion (or belief) X

Sexual Orientation X



Appendix A: PACU Discharge Criteria



Divisional Nurse Divisional DirectorAssociate Medical Director

Service ManagerAnaesthetics Lead Clinician

Trauma & Orthopaedics Lead Clinician

Booked Admissions

Operating

Department

Manager Theatres

DSU

Pre-op Assessment

Service ManagerGeneral Surgery Lead Clinician

Urology Lead Clinician

Private Patients

Patient Access Team

Angela Walton Outpatient Nurses

Orthotics & Patient Appliances

Outpatient Clerical Teams

Jane Martin Radiology Lead Clinician

Service ManagerOphthalmology Lead Clinician

ENT

Oral Max Fax

Plastics

Group Manager Pharmacy

Group Manager Pathology Lead Clinician

ICU Medical Lead

KGV

Lundy

Tarka

Capener

Group Manager

Group Manager

Group Manager

Appendix B: Planned Care and Surgery Organisational Chart



TH1 TH2 TH3 TH4 TH7 TH5 TH6 TH8 TH12

Deputy Deputy Deputy Deputy Deputy Deputy Deputy Deputy

* CLERICAL STAFF: Anaesthetic Co-ordinator, Theatre Management Secretary, Materials Management, Theatre Reception/Clerical Support

NB: 3 Staff in Theatre for a list - 2 scrub and 1 circulating, 1 anaesthetic support and 1 x recovery staff member for each list

Band 2s

Clerical Staff *

Band 2s Band 2s

Band 5s

ODPs / Nurses

Deputy Managers

Band 3s

Deputy Manager

Operating Department Manager

Band 3 Band 3s

Manager

Band 3s

Band 2s

Pre-Assessment

Band 5s

ODPs / Nurses

Deputy Managers

Band 5s ODPs & Nurses

Band 3s

Band 5

Ward Nurses

Day Surgery

Ward &

Admissions

Band 5

Nurses

(part time job share)

Band 5s ODPs & Nurses

Simulation Suite

Theatre Co-ordinatorDeputy Theatre

Day Surgery Theatres:

Team Leaders & Deputies

Manager

Education Facilitator

Team Leaders & Deputies

Main Theatres:

Deputy Managers

Day Surgery Ward

Support ManagerManager

Anaesthetics

Manager

Management Structure for Operating Department at NDDH

Recovery Services

Appendix C: Theatre Department Structure Chart



Appendix D: Cancelled Operation Reporting Process

NDHT CANCELLED-OPS REPORTING PROCESS

To provide for the notification of:-

patients admitted for elective surgery but not treated