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THEATRE PRACTICE POLICY
Reference Number:
416 2009 Heather Cooper, Lynn Wallace, Justine Archman, Pippa Humphries, Lynn Howes. Surgical
Author & Title:
Responsible Directorate:
Review Date:
September 2012
Ratified by (committee):
Surgical Board
Date Ratified:
September 2009
Version:
Related Policies
Page 1 of 131
Index: POLICY _______________________________________________________________________7 INTRODUCTION _______________________________________________________________7 SECTION A ANAESTHETIC STANDARDS ______________________________________7 Anaesthetic Theatre Standards Contents ________________________________________7 Anaesthetic Theatre Standard No 1 _____________________________________________8 Anaesthetic Theatre Standard No 2 ____________________________________________10 Materials & Equipment for both Adult & Paediatric ______________________________10 Anaesthetic Theatre Standard No 3 ____________________________________________11 Anaesthetic Theatre Standard No 4 ____________________________________________12 Anaesthetic Theatre Standard No 5 ____________________________________________13 Anaesthetic Theatre Standard No 6 ____________________________________________14 Anaesthetic Theatre Standard No 7 ____________________________________________14 Anaesthetic Theatre Standard No 8 ____________________________________________15 Anaesthetic Theatre Standard No 9 ____________________________________________16 Anaesthetic Theatre Standard No 10 ___________________________________________16 Anaesthetic Theatre Standard No 11 ___________________________________________17 Anaesthetic Theatre Standard No 12 ___________________________________________18 Anaesthetic Theatre Standard No 13 ___________________________________________18 Anaesthetic Theatre Standard No 14 ___________________________________________19 Anaesthetic Theatre Standard No 15 ___________________________________________20 Anaesthetic Theatre Standard No 16 ___________________________________________21 Anaesthetic Theatre Standard No 17 ___________________________________________21 Anaesthetic Theatre Standard No 18 ___________________________________________22 Anaesthetic Theatre Standard No 19 ___________________________________________23 Anaesthetic Theatre Standard No 20 ___________________________________________24 Anaesthetic Theatre Standard No 21 ___________________________________________25 Anaesthetic Theatre Standard No 22 ___________________________________________26 Anaesthetic Theatre Standards No 23 __________________________________________27 Anaesthetic Theatre Standard No 24 ___________________________________________28 Anaesthetic Theatre Standard No 25 ___________________________________________29 Anaesthetic Theatre Standards No 26 __________________________________________29
Document Name: Theatre Practice Policy
Issue Date: September 2009 Page 2 of 131
Ref 416/2009 Status: Final
Step One: ____________________________________________________________________30 Step Two: To prepare the collection system ____________________________________30 Step Three: Preparing the machine and disposables ____________________________31 Step Four: Inspect & Finish ____________________________________________________32 Trouble Shooting _____________________________________________________________32 Anaesthetic Theatre Standard No 27 ___________________________________________33 Prior to receiving a child into the anaesthetic room _____________________________34 Ensure the location and availability of the following _____________________________34 Please refer to the following Anaesthetic Theatre Standards _____________________36 Anaesthetic Standard No 28 ___________________________________________________36 Anaesthetic Theatre Standard No 29 ___________________________________________39 Anaesthetic Theatre Standard No 30 ___________________________________________40 Anaesthetic Theatre Standard No 31 ___________________________________________41 Anaesthetic Standard No 32 ___________________________________________________42 Anaesthetic Standards No 33 __________________________________________________44 Anaesthetic Theatre Standard No 34 ___________________________________________45 Anaesthetic Theatre Standard No 35 ___________________________________________46 Anaesthetic Theatre Standard No 36 ___________________________________________47 Anaesthetic Theatre Standard No 37 ___________________________________________48 Operating Theatre Standard 38 ________________________________________________49 Anaesthetic Standard 39 ______________________________________________________50 Operating Theatre Standard 40 ________________________________________________51 Anaesthetic Theatre Standard No 41 ___________________________________________54 Anaesthetic Theatre Standard No 42 ___________________________________________56 Operating Theatre Standard No 1 ______________________________________________57 Operating Theatre Standard No 2 ______________________________________________58 Operating Theatre Standards No 3 _____________________________________________59 Exceptions: None ___________________________________________________________60 Operating Theatre Standard No 4 ______________________________________________60 Addenda to Collection of Specimens Standard __________________________________61 No 4a Localised Excision of Breast Lesion: _____________________________________62 No.4b Other Breast Specimens: ________________________________________________62 No 4c) Frozen Sections: _______________________________________________________62
No 4d) E.N.T. Specimens: _____________________________________________________63 No 4e Foetal Tissue and Remains ______________________________________________63 Operating Theatre Standard No 5 ______________________________________________64 Operating Theatre Standard No 6 ______________________________________________64 Operating Theatre Standards No 7 _____________________________________________65 Operating Theatre Standard No 8 ______________________________________________66 Operating Theatre Standard No 9 ______________________________________________67 Operating Theatre Standard No 9A _____________________________________________68 Operating Theatre Standard No 10 _____________________________________________69 Operating Theatre Standard No 11 _____________________________________________70 Operating Theatre Standard No 12 _____________________________________________71 Operating Theatre Standard No 13 _____________________________________________72 Operating Theatre Standard No 13A ____________________________________________74 Operating Theatre Standard No 14 _____________________________________________75 Operating Theatre Standard No 15 _____________________________________________76 Operating Theatre Standard No 16 _____________________________________________76 Operating Theatre Standard No 17 _____________________________________________78 Operating Theatre Standard No 17a ____________________________________________80 Radiation Protection __________________________________________________________80 Standard Statement: __________________________________________________________80 Operating Theatre Standard No 18 _____________________________________________81 Operating Theatre Standard No 19 _____________________________________________81 Operating Theatre Standard No 20 _____________________________________________84 Operating Theatre Standard No 21 _____________________________________________85 Operating Theatre Standard No 22 _____________________________________________86 Standard: ____________________________________________________________________86 Sharps use and safe disposal. _________________________________________________86 Method: ______________________________________________________________________86 Compliance: 100%_________________________________________________________86 Operating Theatre Standard No 23 _____________________________________________86 Operating Theatre Standard No 24 _____________________________________________88 Operating Theatre Standard No 25 _____________________________________________90 Addenda to Swab and Instrument Counts Standard No 25 _______________________91
No 25a: Swab and Instrument count for Obstetric Emergencies.__________________91 Operating Theatre Standard No 26 _____________________________________________91 Sterile Services Unit Documentation ___________________________________________92 Operating Theatre Standard No 27 _____________________________________________93 Operating Theatre Standard No 28 _____________________________________________94 Operating Theatre Standard No 29 _____________________________________________96 Operating Theatre Standard No 31 _____________________________________________97 See also______________________________________________________________________99 Operating Theatre Standard No 32 _____________________________________________99 Operating Theatre Standard No 33 ____________________________________________100 Operating Theatre Standard No 34 ____________________________________________101 Operating Theatre Standard No 35 ____________________________________________102 Operating Theatre Standard No 36 ____________________________________________103 Wound, drain and catheter dressings. _________________________________________103 Method: _____________________________________________________________________103 Reference: 1998 NATN Principles of Safe Practice in the Perioperative Environment 104
Operating Theatre Standard Number 37 _______________________________________104 Operating Theatre Standard No. 38 ____________________________________________104 Operating Theatre Standard No. 39 ____________________________________________105 Operating Theatre Standard No 40 ____________________________________________106 Operating Theatre Standard No 41 ____________________________________________107 Ordering:____________________________________________________________________108 Receipt: _____________________________________________________________________108 Use: ________________________________________________________________________109 Operating Theatre Standard No 42 ____________________________________________109 SECTION C POST ANAESTHETIC CARE UNIT STANDARDS ___________________110 ORSOS Layout of PACU Standards Of Care____________________________________110 Maintenance of temperature 5 ________________________________________________110 High Dependency Care 16 + 17 _______________________________________________111 PACU Standard No 1 _________________________________________________________112 PACU Standard No 2 _________________________________________________________112 PACU Standard No 3 _________________________________________________________113 PACU Standard No 4 _________________________________________________________114 Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 5 of 131
PACU Standard No 5 _________________________________________________________115 PACU Standard No 6 _________________________________________________________116 PACU Standard No 7 _________________________________________________________117 PACU Standard No 8 _________________________________________________________118 PACU Standard No 10 ________________________________________________________119 PACU Standard No 10a _______________________________________________________120 PACU Standard No 10b_______________________________________________________121 PACU Standard No 11 ________________________________________________________122 PACU Standard No 12 ________________________________________________________123 PACU Standard No 13 ________________________________________________________124 PACU Standard No 14 ________________________________________________________124 PACU Standard No 15 ________________________________________________________125 PACU Standard No 15a _______________________________________________________126 PACU Standard No 15b_______________________________________________________127 PACU Standard No 16 ________________________________________________________127 PACU Standard No 17 ________________________________________________________128 PACU Standard No 18 ________________________________________________________129 CONSULTATION CHECKLIST _________________________________________________131
POLICY INTRODUCTION 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 aim of this policy is to outline the standards of care that must be delivered to each individual patient to ensure a high quality of care is provided to patients entering the Operating Theatres. The objectives of the policy are: To ensure that a standard of care is delivered to each individual that is equitable and fair. 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 Post Anaesthetic Care Unit. To enable auditing of nursing practice throughout 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 of the departments expectation of the standards of care to be delivered to all patients.
Scope of the Policy These standards of care will apply to all Operating Theatres across the Royal United Hospital site. Day Surgery care standards will apply to all patients cared for in the Day Surgery Unit. All new members of staff will receive an electronic copy of the standards applicable to the area they will work in. All staff will be able to access the care standards via desktops in the Department. SECTION A ANAESTHETIC STANDARDS Anaesthetic Theatre Standards Contents Appropriately receive patients for clinical procedures Safely prepare and transfer patients for clinical procedures Safely position patients for clinical procedures Appropriately prepare the anaesthetic room and operating theatre ready for adult/paediatric anaesthesia dependent on theatre operating list Ref 416/2009 Status: Final
The anaesthetic assistant is competent in the location and use of all emergency equipment required within their working environment The patients temperature is maintained at the optimum level appropriate to surgery Safely and competently prepare materials and equipment for intravenous infusion and transfusion Patients physiological parameters are adequately monitored during the induction of anaesthesia The patient is safely transferred to the operating table from the bed or trolley All staff to attend mandatory training Faulty equipment is dealt with promptly and in the correct manner The anaesthetic care plan/ORSOS is accurately completed according to the patients individual needs and received care The anaesthetic assistant appropriately assists the anaesthetist during the reversal of anaesthesia Safely prepare and monitor anaesthetic materials and equipment Safely monitor and maintain medical gas supplies within the operating department Ensure the patient is adequately prepared for clinical procedures Safely assist in venous and arterial cannulation during clinical procedures for both adult and paediatric patients Assist in the establishment and maintenance of the patients airway both adult and paediatric Accurately monitor the physiological parameters and fluid balance of patients undergoing clinical procedures Competently identify and respond to clinical emergencies Competently assist the clinician in treating patients during clinical emergencies Identify the need for and perform immediate life support
Anaesthetic Theatre Standard No 1 Standard: Anaesthetic room and operating theatre preparation Standard Statement The anaesthetic room and operating theatre is appropriately prepared ready for adult/paediatric anaesthesia dependent on theatre list and the anaesthetists requirements Method: All anaesthetic staff will have the required training, skills and knowledge, and will have been assessed as competent The anaesthetic machine in the anaesthetic room and the anaesthetic machine in the operating theatre should be checked following the manufacturers guidelines, i.e. cylinders and pipeline gases, vaporisers, breathing circuits, suction, ventilator, alarms, oxygen analyser, capnograph, airway manometer, spirometer and anaesthetic gas analyser (please refer to the royal college of anaesthetists guidelines for checking all anaesthetic machines) All patient breathing circuits should be changed at the start of each day, the spirometer, CO2 line, pressure monitor tube and D-lites are now disposable items
therefore should be replaced every Monday morning, please ensure that these lines are replaced when visibly soiled Full monitoring should be available and ready for use, i.e. ECG, pulse oximeter, capnograph, non invasive blood pressure, invasive blood pressure, spirometer, nerve stimulator and temperature monitor The following equipment should be available at all times including during local anaesthetic procedureso Airway management trolley o Laryngoscopes (McCoy, Polio, Standard Mcintosh & long blade) o A selection of cuffed endotracheal tubes for adults and uncuffed endotracheal tubes for paediatrics appropriate to the type of surgical or anaesthetic procedure o Appropriate oral & nasal airways o Bougie introducer and stylets o Suction o Mcgill forceps Anaesthetic Theatre Standard No 1 cont o Selection of securing tapes o Invasive/spinal/epidural trolley o Specialised needles o Basic packs o Specialised dressings o Local anaesthetic o Sodium chloride o Selection of needles and syringes o Arterial and central venous equipment The anaesthetic room should be checked to ensure adequate stock levels of all items that may be required appropriate to that speciality Specific paediatric equipment should be prepared appropriately for the patients weight and size, please see paediatric standards The temperature in the anaesthetic room/operating theatre will be adjusted accordingly dependent on the patients individual needs The anaesthetic room and all equipment should be clean after each patient and kept tidy at all times Emergency equipment should be available, in good working order, within the department in the designated areas at all times, and when in use documented on the appropriate information boards Equipment found to be faulty should be sent to the appropriate department for repair and a replacement obtained if necessary Any missing equipment should be traced and returned Play equipment should be readily available and used if appropriate (advice from the play specialist in the childrens unit can be sought) Compliance 100% Exceptions None Ref 416/2009 Status: Final
Reference
Southampton University Hospital ODP Level 3 Standards (Sept 2000) AODP/HPC Standards Please refer to Paediatric Standards (PACU) Royal college of anaesthetists guidelines Anaesthetic Standard No 20 (temperature)
Anaesthetic Theatre Standard No 2 Standard: Anaesthetic materials and equipment Standard Statement: All anaesthetic materials and equipment are safely prepared and monitored in preparation of the list and continuously throughout Method: All staff must undertake the appropriate training and deemed competent in the use of materials & equipment prior to use Ensure the correct materials and equipment are selected and prepared according to the clinical speciality, the type of anaesthesia to be given, the requirements of the operating list, and patients individual needs Ensure all materials and equipment are prepared in the appropriate manner and time, according to the patients clinical status (i.e. elective or emergency) Ensure all equipment is checked and confirmed as safe, ready for use & functioning correctly Ensure all equipment is set up & calibrated correctly in line with the manufacturers instructions, and to meet the needs of the overall operating list and the patients plan of care Where equipment is found to be faulty or unsafe during preparation, the appropriate action is taken to remedy or report the fault ( Refer to anaesthetic standards for faulty equipment) Ensure all materials and equipment are positioned in a way which facilitates their access and use, according to the sequence of procedures on the operating list Ensure all materials and equipment are handled and moved safely, correctly & hygienically, in accordance with manufacturers guidelines & infection control Anaesthetic machine checks should be carried out using the royal college of anaesthetists guidelines Materials & Equipment for both Adult & Paediatric Anaesthetic machines Ventilators Vaporisers Breathing systems Vascular access/epidural/spinal procedure packs Ref 416/2009 Status: Final
Specialised needles Suction apparatus Hotline fluid warmer and bear hugger Airway management trolley Invasive/spinal/epidural trolleys Laryngoscopes Intubation aids Endotracheal tubes (cuffed, uncuffed, preformed, endobronchial, laser, ILMA) Airways both oral & nasal HMEs Laryngeal mask airways Proseals ECG Pulse oximeter NIBP/IBP Invasive blood pressure monitors and transducers Capnogragh Spirometer Disconnection alarms Nerve stimulator Temperature monitoring probes and equipment Intravenous fluids Syringes and Drugs
Compliance 100% Exceptions None Southampton University hospital - ODP level 3 Standards Reference AODP/HPC Gudelines Paediatric Standards (PACU) Royal college of anaesthetists guidelines Anaesthetic Theatre Standard No 3 Standard: Arterial cannulation Standard Statement: Safely assist in arterial cannulation during clinical procedures for both adult and paediatric patients Method: Ensure the patient is offered appropriate information, support and reassurance in a sensitive manner Ensure the care provided to the patient is consistent with their individual needs, plan of care & expressed personal beliefs, & preferences, within the constraints of the setting and the clinical procedure
Ensure that the required materials & equipment are made available & ready for use before the arterial cannulation procedure is started Ensure the specified cannulation site is prepared & cleaned effectively, and in a way which optimises the patients comfort, dignity & safety and that the site is prepared to provide optimal conditions to facilitate cannulation Ensure the canula/line is secured adequately & safely, to facilitate access and minimise patient discomfort Ensure the transducer line is clearly labelled and identifiable as an arterial line Ensure universal precautions for infection control are applied correctly and that waste & sharps are disposed of safely in the correct manner.
Compliance 100% Exceptions None Reference Southampton University Hospital - ODP level 3 Standards Paediatric Standards (PACU) Manufacturers guidelines for setting up transducers AODP/HPC Guidelines Anaesthetic Theatre Standard No 4 Standard: Airway maintenance and establishment Standard Statement: Assist in the establishment and maintenance of the patients airway both adult and paediatric Method: All staff assisting in the establishment and maintenance of a patients airway will have under gone the appropriate training and deemed competent Ensure liaison with the lead anaesthetic clinician and surgical clinician where appropriate Ensure the required airway establishment & maintenance materials and equipment are selected, according to the patient and the procedure, confirmed as fit for use, and prepared correctly at the appropriate time Ensure the patient is offered the relevant information, reassurance & support in a manner which is sensitive to their needs & concerns Appropriate action is taken to optimise the comfort & dignity of the patient throughout & to minimise pain & trauma Ensure the patient is appropriately positioned for the procedure (rapid sequence induction, oral/nasal intubation, tracheostomy, awake fibre optic intubation) Ensure all materials & equipment are handled correctly & safely throughout, in line with manufacturers instructions Ensure patients physiological parameters are monitored throughout the procedure Ensure all devices used to maintain the patients airway are secured appropriately Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 12 of 131
Apply universal precautions for infection control at all times Ensure that any signs of the patients airway being compromised is recognised promptly and the appropriate action is taken immediately
Compliance 100% Exception None
Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 5 Standard: Clinical emergencies Standard Statement: All staff to competently identify and respond to clinical emergencies Method: Ensure observation and monitoring of the patients condition is sufficient to identify clinical emergencies as soon as they occur Ensure any signs or symptoms of an actual, or potential, clinical emergency is identified correctly and reported to the appropriate clinician Ensure the priorities for the patients care are identified promptly and accurately and appropriate action is taken immediately Ensure the patients vital functions are maintained pending attendance of medical staff and during interventions Ensure the relevant items of equipment are obtained promptly, prepared correctly for use and made available to the appropriate clinician Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards AODP/HPC Guidelines Paediatric Standards (PACU) RUH ILS Information pack
Anaesthetic Theatre Standard No 6 Standard: Clinical emergencies Standard Statement: All staff to competently assist the clinician in treating patients during clinical emergencies Method: Ensure the patients condition, and the clinicians actions, are monitored closely to determine what assistance is needed during the clinical emergency Ensure delegated activities are carried out promptly and correctly Ensure the required materials and equipment are made ready and available for use by the appropriate clinician Ensure the required drugs and diluents are obtained promptly as requested by the clinician Ensure the patient is given appropriate support and reassurance throughout Universal precautions for infection control are applied correctly Ensure all relevant information is clearly and accurately recorded in the appropriate documentation Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines RUH ILS information pack Anaesthetic Theatre Standard No 7 Standard: Documentation is completed accurately and legibly for all patients Standard Statement The anaesthetic care plan/ORSOS is accurately completed according to the patients individual needs and received care Method: All staff to complete ORSOS training All documentation to be legibly written, signed and dated Pre-operative care plan is checked for accuracy Al patient intervention is documented in full on ORSOS Items are recorded on the care plan, Tray labels, LMA labels etc for traceability purposes
The care plan is evaluated for accuracy throughout the peri-operative period and changes to care documented
Compliance 100% Exceptions When the admitted patient is unconscious, direct from A&E or ITU to theatre in a life threatening situation Reference Southampton University Hospital ODP level 3 Standards Orsos Standards AODP/HPC Guidelines Anaesthetic Theatre Standard No 8 Standard: Emergency equipment location and use of Standard Statement: The anaesthetic assistant is competent in the location and use of all emergency equipment required within their working environment Method: All theatre practitioners working within anaesthetics will have undertaken the necessary training to gain the knowledge and skills required, they will have been assessed as competent The anaesthetic assistant will know the whereabouts of all emergency equipment/materials All should undertake the mandatory ILS/BLS course and be deemed competent Competence in location and use of:o o o o o o o o o Airway management trolley Paediatric airway management trolley Difficult intubation trolley (including fibre-optic bronchoscope) Cook exchange catheters Tracheostomy (minitrach/manujet) Portable monitoring, ventilator and suction Emergency drugs/Cardiac arrest drugs Ambu-bag Defibrillator
Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines
Anaesthetic Theatre Standard No 9 Standard: Management of faulty equipment Standard Statement: Faulty equipment is dealt with promptly and in the correct manner in conjunction with the manufacturers guidelines Method: Equipment is made safe and withdrawn from use Staff to be aware of the appropriate repair requisition forms, the process in which to liaise with the appropriate department and arrange for repair The appropriate member of senior staff are informed of any faults or breakages Records are kept of equipment sent for repair Equipment is decontaminated before sending for repair Manufacturers instructions are available and followed Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards AODP/HPC Guidelines Anaesthetic Theatre Standard No 10 Standard: Preparation of and connection of intravenous infusions, delivery lines and transfusion Standard Statement: Staff will safely and competently prepare materials and equipment for intravenous infusion, delivery lines and transfusion after liaison with the lead anaesthetic clinician Method: All staff have undertaken the appropriate training and assessed as competent with the necessary knowledge regarding fluid/drug incompatibilities and route of delivery The appropriate cannulae, administration sets and infusion equipment are prepared in the appropriate manner and time All patient delivery lines and infusions to be labelled appropriately along the whole length of the line intermittently paying particular attention to the distal ends with either a label with IVI (Intra Venous Infusion) written on it or the appropriate coloured DRUG label ( i.e. METERAMINOL/EPHEDRINE/EPIDURAL) All delivery lines and infusions to be labeled correctly with the date and time of preparation and the name of the practitioner setting up the infusion The fluid, rate and volume are to given as prescribed and recorded correctly on to the fluid chart, anaesthetic chart or observation chart
Two trained practitioners to confirm the solution required and the correct connection site prior to connection, and prior to the commencement of the solution Asepsis and universal precautions are to be maintained throughout The cannulae site is secured and supported, observed regularly and any irregularities reported and documented Appropriate connectors are used for multiple infusions, and filters used where necessary Trust policy is adhered to regarding the checking and administration process by the competent practitioners Pressure bags, hotlines and level 1 rapid infusers are used where required and along with manufacturers guidelines Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Universal Precautions and Health and Safety Standards
Anaesthetic Theatre Standard No 11 Standard: Patients physiological parameters are adequately monitored during the induction of anaesthesia Standard Statement: All staff prepare for the safe induction of anaesthesia, taking into account the anaesthetist requirements Method: The patient is given appropriate information, support and reassurance throughout the attachment of monitoring The physiological parameters of the patient are monitored accurately using the correct non-invasive equipment Non invasive monitoring includes:- Pulse oximeter, ECG, NIBP, Capnograph and nerve stimulator Monitoring is carried out in a way which optimises the patients comfort, dignity and safety Any required measurements are interpreted accurately, and recorded correctly using the required format Any deviation from acceptable limits is identified correctly and appropriate action taken immediately, by informing the lead anaesthetist Universal precautions for infection control are applied correctly Compliance 100% Exceptions None
Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) Universal Precautions & Infection Control policy AODP/HPC Guidelines Anaesthetic Theatre Standard No 12 Standard: Immediate life support Standard Statement: All staff able to identify the need for and perform Immediate Life Support Method: Ensure all staff attend the ILS course Ensure the need for immediate life support is identified correctly Ensure medical assistance is summoned immediately Ensure the patients airway is established and maintained Ensure the patient is placed in a position which facilitates Immediate Life Support Ensure external cardiac compression and ventilation of the lungs are performed correctly Ensure the patients physiological parameters are monitored appropriately and any variations or abnormalities are reported immediately to the clinician Ensure a detailed log of events are recorded accurately in the patients medical and nursing notes Universal precautions for infection control are applied correctly Compliance 100% Exceptions None Please see paediatric standards in PACU Reference Southampton University Hospital ODP level 3 Standards Monitoring physiological parameters standard Assist at establishing the patients airway standards Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 13 Standard: Mandatory training responsibilities Standard Statement All staff to attend and take responsibility for their individual mandatory training needs
Method: Staff to take individual responsibility for keeping up to date with mandatory requirements Staff and management produce evidence that all statutory training requirements have been met in the following areas: COSHH FIRE BLS/ILS/PBLS Manual handling Infection control Health and safety Risk management Staff appraisal is done annually to assess individuals needs and to produce a written action plan Compliance 100% Exceptions None Reference RUH Mandatory Training Policy & Procedure Anaesthetic Theatre Standard No 14 Standard: Position patients safely for clinical procedures Standard Statement: Theatre staff will ensure that all patients are positioned safely in accordance with the proposed operation and the clinicians requirements Method: The patient is offered the appropriate information, support and reassurance in accordance with their individual needs and the proposed plan of care, relevant to the specific operative procedure The required positioning equipment is confirmed as safe and in good working order Any necessary assistance is sought from appropriate colleagues and clinicians before starting the positioning procedure Safe and suitable moving and handling techniques are used throughout the positioning of the patient taking into account their conscious level Positioning equipment is used safely and correctly to create the required position, without causing harm to the patient or to staff, Positioning is carried out in a way which minimises the patients pain and discomfort, and which maximises their dignity The patient is observed during positioning and any unexpected change is recognised and the appropriate action taken without delay
Appropriate padding support and covers are used to prevent patient injury and excessive heat loss The patient is positioned correctly to meet the requirements of the clinical procedure, anaesthetist and surgeon
Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 15 Standard: Patient preparation prior to clinical procedures Standard Statement: All staff to ensure the patient is adequately prepared for clinical procedures Method: Ensure the patient is offered the appropriate information, support & reassurance in a sensitive manner Ensure operative site (draping, skin preparation & hair removal) is prepared correctly and safely, and in a manner which optimises the patients dignity, comfort and safety Ensure that information is given to the patient (alert & orientated or disorientated) in a way which facilitates their understanding, and promotes the confidence in the care team Ensure that all questions & concerns from the patients are answered clearly & appropriately by the relevant member of the team Ensure all care provided to the patient takes due account of their individual needs. Plan of care & expressed personal beliefs, preferences & views, within the constraints of the setting & the procedure Ensure the patients operative site is identified correctly, marked & any uncertainties are clarified with the appropriate member of the theatre team prior to the preparation starting Ensure all equipment and materials are selected & used correctly in a manner which minimises risk to all Ensure that the patient is prepared in accordance with the requirements of the procedure and the clinician, & the assessed needs of the patient Ensure that the appropriate site for attaching equipment is selected, attached & repositioned as necessary in accordance with the requirements of the clinical procedure Ensure all waste is disposed of safely & correctly (refer to Waste policy)
Compliance 100% Exceptions None Reference Southampton University hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 16 Standard: Physiological parameters and fluid balance Standard Statement: All anaesthetic assistants to accurately monitor the physiological parameters and fluid balance of patients undergoing clinical procedures Method: Ensure the patient both adult & paediatric, is given the appropriate information, support & reassurance throughout Ensure the patients physiological parameters and fluid balance of the patient are monitored accurately using the correct technique & equipment Monitoring is carried out in a way which optimises the patients comfort, dignity & safety Any required measurements are interpreted accurately, & recorded correctly using the required format Any deviation from acceptable limits of the patients physiological parameters and fluid balance is identified correctly, and appropriate action is taken immediately by informing the lead anaesthetic clinicians Universal precautions for infection control are applied correctly Compliance - 100% Exceptions - None Reference Southampton University Hospital ODP level 3 Standards RUH Universal Precautions Policy Infection Control Policy Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 17 Standard: Receive patients for clinical procedures Standard Statement:
Appropriately receive patients for clinical procedures, ensuring the patient received is the correct patient as stated on operating list, and that the proposed operation correlates with the op list, consent form and patients wishes Method: The patient and any accompanying personnel are welcomed in an appropriate manner, detailing name and role, offering support and reassurance throughout The patient identity is confirmed with the patient and against relevant records such as checking patients notes, completed ward check sheet, operating list and consent form and patient identity band, questioning the patient, inspecting the operation site and checking with accompanying person that all details are correct The appropriate checks are made and recorded to confirm that all required preparation has been completed such as, Hospital number, date of birth, allergies, removal or retained dentures, fasting, removal of jewellery, nail varnish and false nails, the location of prosthesis and any relevant past medical history Dentures and hearing aids and other sensitive prosthetics such as wigs, may be retained until the patient is in the anaesthetic room. These will then be removed and returned to the ward by the accompanying ward escort Details of the proposed procedure, operation site marking and date on the consent form are checked and confirmed with the patient Any items or medication that the patient may need in the immediate post operative period such as hearing aids or dentures and inhalers or sprays should be clearly labeled with the patients details and kept with the patients records until safe arrival into PACU Any problems identified are investigated and recorded, and where necessary the surgeon and/or anaesthetist are informed and the appropriate remedial action taken Compliance - 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Anaesthetic Theatre Standard No 18 Standard: The reversal of anaesthesia Standard Statement: The anaesthetic assistant appropriately assists the anaesthetist during the safe reversal of anaesthesia Method: Planning the patients extubation and reversal of anaesthesia must always be in consultation with the lead anaesthetic clinician
Staff must have the appropriate training and be competent to carry out this procedure During the reversal of anaesthesia the theatre environment is kept as quite as possible Suction apparatus is available and in good working order with a clean yankeur sucker and suction catheters available The patient should be positioned correctly on the bed/trolley as required by type of anaesthetic The airway management trolley is well stocked and available in close proximity to the patient The anaesthetic assistant prepares any necessary equipment specifically required by the anaesthetist for the patient concerned emergency re-intubation equipment should be readily available The anaesthetic assistance should provide any assistance required by the anaesthetist and should continue to care for the patients safety and dignity Once the anaesthetic is reversed and the patient is breathing spontaneously and adequately, oxygen should be provided for the transfer to recovery
Compliance 100% Exceptions Reference None Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) Universal Precautions & Infection Control Policy AODP/HPC Guidelines
Anaesthetic Theatre Standard No 19 Standard: Transfer patients for clinical procedures Standard Statement: Theatre staff will ensure that theatre is prepared ready for the safe transfer of patients for clinical procedures Method: The appropriate method and route of transfer is selected e.g. pat slide and equipment checked for its integrity The patient is informed of the nature and purpose of the transfer in a manner which encourages their cooperation To ensure the immediate surroundings are prepared appropriately for the transfer from the patients bed to the operating table All potential hazards are recognised and removed Safe and suitable moving and handling techniques are used throughout the transfer
Patients level of consciousness is taken into account prior to the transfer and the appropriate support equipment is secured during the transfer, and care is taken not to damage or displace it The conscious patient is offered reassurance and support throughout the transfer The patient monitored during the transfer, and any unexpected changes are recognised, and dealt with appropriately without delay The transfer is carried out in a way which minimises the patients pain and discomfort and maximises their dignity The transfer must be directed by the person at the head of the patient, taking responsibility for the transfer in accordance with manual handling guidelines
Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) Patient Transfer Standard No 21 AODP/HPC Guidelines Anaesthetic Theatre Standard No 20 Standard: Temperature maintenance Standard Statement: The patients temperature is maintained at the optimum level appropriate to the surgical and anaesthetic requirements Method: Room temperature and humidity are within an acceptable range:- humidity 45% 55% and temperature 19 21 degrees Warming devices should be available for use if required Temperature monitoring equipment and devices should be used if warming or cooling aids are used during any procedures Main theatre doors should not be used intra-operatively and traffic flow through theatre should be according to operational policy Compliance 100% Exceptions The theatre temperature may vary according to the age , and weight of the patient, e.g. Paediatrics Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) AODP/HPC Guidelines Ref 416/2009 Status: Final
Anaesthetic Theatre Standard No 21 Standard: Patient transfer from bed to operating table Standard Statement The patient is safely transferred to the operating table from bed or trolley under the instruction of the person at the head of the patient Method: All members of staff had undertaken the mandatory manual handling training The operating table is correctly positioned with the brakes on, brakes also engaged on the bed/trolley Table attachments for positioning are available Appropriate moving aids are available and correctly used An appropriate number of staff are readily available for moving of patient, maximum load per person 25kg, I.e. 75kg patient 3 people, 80kg 4 people The member of staff at the head of the patients must co-ordinate the movement The patient is supported in all areas during transfer Patients limbs are secured and protected from injury All monitoring equipment, iv infusion, catheters etc, are safeguarded A qualified member of staff must be present at all times Pressure care is given as appropriate The patients dignity is maintained throughout manoeuvre Compliance 100% Exceptions Patients size and injuries may dictate safe alternative movement and procedure Reference Southampton University Hospital ODP level 3 Standards Anaesthetic Standards for Safe Transfer Paediatric Standards (PACU) AODP/HPC Guidelines
Anaesthetic Theatre Standard No 22 Standard: Transfer of patients from the operating theatre to the post anaesthetic care unit (PACU) Standard Statement: Staff will ensure the safety and dignity of the patient during the transfer from theatre to PACU post operatively, and ensure full handover takes place Method: A qualified theatre practitioner will accompany the patient and the anaesthetist during the transfer Ensure the bed is appropriate for the patient type Ensure all drains, catheters, infusion etc are protected and are not pulled or dislodged accidentally during the transfer Care should be taken to ensure that limbs remain in an appropriate anatomical position Ensure the patient is moved only at the command or permission of the anaesthetist (if no anaesthetist present, the member of staff at the head of the patient will coordinate the transfer) Ensure the patient is moved carefully and placed in a position appropriate for the surgery undertaken and to ensure an adequate airway is maintained Monitoring should be removed on the instruction of the anaesthetist All patients should have an adequate supply of oxygen during the transfer available, and an appropriate oxygen delivery system e.g. Hudson mask or T-bag Ambu-bags should be available at all times Cot sides should be raised during movement of the bed and for transfer of patient to PACU The patient must remain covered to protect dignity at all times during the transfer process Theatre staff will ensure the exit route is clear to facilitate rapid transfer Cot side guards should be used as necessary On arrival to PACU an appropriate bay will be located. The bed or trolley will be positioned to allow access to the head of the bed, and the brakes applied Theatre staff will assist in the application of the oxygen delivery system and full monitoring as required The anaesthetic assistant will handover any relevant information concerning the patient to the Designated PACU staff member The scrub practitioner should handover any relevant information regarding the surgical procedure etc to the PACU practitioner, any property to the patient should also be transferred to PACU All relevant documentation should accompany the patient and should be completed Using the ORSOS printout, theatre staff will handover to PACU all relevant details i.e. operation performed, skin closure, dressings, drains, catheters, any local anaesthetics given, any items left in situ requiring later removal
Other relevant patient care details such as pressure are problems, known skin breaches or adverse reactions must be recorded in the peri-operative printout and handed over to PACU for communication to the ward staff The theatre staff will sign the printout on completion of handover
Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) Transferring patients from table to bed Standard No 21 Patients safety and dignity Standard AODP/HPC Guidelines
Anaesthetic Theatre Standards No 23 Standard: Transfer of patients from theatre to ITU/HDU Standard Statement: All patients requiring ITU/HDU postoperatively will be transferred safely and rapidly Method: Once it is identified that the patient will require an ITU/HDU bed, the anaesthetist will ascertain its availability, and inform the ITU anaesthetist and staff of patients requirements The transfer will be discussed with the anaesthetist to allow accurate preparation The anaesthetic practitioner will liaise with ITU on the collection of the ITU bed, Oxylog ventilator, full monitoring unit and Oxygen cylinder, and organise the collection with a theatre orderly The anaesthetic practitioner will ensure the orderly returns the ward bed back to the correct ward, and that the ward is notified of the patients projected destination The anaesthetic Practitioner will ensure that the following accompany the patient to ITU o Ambu-bag o Emergency drugs o Additional intravenous fluid o Oxygen cylinder applicable to ambu-bag connection o Patient notes, x-rays and theatre ORSOS form The anaesthetic practitioner and scrub practitioner will accompany the lead anaesthetist and the patient during the transfer to ITU A member of the theatre team will phone ITU/HDU to advise that transfer and arrival of the patient is imminent An orderly will be directed to call for and hold a lift to facilitate as rapid a transfer as possible
The patients physiological parameters will be monitored closely during the transfer and any deviation remedied immediately On arrival to ITU the theatre staff will ascertain which entrance is the most appropriate for the available bed space and direct the transfer team accordingly Once the anaesthetic handover has been completed and the patient is settled, the accompanying theatre members will ensure all relevant patient care details are handed over, and the theatre database printout is signed Confirmation from the ITU practitioner is essential prior to leaving The anaesthetic practitioner and theatre tem member will ensure that all theatre equipment used during the transfer is returned to the operating department
Compliance 100% Exceptions None References Southampton University Hospital ODP level 3 Standards Transfer patients to PACU Standard No 22 Patient dignity and safety Standard Transfer from operating table to bed Standard No 21 AODP/HPC Guidelines Anaesthetic Theatre Standard No 24 Standard: Venous & central venous cannulation Standard Statement: Safely assist in venous and central venous cannulation during clinical procedures for both adult and paediatric patients Method: Ensure the patient is offered appropriate information, support and reassurance in a sensitive manner Ensure the care provided to the patient is consistent with their individual needs, plan of care & expressed personal beliefs, & preferences, within the constraints of the setting and the clinical procedure Ensure that the required materials & equipment are made available & ready for use before the venous and CVP cannulation procedure is started Ensure the specified cannulation site is prepared & cleaned effectively, and in a way which optimises the patients comfort, dignity & safety and that the site is prepared to provide optimal conditions to facilitate cannulation Ensure the canula/line is secured adequately & safely, to facilitate access and minimise patient discomfort Ensure the transducer line is clearly labeled and identifiable as an venous and central venous line Ensure universal precautions for infection control are applied correctly and that waste & sharps are disposed of safely in the correct manner
Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards Paediatric Standards (PACU) Manufacturers guidelines for setting up transducers AODP/HPC Guidelines Anaesthetic Theatre Standard No 25 Standard: Maintenance of medical gas supplies within theatres Standards Statement: All staff will safely monitor & maintain medical gas supplies within the operating theatre department Method: All staff dealing with medical gases must have undergone the appropriate training and be competent in there use Ensure cylinders both on anaesthetic machines and for transporting patients to recovery are correctly identified & confirmed as being at the correct temperature before use Ensure cylinders are handled correctly & safely with minimum risk to self, others & cylinders Ensure gas supply connectors are attached safely and correctly to anaesthetic machines Ensure that cylinders are stored safely in the designated racks and ensure that full & empty cylinders are stored separately from each other & are clearly identifiable Ensure the pipeline, valves and connectors are checked to be in good condition Ensure that the integrity and pressures of the pipeline system and cylinders are monitored effectively and the appropriate action taken if faults occur (refer to policy) Compliance 100% Exceptions None Reference Southampton University Hospital ODP level 3 Standards AODP/HPC Guidelines Anaesthetic Theatre Standards No 26 Standard: Cell Saver Preparation and use
Standard Statement: All staff to be trained in the preparation and use of the Haemonetics Cell Saver Machine, be competent in its use and be able to identify when its use is appropriate Method: All anaesthetic staff will have the required training on the preparation and use of the Cell Saver Machine, and be deemed competent by the trainer The use of the Cell Saver will be in consultation with the lead anaesthetic clinician Staff must ensure that the patients rights, choices and wishes are maintained throughout the use of the Cell Saver Machine Use of the Cell Saver must be in conjunction with the written standards The required equipment and materials will be collected from theatre 6s anaesthetic room, ensuring that its location detailed on the communication board Universal precautions will be applied throughout Ensure that the following steps are followed Step One: This anaesthetic theatre standard for the preparation and use of the Haemonetics Cell Saver is intended to aid in its use and is not in place of appropriate individual training sessions that you must have with SODP Pippa Humphries The supplies you will need can be found in theatre 6s anaesthetic room please also refer to the guide on the wall of what disposables are required 1. Cell saver machine 2. High speed cell saver bowl set 3. Hard shell reservoir 4. Aspiration Set 5. ACDA (Anticoagulant Fluid) 750ml 6. 1000ml sodium chloride x 2 Anaesthetic Theatre Standards No 26 cont 7. Standard suction tubing to connect to the suction unit and reservoir 8. Suction apparatus Step Two: To prepare the collection system The use of the disposables with this machine is expensive, so to help keep our costs down, during elective cases please follow steps one and two, when the hard shell reservoir contains 500ml or more then the remaining steps can be followed, this is because during an elective case the patient may not have excessive blood loss in order for the machine to be cost effective. Gloves must be worn during the set up of the disposable kit to avoid finger marks on the tubing as sensors shine through, and will pick up finger prints which will cause the machine to alarm during its use Place the hard shell reservoir suction unit onto the shelf on cell saver machine Close the red clamp Hang the ACDA anticoagulant fluid on the top pig tail on IV pole Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 30 of 131
Attach the standard suction tubing to the yellow port on the hard shell, and attach the other end to the suction apparatus Set the suction level at 80 120 mmHg Using an aseptic technique pass the aspiration set to the scrub nurse Ask the scrub practitioner to pass out the double end, from the sterile field, attach the aspiration set to the hard shell, which consists of a suction line and infusion line, connect the blue end to the blue port on the hard shell, turn the roller clamp off on the infusion end and aseptically spike the ACDA anticoagulant bag Turn the suction on Open the roller clamp to prime the line and fill reservoir with 100ml of the ACDA anticoagulant fluid, to ensure the sponge in the reservoir is soaked through Adjust the roller clamp to set the delivery rate at 1 drip per second Please continue only if there is an excess of 500mls of blood in the hard shell reservoir, or if the patient is an emergency with expected high volume loss e.g. Abdominal Aortic Aneurysm or Bleeding DU
Step Three: Preparing the machine and disposables Plug in the cell saver machine, turn the power on & wait for the self test to be completed Open the High Speed Cell Saver Bowl set Install the centrifuge bowl by pushing it into the centrifuge chuck, there are two tubes they should be facing left & right as you look at it, the right facing tubing has the waste bag attached, the left had three coloured lines attached To secure the bowl, move the bowl arm forward & turn locking knob to 12 oclock Thread the right facing tubing through the lower line sensor, try to avoid leaving finger marks on sensor area Hang waste bag onto the front of the machine and ensure the drain port is closed Hang the saline x 2 on the lower two pig tails ensuring they are at different heights Thread the left facing tube through the air detector on the left ensuring it is over upper hook, continue to thread tubing around the pump and install manifold, in the sequence from left to right red, yellow & then blue Close pump lever (pale blue handle) and close & lock manifold door (Bring grey door above pump over and lock with pale blue clamp) Hang the reinfusion bag (marked with a blue stripe) from the top pig tail on IV pole, close the two small white clamps, keep the large clamp on the blue stripped line open at all times Ensure the blood bag for re-infusion is labeled correctly, legibly and accurately detailing the patients name, hospital number, date of collection time of collection and expiry time (labels supplied with disposable kit) Attach the red line to the red clamp on the bottom of the reservoir hard shell, ensure the red clamp is open Spike the two sodium chloride bags with the double ended yellow infusion line and unclamp lines
Step Four: Inspect & Finish Inspect all parts of the disposable for twists, kinks or flat spots and check that all appropriate clamps and covers are closed The machine will ask you to press start to confirm that the disposable has been loaded Press start once the system is properly loaded & checked The system will then enter standby mode and be ready to start processing The following screen will be displayed STANDBY AUTOMATIC Volumes ml PROC 0 REINF 0 Wash volume 0 Bowls processed 0
Need 800ml in reservoir to FILL automatically Press START to fill bowl Press MODIFY to change parameters Press YES to reset modify parameters Press start to fill bowl or alternatively you can press nothing and allow the reservoir level sensor to initiate automatic filling
Trouble Shooting Blood for reinfusion should be reinfused within 6 hours from the time of initial collection Attach the blood for reinfusion to a hotline as blood is cooled during the washing process The slide clamp on the blue line between the reinfusion bag and the cell saver machine must not be clamped off Do not use a pressure bag or level one pressure device with the cell saver, as this increases the risk of air infusion & the clamp being closed confuses the machine
Anaesthetic Theatre Standards No 26 cont Due to washed & packed cells being depleted of clotting factors during the cell saving process, FFP & platelets may be required, Therefore consultation with the lead anaesthetic clinician is essential The on screen display PROC = the total volume of fluid which has been processed from the reservoir The on screen display REINF = the total so far of RBCs which have been sent to the reinfusion bag Ref 416/2009 Status: Final
1. 2. 3. 4. 1. 2. 3. 4. 5. 6. 7. 8.
The on screen display Wash Volume = the total mls of sodium chloride used during the wash cycles, this does not include the ACDA (750 ml bags) The on screen display Bowls processed = the total amount of bowls emptied A high blood loss situation can be managed by following the steps below Press the Mode key twice Confirm the selection by pressing the Yes key within 10 seconds An option will appear on the screen during the emergency mode to allow you to go back to automatic mode This emergency mode allows the cell saving process to speed up during emergency procedures The use of blood from the cell saver may be contraindicated in the cases listed below Sepsis, Malignancy & Tumour cells (unless the leukocyte depletion filter set is used during re-infusion, liaise with lead clinician) Amniotic fluid (unless the leukocyte depletion filter set is used during re-infusion, liaise with lead clinician) Antibiotics not licensed for parenteral use Betadine, hydrogen peroxide, sterile water & alcohol Clotting adjuncts (microfibrillar collagen agent, topical thrombin) faecal contamination & Gastric fluids fibrin glue Methylmethacrylate
Please make sure you keep yourself up to date with training on the Haemonetics cell saver machine, it is your responsibility. If you experience any problems please do not hesitate to contact SODP Pippa Humphries, theatre 6. Anaesthetic Theatre Standard No 27 Standard: All children requiring an anaesthetic will be cared for by appropriately trained competent anaesthetic support staff Standard Statement: The anaesthetic room and operating theatre is appropriately prepared with all required equipment and materials, necessary to carry out the proposed anaesthetic techniques, there will be close liaison with the lead anaesthetic clinician, on the proposed plan of care Method: All anaesthetic staff will have the required training, skills and knowledge, and will have been deemed competent in paediatric anaesthetic care All staff to be aware of the child protection policy and procedure Ensure that children where possible are scheduled early onto and adult operating list thus decreasing the amount of anxiety, hunger and fasting time and any risks of delay or cancellation
Prior to receiving a child into the anaesthetic room All routine anaesthetic equipment will be checked following written anaesthetic standards Ensure the correct materials and equipment are selected and prepared according to the clinical speciality, the type of anaesthesia given, the requirements of the operating list, and the childs weight (a weight can be obtained by contacting the childrens ward prior to sending) Ensure that the ward staff have applied a local anaesthetic cream to the childs dorsum of hands and ante-cubital fossa at least half an hour before coming to theatre Ensure that the necessary volatile agents and anaesthetic drugs, to perform either drug or gas inductions, are easily accessible Ensure that the operating theatre temperature is adjusted accordingly, ensure that a bear hugger & hotline is available for the child during surgery, always cover the childs head where possible Ensure all materials and equipment are prepared in the appropriate manner and time, according to the patients clinical status (elective and emergency) Ensure all equipment is checked and confirmed as safe, ready for use & is functioning correctly
Ensure the location and availability of the following Emergency Paediatric Airway Management Trolley Defibrillator and paediatric paddles Paediatric drugs and doses handbook Paediatric emergency drug box Intravenous fluids and paediatric giving sets (burette) Penlon ventilator Paediatric circuits, reservoirs and spirometers, including an paediatric ambu-bag Paediatric oropharyngeal airways Paediatric HMEs Paediatric Endotracheal uncuffed tubes & laryngoscope blades Paediatric Magill forceps Paediatric LMAs Paediatric venous, arterial & intra-osseous canulas Paediatric Epidurals Paediatric rigid bronchoscopes (outside theatre 8) Fibre optic bronchoscope (fits smallest tube size 4.5) Ensure that the environment is as child friendly as possible prior to the childs arrival, including the availability of distraction therapy books and toys, and that all excessive equipment has been removed One carer accompanied by the ward nurse may remain in the anaesthetic room until such a time when the childs anaesthetic begins, as soon as the child becomes unconscious the ward nurse and accompanying carer must Ref 416/2009 Status: Final
leave the anaesthetic room without delay, and exit the theatre department immediately via the quickest route The anaesthetic room and surrounding areas must remain quiet and calming, all staff in the immediate surrounding must be informed that a child & carer are present in the department Ensure a full introduction of the anaesthetic team to both child and carer are completed Ensure identification of any language or learning difficulties that the child may have Ensure the developmental age of the child is taken into consideration, ensuring as far as possible that the child fully understands what will happen to them during their stay The childs details must be checked, following the written standards ensuring that the correct consent form is signed by the appropriate legal guardian The induction of anaesthesia will take place in the anaesthetic room if the lead anaesthetic clinician requests it, but only if the appropriate monitoring is available (Co2, SpO2, BP & ECG) Entry through the anaesthetic room during the induction of anaesthesia must be kept to a minimum Ensure that a chair is available for the carer in the anaesthetic room, to make the childs hand more accessible for the insertion a cannula One carer accompanied by the ward nurse may remain in the anaesthetic room until such a time when the childs anaesthetic begins, as soon as the child becomes unconscious the ward nurse and accompanying carer must leave the anaesthetic room without delay, and exit the theatre department immediately via the quickest route Ensure that both child and carer are offered the appropriate information, support and reassurance in a sensitive manner throughout Ensure that the care provided to the child is consistent with their individual needs, plan of care, expressed personal beliefs & preferences within the constraints of the setting and the clinical procedure Ensure that the child is never left alone whether awake or anaesthetised at any one time Ensure that any electrosurgical return plates are of the appropriate size
Compliance 100% Exceptions None Reference AODP/HPC Standards National Association of Theatre Nurses Child Protection Policy & Procedure
Please refer to the following Anaesthetic Theatre Standards No 1 Anaesthetic room & operating theatre preparation No 2 Anaesthetic materials & equipment preparation No 4 Airway establishment and maintenance No 5 Clinical emergencies (identify & respond) No 6 Clinical emergencies (assist in treatment) No 7 Documentation No 10 Intravenous infusion and transfusion No 11 Induction of anaesthesia & patient monitoring No 14 Positioning patients in theatre No 15 Patient preparation prior to clinical procedures No 16 Patients physiological parameters & fluid balance No 17 Receive patients for clinical procedures No 18 Reversal of anaesthesia No 20 Temperature maintenance No 21 Transfer of patients to operating table from bed/trolley No 22 Transfer of patient from operating theatre to PACU No 24 Venous and central venous cannulation No 28 Tourniquet application No 29 Use of electro surgical equipment
Anaesthetic Standard No 28 Standard: Tourniquet application. Standard Statement: All staff will ensure that tourniquets are applied safely and securely without risk of injury or damage to the patient or staff. Method: All staff who need to apply and monitor tourniquets will be trained appropriately and assessed as competent before carrying out this task unsupported. All staff applying tourniquets must be conversant with the equipment and the manufacturers guidelines regarding maintenance and checking of the equipment. o All pipes, tourniquets and connectors must be in good working order. o There should be 2 x 12 cuffs, 2 x 24 cuffs and 2 x 34 cuffs. o The connection of the machine to the compressed air outlet should be checked. o The controls should be set to 150mmHg, and each cuff connected and inflated to check for leaks. Ensure the cuff is tightly wrapped prior to inflating. o The Rhys-Davies exsanguinator should measure 18 in diameter, if not inflate or deflate appropriately.
o Any damaged or leaking equipment must be removed from service, reported to the Theatre Coordinator and sent for repair. It remains a surgical decision whether to use a tourniquet, always ask, never assume. All tourniquets must be applied as far up the limb as possible, checking for preexisting skin damage in the area. The upper part of the limb must be wrapped with sufficient padding to prevent skin damage. The appropriate sized tourniquet should be selected allowing sufficient overlap when wrapped around the limb. The tourniquet must be wrapped firmly over the padding ensuring no skin folds or genitalia are trapped. The pressure on the control box should be set to 100mmHg above the patients systolic blood pressure for arm tourniquets and 150mmHg above for leg tourniquets. Always check the inflation pressure with the surgeon prior to inflation, and confirm the pressure achieved once inflation has taken place. Please ask the surgeon regarding pressures if tourniquets are to be used on children. Check that the surgeon is ready to start before inflating the tourniquet in order to minimise the time the tourniquet remains inflated. A clean plastic bag should be placed over the limb to be exsanguinated. Exsanguination may be by use of the Rhys Davies exsanguinator, elevation or Esmarch bandage. o To use the Rhys Davies exsanguinator, roll the exanguinator up your own arm first and grasp the patients foot or hand, ensuring all the patients digits are lying flat in your palm. Then roll the exsanguinator down your arm and over the patients limb in one movement. Holding the Rhys Davies exsanguinator as far up the limb as possible, turn on the tourniquet machine, wait until the required pressure is achieved before releasing the exsanguinator. o When elevating a limb to exsanguinate, the limb should be held upwards as vertically as possible to aid blood return. Gentle massage may also be used to assist exsanguinations, in the direction of the heart, depending on the skin condition. Elevation should continue for a minimum of 5 minutes before the cuff is elevated. o When using an Esmarch bandage, ensure that the bandage is stretched before you wrap it around the limb. Starting at the distal end of the limb wrap the bandage tighly around the limb, moving towards the tourniquet cuff, ensuring an overlap as you go. Inflate the cuff to the required pressure, remove the Esmarch bandage and check the patients skin condition. Once the tourniquet has been inflated, the time must be noted and recorded in the theatre register and on the theatre database. The stop clock in theatre may be used as a secondary reminder, if there is no counter on the tourniquet machine, and the inflation time should also be clearly recorded on the dry-wipe board in theatre.
The surgeon must be informed of the duration of the tourniquet at regular intervals, the first reminder at 60 minutes, then at 90 minutes, then every 15 minutes thereafter. It is the surgeons decision how long the cuff may remain inflated. If required a cuff may be re-inflated providing at least 10mins has elapsed to allow sufficient perfusion of the limb. The anaesthetist must always be informed prior to the tourniquet being deflated as there may be a drop in blood pressure as perfusion of the limb occurs. Also waste products such as CO2 and lactic acid build up in the tourniqued limb, which are then released into the circulatory system. If bi-lateral cuffs are used, each cuff must be deflated separately allowing sufficient time for the blood pressure to stabilise before deflating the second. After deflation the tourniquet and padding must be removed immediately to prevent venous congestion and arterial stasis. The skin condition must be assessed following removal and the limb assessed for full perfusion prior to the patient being transferred to PACU. Any doubt about the quality of capillary return in the digits must be reported immediately to the surgeon. The method of exsanguination, inflation, deflation and total tourniquet times must be recorded on the perioperative theatre database, and in the theatre register. Caution must be exercised in the use of tourniquets in patients with the following conditions; o Blood diseases e.g. sickle cell anaemia o Localised infection of the limb o Regional infections e.g. cellulitis o Peripheral vascular disease o Severe bone trauma Soiled tourniquets must be washed with warm water and detergent and dried thoroughly.
Compliance: 100% Exceptions: None References: Southampton University ODP Level 3 Standards NATN Principles of Safe Practice in the Perioperative Environment 1998 See also Theatre Standards: Theatre Documentation
Anaesthetic Theatre Standard No 29 Standard: Use of Electro surgical Equipment. Standard: Staff will ensure that all patients whose surgery requires the use of diathermy, will be protected from the risk of burns. Method: All personnel using diathermy equipment will receive the appropriate training and have been assessed as competent. They must be fully conversant with the safe use of the equipment and understand the principles of electro surgery. Diathermy machines will be checked prior to the start of every list, in accordance with the manufacturers guidelines. Yearly maintenance and testing of equipment must take place by MEMS to ensure its safety, any faulty or damaged items must be removed from use immediately and reported for repair. Application of diathermy grounding plates is only done by competent practitioners in accordance with the manufacturers instructions, ie. Applied to a clean, dry, hair free, muscular area, as close to the operation site as possible, away from any pre-existing metal work in the patient. Diathermy grounding plates must be kept clean and dry, and preventative measurers taken to ensure the plate does not become soiled with prep. Solutions or body fluids. The scrub person must check diathermy forceps and leads prior to use, to confirm intact insulation and good connections between components. The scrub person must keep the diathermy forceps/ blade etc. within a suitable insulated receptacle during surgery, to prevent accidental burns to the patient or members of the surgical team. All staff must be aware of any patient contraindication to the use of monopolar diathermy e.g. pacemaker, prior to commencement of surgery. Staff will be educated regarding the use of visor masks to prevent inhalation and eye contamination with diathermy plume. The diathermy machine must be switched off or set to standby before connecting or disconnecting live electrodes, and the surgeon informed of the power settings before commencing use. Single use return electrodes (grounding plates) must never be reused. The return electrode must be in direct and complete contact with the patient throughout their surgery. If the patient position is changed after application of the plate, the site must be rechecked.
Patient skin condition must always be checked after removal of the grounding plate, and the site and skin condition recorded on the perioperative documentation. The patient must be shielded from metal objects to prevent a short circuit bypass of the grounding plate.
Compliance: 100% Exceptions: Reference: None Principles of Safe Practice in the Perioperative Environment. Southampton University ODP Level 3 Standards
Anaesthetic Theatre Standard No 30 Standard: Theatre handover of post-op patients to ITU Standard Statement: All anaesthetic support staff to appropriately hand over the care of patients requiring ITU to the designated ITU nurse, in the most appropriate manner according to the individual situation Method: All anaesthetic support and scrub staff to ensure that the Theatre to ITU/HDU patient transfer communication sheet is accurately and legibly completed with all relevant information In cases where the handover time is limited (When another patient is to follow) the anaesthetic support staff member can phone ITU, to complete handover to the designated ITU nurse, (approximately half an hour prior to the departure from theatres) the responsibility of completing this handover sheet then lies with the ITU nurse Theatre to ITU/HDU patient transfer communication sheets will be kept in Theatres 1 & 6 anaesthetic room & in PAW Th9A for completion by anaesthetic support staff The ITU department will keep copies of the Theatre to ITU/HDU patient transfer communication sheet for completion during the telephone handover All information collated for the handover will be checked with the Anaesthetist The Theatre to ITU/HDU patient transfer communication sheets will be kept with the patients notes at all times On collection of the ITU bed details of the required equipment on the bed will be advised by the anaesthetic support staff (Number of pumps required, full monitoring, ventilator, drip stand, oxygen cylinders etc) ITU staff will send up the required amount of pumps with the bed when requested Compliance:100% Exceptions:None
Reference: Theatre to ITU/HDU patient transfer communication Anaesthetic Theatre Standard No 31 Standard: Monitor, identify and report fluid and blood loss during the intra-operative period, to the lead anaesthetic clinician, to reduce the risks of hypo-volemic shock Standard Statement: All staff to understand the importance of fluid balance, monitoring and identifying fluid and blood loss, and the necessary action to be taken when blood losses occur Method: All staff to understand the importance of monitoring, identifying and reporting fluid and blood loss during surgery, in an overall aim in reducing the risks of hypovolemic shock All staff to ensure that there is consultation with the lead anaesthetic and surgical clinician regarding whether they require the swabs to be weighed throughout the procedure Ensure all staff are aware of average blood volumes and that blood losses of approximately one-fifth or more of the normal blood volume produces hypo-volemic shock, if left untreated or unreported Average Blood Volumes Age Blood Volume Premature Neonates 95ml/kg Full Term Neonates 85ml/kg Infants 80ml/kg Adult Men 75ml/kg Adult Women 65ml/kg Example 1: ABV of a 75kg Adult Male 75ml x 75kg = 5625ml ABV Allowable blood loss = 5625ml/5 = 1125ml ABL Example 2: ABV of a 25kg infant 80ml x 25kg = 2000ml ABV Allowable blood loss = 2000ml/5 = 400ml ABL All staff to ensure that blood loss is monitored and reported immediately intraoperatively. It is the scrub nurses responsibility to ensure that blood soaked swabs are discarded into the non sterile area for weighing as soon as five of the same size swab becomes available Swabs must be weighed in clear bags of five of the same size (e.g. 5 x SR, 5 x LR, 5 x Abdo packs) on a simple pair of kitchen type scales, the weight of the dry swabs is then subtracted from the total weight, leaving an estimated blood loss from the swabs, the swabs should be weighed before they dry, because of the inaccuracies due to evaporation Suction must be carefully measured throughout the procedure Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 41 of 131
1. 2. 3. 4. 5.
An accurate record of the wash in mls that has been used must also be recorded to ensure an accurate measure of blood loss can be calculated All losses must be reported to the lead anaesthetic clinician continuously to ensure losses can be corrected immediately All losses must be documented accurately on the following: The white board for all staff to view throughout the procedure (to be updated by the person weighing swabs and monitoring the suction) On an estimated blood loss form On the anaesthetic chart On ORSOS at the end of the procedure Verbally to the lead clinicians as appropriate
Compliance: 100% Exceptions: None Reference: Theatre standards BMJ Advanced Paediatric Life Support 2nd Edition NATN Guidelines AODP/HPC Guidelines Anaesthetic Standard No 32 Standard Maintenance of patient dignity & privacy during emergency & elective Lower Segment Caesarean Sections Standard Statement All staff will ensure the privacy & dignity of all patients having an LSCS in an elective or emergency environment Method On arrival into the theatre environment the patients birthing partner will be escorted to the visitors room, where they will prepare for the theatre environment (e.g. Dress) as per policy Communication will be efficient, effective and thorough with all team members, the patient and birthing partner The patient and birthing partner will be aware of the procedures taking place throughout their stay Noise levels in theatre should be kept to a minimum in respect of the patients wishes and birthing partner Throughout the patients stay in theatre, staff will demonstrate compassion & empathy for the patient Staff must respect & maintain the dignity of the patient Anyone entering the theatre once the patient is there must use the PACU door entrance and not the main corridor entrance to ensure privacy for the patient, if there is a patient in PACU & in theatre then the prep room door should be used
All additional patient clothing will be removed & placed in a bag on the patients bed Once the checking in procedure has taken place, consent from the patient will be obtained to whom maybe present (i.e. birthing partner) during the LSCS procedure During clinical procedures (e.g. spinal, cannulation & insertion of urinary catheter) staff must maintain the patients dignity & maintain privacy as much as possible The presence of the birthing partner will be at the appropriate time once the catheter, spinal, cannula and shave are complete and in place To maintain the patients dignity as much as possible, the birthing partner should only be bought into theatre once all pre-operative procedures are complete (i.e. cannula, spinal & urinary catheter) and the patient is ready for the surgical procedure, Prior to the entrance of the birthing partner, it should be checked with the lead anaesthetic clinician & theatre team leader Once the birthing partner is present in theatre they should remain seated at all times in the chair provided During the procedure if the anaesthetic converts from a regional anaesthetic to a general anaesthetic the birthing partner must be escorted back to the visitors room without any delay, and remain there until they are called by the PACU team All patients under going an LSCS under GA will not be permitted to have a birthing partner present The birthing partner will be escorted to the visitors room at anytime where the lead anaesthetic clinician, surgeon or team leader deem necessary The patients medical notes should remain with the patient throughout their stay in theatre and PACU When the checks take place on the placenta by the midwife, the instruments must be returned to theatre in time for the final instrument count The team leader must organise the collection of a ward bed and ensure the bed is electric whenever possible At the end of the procedure the midwife is responsible for carrying the baby into PACU and escorting the birthing partner to the visitors room to change clothing The baby should not be left unattended by the midwife at any one time during their stay in the theatre department Once the patient is in PACU, it is the PACU teams decision to invite the birthing partner into PACU at the appropriate time Only one visitor maybe present in PACU, mobile phones much be switched off at all times If at anytime the PACU or theatre team feel it inappropriate for a visitor to be present in the department, the visitor will be escorted back to the visitors room or CDS Any luggage that belongs to the patient must be kept in the fathers/visitors room opposite PACU or on a trolley in the corridor, and NOT in PACU due to lack of space
Compliance: 100% Exceptions: None

Reference: Privacy & Dignity Policy Health & Safety Infection Control Noise Control Standards Anaesthetic Standards No 33 Standard To ensure safe working practices at all times when using, handling and cleaning fibre optic scopes Standard Statement All staff to follow the correct procedure and protocol for the handling of fibre optic scopes Method: We have at present 4 working Fibre optic scopes All scopes must be leak tested before and after use, sent for decontamination (Diag/Gastro Dept. Ext 4075) and re-tested when returned clean To leak test a scope: 1. 2. 3. 4. 5. Remove the battery and replace it with a blank end Attach the testing equipment Pressurise to the red mark, check if the needle drops (hold for at least 30 secs) Adjust the scope end, and recheck if needle drops Deflate balloon and remove testing equipment To use the scope replace the battery, if not using send scope to diag/gastro dept. If you discover a leak do not use, contact J. Hughes or bleep 7576 who will send it for repair, you should get a temporary replacement Each scope has a serial number on it, this number is below the battery port, and it also has its own record book The record book is used for traceability and also to show how often they are used, in order to get replacements or new ones Take it with the scope and enter the following information, The date, The patients hospital number, The name of the ODP/Nurse who prepared the scope for use, Date and time sent for decontamination, Date and time returned from decontamination Each scope should have a decontamination label with it, this is kept in the top drawer of the trolley, and this can be stuck on the back of the care plan when next used The scope number should be recorded on the ORSOS theatre management system under comments on the resources page If the scope is used for trials, fill in the record book for all patients and put trial by the side Whenever scopes are transferred between departments, always use the shallow drawers (not plastic bags or inco sheets) and these must be labeled clean and dirty When taking a scope for use please write (on the white board) which theatre it will be used in, and date Ref 416/2009 Status: Final
Compliance 100% Exceptions None Reference Manufacturers Guidelines Infection Control Health & Safety Anaesthetic Theatre Standard No 34 Standard: An acceptable working environment to perform surgical operation, and allow patients, visitors and staff to be safe and comfortable. Allowing for the save storage of equipment and supplies. Standard Statement: For all staff to work within an acceptable working environment that is in good condition and that is maintained on a continuous basis Method: All staff must be responsible for the operating theatre environment at all times when on duty, maintaining the environment to an acceptable level, and reporting all faults or problems to the appropriate persons All staff will maintain a quiet, peaceful working environment at all times The operating theatre department will be clean & tidy at all times, The weekend cleaning file jobs will be undertaken by all staff during non-operating times on a 24hrs basis Theatre lighting will be in good working order, and checked on a daily basis, flickering or dead bulbs will be reported immediately, all light fitting and fixtures will be safe and secure Walls will be in good condition, with the appropriate cleanable paint, paint must be in good repair, with no flaking, holes or damage to them Floors should remain uncluttered as much as reasonably possible, any floor damage, peeling of floor coverings will be reported immediately All theatre & fire doors, hinges & frames will be in good condition, not splintered, damaged or broken in any way The temperature in theatre will be at 21c, any alteration to the temperature due to individual patients care should be made through the theatre team leader, any adjustments can be made by the maintenance department if necessary (this should be done through the theatre co-ordinator) Temperatures other than 21c will be recorded and monitored The lowest acceptable temperature in theatre is 18c The highest acceptable temperature is 27c with a relative humidity of 50% All fabrics of any description will be in good condition, no holes or damage All fixtures & fittings of any description in the theatre environment will be in good working order and in an acceptable condition. The Theatres, Anaesthetic rooms and corridors should be quiet at all times and every effort should be made to keep noise levels to a minimum. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 45 of 131
Where maintenance work is to be carried out this should be done with cooperation of the Theatre and co-ordinator All deviations from this written standard will be reported to the theatre co-ordinator in person or documented in the co-ordinators diary, specifying the actual problem, theatre number, or area within theatres affected, name of person reporting problem, time & date For immediate attention facilities must be contacted on ext 4141, stating a cost code: 123------Facilities visit the department every morning and check the board outside theatre 1 for any minor problems that need attention, if a problem arises that can wait and that is relatively minor, it must be written on this board for them to deal with Any other issues or problems that may cause a health or safety risk to patients or staff must be reported immediately to the theatre co-ordinator to ensure immediate attention
Compliance: 100% Exceptions: None Anaesthetic Theatre Standard No 35 Standard To ensure the safe use and safe care of suction equipment within the theatre department Standard Statement All staff to be competent in the safe use of suction units within the theatre department. Method: All staff using suction equipment should receive the appropriate training and should be assessed as competent. Staff must understand the risks associated with high levels of suction, and situations when the vacuum level should be reduced. If the suction device is attached to a vacuum pipeline, a tug test should be performed to ensure the connection between the Schrader probe and socket is secure. Suction equipment should be checked that it is safe to use prior to the start of every list. The suction equipment should consist of a reservoir jar, suction liner, a controller to adjust the vacuum pressure, suction tubing and yankauer sucker. When testing the suction equipment, the reservoir jar and suction liner must be clean and the suction liner should be firmly pushed into the reservoir jar. All connections must be firmly secured. The suction should be turned on at the desired vacuum level, the patient suction tubing should be occluded at the patient end, to ensure that the suction level is maintained when the tubing is clamped. The suction equipment, suction liner, suction tubing and yankauer, should be replaced after it has been used on each patient and when it is visibly soiled. Every time the suction equipment is changed it is important to ensure that safety checks are carried out to ensure that suction is adequate.
When handling suction equipment, universal precautions, health and safety and infection control safety procedures should be applied at all times. Suction equipment must be maintained and tested annually by MEMS to ensure its safety, any faulty or damaged items must be removed from use immediately and reported for repair.
Compliance 100% Exceptions None References Infection Control Health and Safety Ohmeda Medical instructions for use Theatre Standards Anaesthetic Theatre Standard No 36 Standard: Anaesthetic obstetric cover Standard Statement All anaesthetic assistants to take responsibly for the following duties during obstetric emergency cover Method Each morning locate & collect the obstetric anaesthetic assistants bleep no 7151. Identify yourself to main theatre co-ordinator and P.A.W. person in charge. It is expected that you will spend the time down in the P.A.W. theatre area. Having identified yourself to the senior member of staff in the P.A.W. you should then undertake the routine checking of the obstetric theatre machine as laid out in the Anaesthetic standards 1 and 2, should there be any problems with the machine or associated equipment contact the 7576 bleep holder. Ensure the obstetric PACU controlled drugs are checked in line with theatre policy Ensure that all equipment is clean and in good working order and ready for use Ensure all stock levels are adequate in line with lean Establish who the obstetric Anaesthetist is Check the fibreoptic intubation trolley is stocked and the scopes are clean and working as per the guide lines attached to the trolley. Communicate with other anaesthetic staff in theatres 9A & 9B to determine if equipment or help is required Ensure that PAW is adequately supplied with anaesthetic stock (in the store rooms items marked with a white label are from the central stores items marked with a pink label are from Main theatres if you are unsure please contact the stores team) Ensure the stock levels of I.V.s fluids and drugs in and out of the fridges are of adequate supply, and that they are in date
Ensure when leaving the department, you inform the senior practitioner in charge of PAW theatres of where you are going and how long you will be. 100% None Senior ODP John Hughes, ODP Lesley Carter and SODP Karen Collins
Compliance Exceptions Reference
Anaesthetic Theatre Standard No 37 Standard Identification of each infant and placenta during multiple delivery Lower segment caesarean sections Standard Statement All staff will ensure that in all cases of twins/multiple deliveries by LSCS, the placentas are clearly identified to correspond with the appropriate infant. Method Normal protocol for either Elective, or Emergency LSCS will be followed An extra pair of (pre-pack) Kochers will be available for each subsequent infant. These have colour-coded tags so that each pair used is different from those on the LSCS tray. (Found in Th. 9c prep room) The Scrub Nurse will be responsible for communicating to the team which colour Kochers are to be used for which placenta (eg Blue tag = Baby 1 (placenta 1) ; Plain = Baby 2 (placenta 2)) The circulating person will be responsible for writing on the whiteboard which colour Kochers have been used for which placenta/infant. This can be written alongside the baby delivery time (BDT). Theatre staff must ensure that a Midwife is present for each expected infant, and that the appropriate number of resuscitaires are available, ready for use. The Scrub Nurse will be responsible for ensuring that the Midwives present are aware of which placenta belongs to which infant. The instruments that leave the sterile field (ie; with the placenta and/or infant(s) will be recorded on the whiteboard alongside BDT As with all Caesarean sections, the Scrub Nurse will be responsible for ensuring that all instruments taken with the placenta(s), by the Midwife, are returned prior to the final instrument count The circulating person will assist the Midwives in calling for Paediatric support, when required. Compliance 100% Exceptions None Reference NATN Principles of Safe Practice in the Perioperative Environment
See also Operating Theatre Standards for: Handling of Instruments Swab and Insrument Counts Theatre Documentation Operating Theatre Standard 38 Standard Preparation of the Emergency Obstetric Theatre Standard statement All staff must ensure the safe preparation and set-up of the obstetric theatre, in anticipation of obstetric emergencies. Method
It will be the responsibility of all staff covering emergencies, to ensure they know which P.A.W. theatre is designated for emergencies for that day/session Scrub staff will ensure that the appropriate instrument tray is available on a trolley, ready for use Scrub staff will ensure that all disposables are available on the side in theatre, ready for use. (To include: LSCS drape, 1 x pack small swabs, 1 x pack abdos, 2 x size 22 blades, suction, appropriate sutures, dressing) Scrub staff will ensure that all bags are labelled appropriately and are out ready for use Scrub staff will ensure that the designated theatre is stocked to appropriate levels, including the catheter trolley and shaving equipment The anaesthetic assistant will ensure the anaesthetic machine is tested and made ready for use, on a daily basis The anaesthetic assistant will ensure that the airway trolley and spinal trolley are checked and are stocked with appropriate equipment, on a daily basis, in anticipation of use. It must be ensured that the airway trolley is easily accessible (ie not blocked in, behind the anaesthetic machine!) The anaesthetic assistant will ensure that anaesthetic stock levels in theatre are appropriate, including drugs, fluids and fridge items The diathermy and suction machine will be plugged in and tested to ensure it is ready for use Flowtron Boots will be available and plugged in ready for use Theatre staff must ensure that the Midwife has placed a resuscitaire in theatre, checked ready for use. It must be ensured that the Midwife is then present for the start of surgery. Following the use of the Operating Theatre for an emergency procedure, all staff are responsible for ensuring that it is cleaned and prepared, as above, ready for any subsequent emergency.
Compliance 100% Exceptions None

Reference NATN Principles of Safe Practice in the Perioperative Environment. See also Anaesthetic Standards: Anaesthetic room and operating theatre preparation Airway establishment and maintenance Clinical Emergencies (identify and respond) Clinical Emergencies (Assist in treatment) Use of Electrosurgical Equipment Anaesthetic Standard 39 Standard: Provision for Emergency Obstetric surgery when ALL Theatres are in use in P.A.W. Standard statement: All staff will be aware of procedures for conducting a category 1 (crash) LSCS in Theatre 9Bs Anaesthetic room, in the event that all other theatres are occupied. Method: The Anaesthetic Assistant in Theatre 9B will be responsible for ensuring the anaesthetic machine, including all monitoring, in the anaesthetic room is checked, prepared and ready for use, daily. Theatre staff will be responsible for keeping a single stock of the consumables required for a LSCS, in the cupboard in Anaesthetic room 9B (marked Emergency LSCS kit). This must be replaced weekly,(Monday am) using stock rotation methods. The suction unit in Anaesthetic room 9B will be checked daily and left ready for use The diathermy machine kept in the store room will be checked daily. The 7229 Bleep holder will be responsible for ensuring all Theatre and Obstetric staff are informed the surgery will be performed in Anaesthetic Room 9B The Midwifery staff will be responsible for ensuring a resuscitaire is available and ready for use outside of the anaesthetic room doors. They will also be responsible for informing the paediatrician of their location. The Patient will be transferred to the Anaesthetic Room on the bed. A pillow should be used beneath the sheet, in order to provide left lateral tilt A LSCS instrument tray will be collected from 9C prep room, and emergency drugs collected if necessary from Theatre 9C fridge Staff will inform those in Theatre 9B that the anaesthetic room will be in use, so alternative exits should be used by all. The Anaesthetic Assistant will ensure immediate availability of an airway trolley, complete with devices to aid difficult intubation The patient will be monitored and prepared for surgery as per normal protocol A portable light will be collected from Delivery Suite as soon as possible The diathermy machine will be collected from the store room as soon as it is appropriate
The circulating person will be responsible for ensuring the swab count and KTS etc times are recorded onto paper, which will then be transferred onto the Orsos system at the end of the procedure Theatre staff must liase with PACU staff regarding the most appropriate recovery location for the patient The Patients details will be recorded in Theatre 9Bs operating book as soon as it is appropriate to do so (ie when Theatre 9B vacant) 100% None NATN Principles of Safe Practice in the Perioperative Environment.
Compliance: Exceptions: Reference:
See also Anaesthetic Standards: Anaesthetic room and operating theatre preparation Airway establishment and maintenance Clinical Emergencies (identify and respond) Clinical Emergencies (Assist in treatment) Use of Electrosurgical Equipment Preparation of the Emergency Obstetric Theatre Operating Theatre Standard 40 Standard: To ensure the safe handling, storage & transfusion of blood components Standard Statement: All theatre staff to be competent in the safe handling of all blood components, understanding the importance of storing blood correctly, the implications of incorrect storage, the location of all blood storage areas and fridges in all theatre departments and to follow the correct procedures and policies for the transfusion of all blood components Method: All Theatre staff to have read and understood the RUH Blood Component Transfusion Policy Ref: 702 2005 All staff dealing with blood components to attend the mandatory blood transfusion study session led by Helen Maria (RUH Blood Transfusion Co-ordinator) All patients received into the department to whom have the possibility of requiring a blood component transfusion must have a wrist band attached to their wrist or ankle and one attached to their chest or forehead once anaethetised for the checking procedures if the patients arms will not be accessible during surgery Standard procedures must be followed for the infusion of any blood components All blood components must be prescribed by a doctor prior to infusion When requesting blood for collection from the main blood bank or south bank, details of the patient requiring the transfusion must be supplied to ensure the
correct blood is collected, The blood must be logged in blood track on collection from the designated fridge The blood must be transported safely & immediately to the clinical area in a red box which are kept by the fridges for this purpose. Blood can only be in transit in the red boxes provided at room temperature for NO LONGER THAN 30 MINUTES. If, on arriving in the clinical area, the blood is not needed, or the patient is not ready to receive it, the blood MUST be returned and scanned back into the relevant blood fridge in the theatre dept within the 30 minutes of its removal Blood must be kept only in equipment specifically designed for the purpose; blood refrigerators Any other blood components such as plasma & platelets on arrival to the clinical area must be used immediately as they can not be stored Access to all the blood fridges requires entry to the BloodTrack system. It is the responsibility of each member of staff within the theatre department to ensure they have the correct bar code attached to their ID badge. Barcodes and registration for this tracking system are allocated direct from the Blood bank laboratory. Instructions for operation are available at the fridges and on the RUH intranet There are small blood fridges in Main theatres at reception, Princess Anne Wing (PAW) Theatres in the prep room of theatre 9b Blood is only to be removed from blood refrigerators immediately prior to use and must not be kept out for longer than 30 minutes before starting the transfusion If the blood isnt required, and is replaced after 30 minutes have elapsed, the blood tracking system will not allow it to be scanned back in. If a verbal alarm message is received contact the Blood Bank laboratory immediately Under NO circumstances should it be stored in domestic or drug refrigerators Blood must be returned to the blood fridge if not used within 30 minutes of removal and booked back into the blood bank using the blood tracking system The policy for the use of emergency O Rh(D) Negative blood can be found in the above policy reference number Blood components can only be administered by IV trained staff, ensuring all Pre-administration checks have been completed The Administration procedure checks must be adhered to, to ensure compatibility, extra vigilance must be taken when checking the identity of the unconscious or compromised patient in the theatre environment The Documentation Procedure prior to the administration of blood components must be adhered to, to reduce risks of blood transfusion reactions All staff must complete the blood track forms attached to each individual unit of blood and blood product when infusing, once the forms are complete they are put into the blood track box at main theatre reception by the blood fridge and in PAW by the blood fridge in th9b prep room, these are legal Ref 416/2009 Status: Final
documents that must be returned to the blood bank, if they are not completed the blood bank will contact you Ensure that the full pre, intra and post transfusion Monitoring Procedures are followed to ensure that any transfusion reactions are detected as early as possible All blood bags from the transfusion should be retained for approximately 2 hours following completion of transfusion, after 2 hours the used bags can be disposed of as clinical waste In case of any transfusion reactions the blood bank staff will request that all used and unused blood bags be sent back to the blood bank for testing Any adverse reactions must be reported to a doctor immediately, If a transfusion reaction is suspected STOP the transfusion immediately All clinical, non-clinical and near-miss incidents relating to the transfusion process must be reported using the Adverse Incident Policy Ensure that when administering blood components that the correct transfusion sets are used:1. All blood components must be administered with the correct giving set, using a fluid warmer 2. A new giving set must be used after a transfusion has run for more than 12 hours or if another infusion is continued after the transfusion 3. Red blood cells must be administered only through a blood administration set (4 units of blood per administration set) this does not apply to intra operative cell salvaged blood 4. Platelets & Cryoprecipitate must only be administered through a Platelet/Cryoprecipitate Infusion set which is issued with the products with each Platelet or Cryo request 5. Fresh Frozen Plasma (FFP) must be administered through a blood administration set Any discrepancys in the checking of blood product documentation should be reported immediately to the RUH Blood Bank 01225 824734/5 (4734/5 from the RUH, bleep 7555 out of hours).
Compliance - 100% Exceptions None Reference 1. RUH Blood Component Transfusion Policy 2. Infection control policy 3. Adverse incident policy 4. RUH intranet
Anaesthetic Theatre Standard No 41 Standard All Staff will adhere to the infection control policy incorporating the new changes to theatre practices Standard Statement All staff have a duty to comply with trust policies and the Hygiene code underpinning and control of arrangements in place. All staff will have read and understood the RUH Infection Control Policies (Found on the intranet under clinical policies) Method All staff have a responsibility to comply with Trust Infection Prevention & Control policies and procedures To attend mandatory training as specified in the mandatory training matrix All staff to remind & challenge colleagues of their infection control responsibilities if there is a potential or actual breach of policy Staff will read, understand and keep up to date with the Theatre Standards (Found in every Prep & Anaesthetic room) All staff will ensure they are up to date with new improvements & changes that have been made. Staff will ensure that all changes are implemented and practiced by all staff within the theatre environment, inline with the Trust Objective getting it right first time All staff will implement effective hand washing as follows:1. Before patient contact 2. Before an aseptic task 3. After body fluid exposure with or without gloves 4. After contact with a patient 5. After contact with the patients environment The below the elbow initiative is to be implemented and adhered to within the theatre department The Theatre Department will undertake Hand Hygiene audit on a weekly basis until a 95% result is achieved, in line with the trust policy & agreement Any staff with questions regarding any infection Control issues will contact the Theatre infection control link practitioner (Senior ODP Sue Ackers or the RUH Infection Control team) All Patients are to be accompanied into the PACU area by the Scrub Practitioner who will accompany the patient and anaesthetist The Anaesthetic Practitioner will remain in theatre, ensure that the anaesthetic machine, leads, monitoring, dials, controls & surfaces are wiped down and decontaminated appropriately in preparation for the next patient, with the appropriate cleaning aid All surfaces are to be wiped down in between cases, this is to include the following:1. Scrub Trolleys where trays have been placed 2. Pat slides 3. Operating table
Door handles and door plates (used to push the doors open) Computer keyboards Diathermy control panel & pedals Anaesthetic Regional & Airway management trolleys All clutter and excess stock to be removed from the top of the anaesthetic machines. Emergency drugs that may be required by the anaesthetist are the only items to be placed on the top of the anaesthetic machines in a disposable kidney dish Anaesthetic Airway Management trolleys will only contain the following:1. The top of the trolley will only contain the equipment required for the patient that is about to commence or is underway in theatre 2. The first drawer will contain the equipment that may be required in an emergency. E.g. spare laryngoscope blades & handles, oral airways & a selection of alternative sized endotracheal tubes 3. The remaining drawers should contain minimal stock levels All gratnell trolleys in theatre will be cleaned weekly, All items are to be removed, the drawers and the runners are to be cleaned with the appropriate cleaning solution Stock levels in the gratnell Trolleys will to be kept to a minimum in accordance with agreed levels for each speciality All prep rooms will be cleaned weekly, all prep room cupboards to be emptied & cleaned All empty Cardboard boxes are not to be left lying in corridors or in any theatre areas, they are to be placed in the Back corridor ready for disposal by the ODO There are to be NO Paper notices placed on theatre, anaesthetic room, PACU walls or anywhere within the corridor areas in the theatre department Only laminated notices that are washable are to be placed on walls with the agreement of the Theatre Manager or band 7 staff No one is to enter the prep rooms in outdoor clothes, If they do they should be challenged by the team leader Only parents or ward nurses are to be permitted to enter the anaesthetic rooms in outdoor clothing All surfaces in restricted areas within the dept i.e. from the prep rooms and anaesthetic rooms through the theatres into the sluices should be kept free from clutter at all times All staff will be responsible for ensuring that the weekly cleaning is carried out to ensure that the department is kept clean and tidy All staff will sign weekly cleaning log when cleaning task complete Compliance 100% Exceptions None
4. 5. 6. 7.
References RUH Infection control policies Theatre infection control meeting 12th June 2008 Theatre Manager Heather Cooper Dr Malcolm Thornton Anaesthetic Theatre Standard No 42 Standard The use of surgical diathermy in patients with implantable pacemakers or implantable cardioverter defibrillators.
Standard Statement All staff will be aware of the perioperative management of patients with an implantable pacemaker or implantable cardioverter defibrillator, where the use of surgical diathermy is anticipated.
Method When a patient is identified with an implantable pacemaker or implantable cardioverter defibrillator, it is the lead anaesthetist and surgeons responsibility to clearly document this in the patients notes and bring it to the attention of staff. They should contact the cardiologists to check the condition of the patients pacemaker or implantable cardioverter defibrillator. Manufacturers of implantable pacemakers or implantable cardioverter defibrillators either contra indicate the use of surgical diathermy or give strong warnings against its use. However if surgical diathermy is deemed essential, the use of bi polar surgical diathermy should be first considered, bearing in mind that this can also cause interference with pacemakers and implantable cardioverter defibrillators. If the lead anaesthetist and surgeon decide that the use of monoplolar diathermy is unavoidable, they must clearly document this in the patients notes. During surgery, cardio pulmonary resuscitation, temporary external pacing and external defibrillation equipment must be available. The patients physiological parameters must be monitored before the induction of anaesthesia and throughout surgery using an ECG monitor and pulse oximeter. An arterial line may also be required as an alternative method of detecting the patients pulse. Where a problem is identified with a pacemaker during surgery, the surgeon should be informed immediately and diathermy use must be discontinued or used intermittently. Where the use of monopolar diathermy is unavoidable: The return electrode (diathermy plate) should be placed so that the current pathway between the diathermy electrode and return electrode is as far away from the patients pacemaker or implantable cardioverter defibrillator and leads as possible. Ref 416/2009 Status: Final
Its use should be limited to short bursts. Whether monopolar or bipolar diathermy is used it is important that all cables attached to the diathermy machine are kept as far away as possible from the pacemaker or implantable cardioverter defibrillator site. If patients have an implantable cardioverter defibrillator, the lead anaesthetist may decide to position a clinical magnet over the implant site to prevent inappropriate shock delivery, this may be secured to the patient for the duration of surgery using Micropore tape.
Compliance 100% Exceptions None References MHRA Perioperative management of patients with implantable pacemakers or implantable cardioverter defibrillators, where the use of surgical diathermy/electrocautery is anticipated (March 2006) Operating Theatre Standard No 1 Standard: Aseptic Technique. Standard Statement: All staff involved in the preparation and performance of surgical procedures will ensure a safe environment for the patient by maintaining asepsis and limiting the risk of contamination. Method: All staff will be aware of the principles of asepsis, have received appropriate training in and have been assessed as competent in this skill, before undertaking any procedure requiring an aseptic technique to be applied. Perioperative staff with infected skin lesions of the skin or bacterial infections of the upper respiratory system should not participate in any aseptic technique. Staff participating in an aseptic procedure should be scrubbed, gowned and gloved. Personnel participating within sterile procedures must stay within the sterile boundaries, and a wide margin of safety should be given between scrubbed and non-scrubbed persons. All pre-sterilised articles must be checked for damage and expiry date prior to use. Any packs found to be in an unsatisfactory condition must be discarded. All items used within the sterile field must be sterile. An adequate quantity of sterile drapes must be used to establish a sterile field. To maintain asepsis, it is essential that all staff are aware of the correct method of opening sterile packages, to avoid contamination of their contents. Dressings must be removed carefully from pre-existing wounds to prevent scattering of microorganisms into the air. An assistant wearing gloves rather than a scrubbed member of the surgical team should carry this out.
Talking, moving, opening and closing of doors, exposure of wounds, disturbance of clothing or linen and number of personnel in theatre should be kept to a minimum to reduce the risk of airborne cross infection. Every sterile field must be constantly monitored and maintained, as sterility cannot be assured without direct observation of the sterile field.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment. RUH Trust Universal Infection Control Precautions Policy
See also Theatre Standards; Opening Sterile packages Handling of Prostheses and Implants Preparation of Personnel in the Perioperative Department Prepping and Draping Scrubbing, Gowning and Gloving Personal Protective Equipment Operating Theatre Standard No 2 Standard: Booking Emergency Theatre Cases Standard Statement: All cases booked for the Emergency theatre will be dealt with in order of clinical priority as determined by the surgeon and anaesthetist. Method: All cases requiring emergency surgery must be listed via the emergency theatre coordinator on bleep 7566 All cases booked, that require anaesthetic intervention, must be referred to the oncall anaesthetist on bleep. 7001, by the booking surgeon. Details including the patients name, hospital registration number, date of birth, ward or location, surgery required, booking doctors name and bleep number, the name of the surgeon expected to perform the surgery and contact details, consultant whose care the patient is under, time and date of booking, and the theatre practitioner who accepts the booking, must be recorded on the emergency theatre list. The doctor booking the case must identify the clinical priority of the surgery according to agreed guidelines. (Details available in Theatre 1) The theatre coordinator must be notified of any cancellations as soon as possible, and the reason for the cancellation must be identified. The name of the person canceling the case must be recorded on the emergency theatre list.
Compliance: 100% Exceptions: NCEPOD Category 1 patients who require immediate life saving surgery, and whose details may not be complete. Theatre booking guidelines NCEPOD Guidelines
Reference:
Operating Theatre Standards No 3 Standard: Catheterisation of Female Patients Standard Statement: To ensure safe and hygienic insertion of urinary catheter in female patients undergoing surgical procedure. Method: All staff will be familiar with the hospital policy regarding female catheterisation. Theatre staff will maintain patient dignity and minimise risk of infection to the patient. All staff will receive the appropriate training and have been assessed as competent prior to performing this procedure. Theatre staff will place patient with hip flexed and knees bent, feet should be resting about 60cm apart. Theatre personnel must ensure that the patients privacy and dignity are maintained at all times. Excess staff/ visitors must be asked to leave the theatre. Staff must ensure that the patient remains covered until theatre staff are ready to perform the procedure. Good visibility must be ensured by use of theatre lighting. Staff must wash their hands using bactericidal soap or bactericidal alcohol hand rub. Staff must don sterile gloves and an apron. A member of staff is to open the outer catheter pack; the nurse performing the procedure can then proceed to open supplementary packs maintaining an aseptic technique. Place a sterile sheet across the patients thighs. Separate the labia minora so that the urethral meatus is seen. Using swabs provided on the pack, one hand should be used to maintain labial separation until catheterisation is complete. This provides better access to the urethral orifice and helps prevent labial contamination of the catheter. The urethral orifice will be cleaned using 0.9% NaCl solution, single downward strokes will be used. This minimises the risk of cross-infection. The urethral orifice or catheter should be lubricated using sterile aqueous lubricating jelly, or sodium chloride solution. Ref 416/2009 Status: Final
The catheter, of appropriate size as assessed by the theatre practitioner or surgeon, is placed in the receiver between the patients legs, this provides a temporary container as the urine drains. The tip of the catheter is introduced into the urethral orifice and the catheter advanced 6 8 cm, to prevent the balloon from being trapped in the urethra. The balloon is inflated with the appropriate quantity of sterile water as dictated by the manufacturers instructions, having ensured that the catheter is draining adequately i.e. having visualised urine flowing. The catheter bag is attached to the catheter, using hourly drainage measuring devices when appropriate to the surgery. Ensure that the catheter lumen is not occluded and that the patient is not lying on the catheter. Staff must ensure that the patient is dry to prevent secondary infection and skin irritation. Used equipment is disposed of into the yellow contaminated waste bag.
Compliance: 100% Exceptions: None References: Mallett, J. Dougherty, L. (2000) Manual of Clinical Nursing Procedures. The Royal Marsden Hospital, 5th Edition.
Operating Theatre Standard No 4 Standard: Collection of specimens and transportation to the laboratory. Standard Statement: In the operating theatre, specimens are regularly taken during surgical procedures. It is essential that every specimen reaches the pathology, bacteriology, histology or cytology department without undue delay and in optimum condition, to facilitate the survival and identification of organisms. Method: All staff will receive training before undertaking handling of specimens and will achieve the required levels of competency before undertaking this task. The scrub person will confirm with the surgeon the nature of the specimen, the site the specimen was taken from and the analysis required. The necessary form will be completed in a clear and concise way. It is the duty of the scrub nurse to ensure that the surgeon completes the necessary details on the specimen form at the end of the case. The circulating person must follow Universal Precautions when handling the specimen/placing in its container.
All staff must adhere to COSHH regulations and be conversant with Trust COSHH policy for treatment in respect of splash injuries from specimen fixative or body fluids. All specimens must be handled with care to avoid crushing or distortion to anatomical detail. Specimen containers of sufficient size and strength must be provided for each specimen. Sterile containers must be made available where necessary. In the event of several specimens, each container must be clearly numbered and these numbers duplicated onto the specimen form. The scrub nurse must ascertain, from the surgeon, whether a fixing medium (Formalin) is required or not. The circulating person is responsible for completing the label for each container. All details must be checked with the patients notes, and ORSOS screen NOT the operating list to avoid potential confusion with other patients with similar details. All parts of the label must be completed as fully as possible. The label must be placed on the container, not the lid, prior to placing the specimen inside. The details on the container can then be shown to the scrub nurse prior to the specimen being placed inside. Any specimen held in a fixative must be labeled with an appropriate hazard label. The scrub nurse must not discard of any tissue or fluid until it has been ascertained that it is not required for the laboratory. Completed specimens and forms must be placed in a sealed bag. Urgent specimens must be placed in a bag labeled as such and given directly to an orderly for immediate dispatch to the laboratory. These specimens must still be recorded in the specimen log book and the laboratory forewarned of their arrival. Specimens will be taken to the specimen collection area and formalin added as necessary. Formalin must cover the entire specimen plus one third. The patients details, nature of the specimen, date, and surgeons name must be recorded in the logbook. 100% See addendas for frozen sections, ENT specimens and breast specimens. NATN Principles of Safe Practice in the Perioperative Environment Manual of Clinical Nursing Procedures. The Royal Marsden Hospital.
Compliance: Exceptions: References:
Addenda to Collection of Specimens Standard
No 4a Localised Excision of Breast Lesion: This applies to patients who have a specimen taken with a wire in situ. The specimen must be placed in a clear plastic bag. The relevant specimen form and X-ray request must be completed by the surgeon prior to the case commencing. Staff must ensure that the relevant forms accompany the specimen i.e. the specimen form and the X- ray form. The telephone extension number of the theatre in which the operation is being performed must be marked on the specimen form. The patients existing X-rays must also accompany the specimen. Theatre staff will provide a labelled specimen pot large enough for the specimen to be placed in following X-ray. Formalin must be added to the pot prior to it leaving the department. X- Ray will place the specimen in the pot following their handling of it. The patients details must be placed in the specimen logbook and the name of the orderly transporting the specimen obtained by theatre staff. Specimens must be taken directly to the Breast Unit Theatre staff will inform the breast unit that the specimen is en-route to them. The Breast Unit will contact the relevant theatres to inform surgeon if the excised margins of the specimen are adequate.
No.4b Other Breast Specimens: Breast specimens must have a red dot affixed to the specimen form to denote their priority status to the laboratory. A red dot needs only to be applied to the form and not the receptacle.
No 4c) Frozen Sections: It is the responsibility of the medical staff to give notification to the histology department of specimens requiring frozen section. They are responsible for completing the relevant specimen forms prior to the case starting. Theatre staff must check that this has been completed. Theatre staff must check that, included on the specimen form, is the extension of the theatre where the surgery is taking place. Specimens going for frozen section must be placed in dry containers only. Specimens must be despatched immediately to the laboratory. Theatre staffs are to call the laboratory when the specimen has been despatched to warn them of its arrival. Theatre staff must enter the details of the patient into the specimen log book. Theatre staff must obtain the name of the orderly delivering the specimen to the laboratory. Only the surgeon or a member of the medical team may take the results from the laboratory.
No 4d) E.N.T. Specimens: All E.N.T Specimens are labelled for E.N.T. On the specimen form where the request for the patients location is made. Some E.N.T. specimens require a pin-board. Theatre staff must obtain this from the Pathology department; they will also provide the container and pins. It is the responsibility of the surgeon to pin the specimen out as required. Theatre staff must label the container with the patients details. This label can be placed on the lid of the container. These pinned specimens are always sent dry, and must therefore be sent directly to the laboratory as soon as possible. The details of these specimens must be recorded in the theatre logbook as normal. No 4e Foetal Tissue and Remains All staff have a duty to ensure that any specimens that include any products of conception i.e. foetus, placental tissue and amniotic tissue, are dealt with and disposed of in accordance with the RUH Trust policy Respectful Disposal of Foetal Remains 2004. All tissue must be collected into a Foetal Tissue Disposal Device, readily available from the Princess Anne Wing Theatres and Emergency Theatre One, Main Theatres. This device can be added in to the usual theatre suction system to allow for direct collection of all foetal tissue when suction aspiration is used for surgical intervention. If the resulting specimen is required for laboratory analysis, the appropriate completed form must accompany the collection device. The lid of the collection device may be accessed to allow additives such as Formalin to be introduced. Staff must ensure aseptic techniques are employed during this manoeuvre and that they protect themselves from contamination using Personal Protective Equipment, available in each Theatre and sluice area. The collection device is then sealed and labelled appropriately according to additive/ fixative used, and the label is completed with all relevant patient details. The entire collection device is then placed inside a sealable plastic bag and replaced inside the cardboard container provided with each individual collection device. The outer box is then labelled with relevant patient details. If laboratory analysis of the collected tissue is not required, the outer box must clearly be labelled For Disposal The complete unit is then forwarded to the Pathology Department using the usual specimen collection procedure as detailed in Collection of Specimens Standard No 4 NO Foetal tissue should ever be discarded as clinical waste. References: RUH Trust Policy, Respectful Disposal of Fetal Remains See also Operating Theatre Standards: Collection of Specimens Personal Protective Equipment and Tissue 2004
Operating Theatre Standard No 5 Standard: Dealing with Hazardous Spillages Standard Statement: All staff in the department must be aware of the measures that need to be taken in the event of the spillage of a hazardous substance. Method: All staff must adhere to COSHH regulations and be conversant with the Trust COSHH policy for dealing with spillages. Staff will be conversant with the substances used in the Operating Theatres that are considered a risk by COSHH All staff handling hazardous substances must receive training appropriate to their role and responsibility. COSHH training is mandatory on appointment to the Trust and it is recommended that updates are received every two years. Staff must wear protective clothing, in adherence with the trust policy, when dealing with disposal of contaminated waste. Staff will be aware of the measures to be taken in the event of a spillage, regarding appropriate protective clothing, evacuation requirements etc. All identified hazardous substances will be handled with care and compliance to manufacturers instructions adhered to. Handling of identified hazardous substances will be kept a minimum. Any untoward occurrences involving hazardous substances must be reported, with referral to the Occupational Health Department as necessary. Compliance: 100% Exceptions: None References: RUH Trust Policy Control Of Substances Hazardous To Health The Control of Substances Hazardous to Health 2002 Approved Code of Practice NATN Principles of Safe Practice in the Perioperative Environment
See Also Theatre Standards: Incident Reporting Disposal of Non Hazardous Spillages Disposal of Waste Refuse and Linen Operating Theatre Standard No 6 Standard:
Dealing With Non Hazardous Spillages Standard Statement: Spillages will be dealt with as soon as possible. Each theatre must ensure that the equipment to deal with spillage is readily available. Method: All staff handling waste or spillage of body fluids must receive training appropriate to their role and responsibilities. Staff will familiarise themselves with the Trust policy on spillages. Wearing protective clothing i.e. gloves, aprons, mask. Substances will be mopped up using paper roll/towels and discarded into a yellow clinical waste bag. Care must be taken not to contaminate the outside of the bag. The surface must be cleaned using detergent and water and dried. Staff must dispose of gloves as clinical waste and wash hands. Compliance: 100% Exceptions: None References: RUH Trust Universal Infection Control Precautions Policy, Disposal of Waste NATN Principles of Safe Practice in the Perioperative Environment.
See also Theatre Standards: Dealing with Hazardous Spillages Disposal of Waste Refuse and Linen Personal Protective Equipment Operating Theatre Standards No 7 Standard: Disposing of Confidential Information in the theatre department. Standard Statement: Theatre practitioners must protect and dispose of any confidential information, concerning patients that is generated for each theatre. Method: Each operating list must be removed and disposed of in an appropriate manner. I.e. in the purpose built sealed paper bin/ by shredding/ into a clinical waste bin. Operating lists for the following day must be left face down and placed in a discreet place. Notes/ X-rays remaining which pertain to patients must be removed and delivered to the appropriate area. Record books must be closed at the end of each shift.
ORSOS sessions must be logged off. And each computer must be closed down when the theatre is no longer in use. Paper containing any patient details must not be reused as scrap paper. Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment. R.U.H. Trust Policy Destruction of Confidential Waste
Operating Theatre Standard No 8 Standard: Disposal of used instruments. Standard Statement: All instruments used during surgical procedures will be returned to DSDU for reprocessing in a manner that minimises risk to all staff handling the contaminated items. Method: All instrumentation used will be accounted for and returned to its original tray at the end of each operative procedure. All disposable items will be removed and safely disposed of. It is the scrub persons responsibility to ensure that all sharps are removed and discarded. Instruments which may potentially cause injury will be closed if possible e.g. ratcheted items, or placed within a receptacle e.g. diathermy point should be placed inside the quiver. All linen will be removed and sent for reprocessing as detailed in the Infection Control Linen Policy. Used trays will be removed from theatre via the sluice area, and placed into the DSDU buggy, with the heaviest trays at the bottom and more delicate items on top, along with the completed DSDU check sheets. The dirty corridor orderly will remove the buggy when full and deliver it to DSDU for reprocessing. If items are required to be reprocessed quickly, the theatre team will telephone DSDU as soon as the item is available to request urgent turn around. The dirty corridor orderly is then contacted to collect the item from theatre, for rapid delivery to DSDU. Compliance: 100% Exceptions: References: None RUH Trust Infection Control Linen Policy Safe Sharps Use and Disposal Ref 416/2009 Status: Final
See also Theatre Standards: Issue Date: September 2009
Page 66 of 131
Waste and Linen Disposal Swab and Instrument Counts Theatre Documentation Operating Theatre Standard No 9 Standard: Disposal of waste refuse and soiled linen. Standard Statement: Waste products and linen must be correctly segregated and placed in the appropriate receptacle: the receptacle must never be overfilled and must be safely sealed and labelled prior to transportation. Method: Staff must have access to and be aware of the Trust Infection Control Policy for Disposal of Waste, and the Linen Policy. Staff must have received appropriate training in the waste disposal procedure. Staff disposing of waste must be able to identify its categorisation and the appropriate packaging necessary for its disposal. Waste must be packaged correctly so that it does not present a risk to the environment and/or personnel when in transit or storage. Clinical waste except used batteries and pressurised cans must be placed into yellow bags; unsoiled household waste into black bags, and soiled linen must be double bagged in both a red alginate inner bag and a green waterproof outer bag. Each department must identify a collection and storage area for the disposal of used electrical batteries and pressurised cans. A clearly labelled container must be provided for each of these i.e. one for batteries and one for cans. When full, Facilities should be contacted and they will arrange for collection and safe disposal. Care must be taken not to inadvertently include non-linen items within the linen disposal system. Disposal bags/containers must be marked with which theatre they have come from, the date, and case number. Sealed bags and containers waiting collection must be stored in the designated area, which is safe and separate from patient areas. In theatres the designated area is the sluice. Where there is doubt as to the type of waste, it should be classed as clinical. Bags should never be more than full. Excess air should be removed, taking care not to squeeze the bag. The bag should be tied securely. Bags that are full prior to the end of the case may be sealed but must remain in theatre; fresh bags can be made up with the same details marked on them. Bags must only ever be discarded at the end of the case. Bags must be handled with care to avoid bursting or splitting. Sharps bins must be carried by the handle and never placed in bags. The details of the persons both assembling the bin and disposing of it must be marked on the receptacle. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 67 of 131
Staff must not decant one bag to another. Staff handling waste must wear gloves and protective clothing at all times. On removal of gloves, hands must be washed.
Compliance: 100% Exceptions: None References: NATN Principles of Safe Practice in the Perioperative Environment. RUH Trust Infection Control Policies; Disposal of Waste, and Linen Policy.
Operating Theatre Standard No 9A Standard: Disposal of Human Tissue Standard Statement: Relevant staff must ensure that all human tissue removed during any operative procedure is disposed of in an ethical and respectful manner. Method: Staff must confirm with the surgeon that the tissue in question is for disposal only and not required for specimens. Any human tissue that is required for laboratory analysis must be dealt with according to Theatre Standard No 4 Collection of Specimens. Any tissue for disposal that includes any foetal remains must be dealt with according to Addenda 4e to the Collection of Specimens Standard. Any tissue for disposal should be kept separate until the operative procedure is complete and all counts have been carried out. The tissue may then be placed securely in a rigid yellow clinical waste bin for incineration. Care must be taken with any tissue containing sharp penetrative items such as bone fragments. Staff must wear appropriate personal protective equipment when dealing with tissue for disposal. Larger items, such as amputated limbs, should be placed directly into a rigid yellow bin. The bin should be sealed and labelled clearly with the Theatre of origin, date and case number. The Theatre Orderly should then be contacted on Bleep 7734 to arrange for removal of the bin to a secure area awaiting collection for incineration. References: RUH Trust Waste Disposal Policy RUH Trust Policy Respectful Disposal of Fetal Remains and Tissue See Also Operating Theatre Standards: Collection of Specimens and Addenda Disposal of Waste Personal Protective Equipment Swab and Instrument Counts
Operating Theatre Standard No 10 Standard: Handling of instruments Standard Statement: All staff will ensure instruments are handled safely to minimise the risk of accidental injury to the patient, self and colleagues. All instruments will be checked prior to and following use to ensure that they are fit for their intended purpose and remain so following their use. Method: All staff will receive training on how to handle instruments and will be assessed as competent before carrying this out unsupported. All staff will be familiar with RUH Trust Infection Control Policies on Linen and Waste Disposal, Occupational Health Policy on Needlestick Injury, and other Theatre Standards as detailed below. The scrub person will check each instrument prior to its use to ensure it is fit for its purpose, and that no parts are missing e.g. screws. All items are handed to the surgeon firmly and precisely, with verbal confirmation of which instrument has been handed if not requested by name by the surgeon. Any item with variable settings, such as cutting jigs, impaction/ delivery devices etc. may be set by the scrub practitioner, according to the surgeons instructions. On delivering the item to the operative field, the scrub practitioner should clearly, verbally state the equipment settings and receive confirmation of correct settings from the surgeon. Items with ring handles should be held by the shank, with the handles facing downwards, to be placed into the palm of the surgeons hand, unless it is indicated by the surgeon otherwise. Instruments with an open/close mechanism must always be handed over in the closed position. If there is a ratchet on the item this should be secured. Holding or touching instruments by the working tips should be avoided wherever possible. Instruments should be kept as clean as possible, using a swab to wipe excess blood and body substances from them. Sharp items should be passed in a receptacle such as a receiver, to minimise the risk of accidental injury. Diathermy equipment must be kept within an insulated receptacle such as a quiver when not in use to minimise the risk of accidental burns. Scratch pads may be used to clean the tips of monopolar diathermy, to ensure good contact with bleeding vessels is maintained, and to prevent sticking. Scratch pads must never be used on bi-polar forceps as they remove the non-stick properties and render the instrument useless. Instruments must not be allowed to rest directly on the patient, as they may either cause injury to the patient and members of the surgical team, or may damage the drapes and compromise the sterile field.
Consideration should be given to the use of appropriate additional surfaces such as Mayo tables or magnetic mats. At the end of the procedure instruments should be returned to their original trays, additional items placed on the principal tray, and all disposable sharps removed and safely disposed of.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment 1998 RUH Trust Infection Control Linen and Waste Policies Sharps Policy
See also Theatre Standards: Aseptic Technique Disposal of Instruments Disposal of Waste and Linen Safe Use and Disposal of Sharps Swab and Instrument Counts Trolley Preparation Use of Electrosurgical Equipment. Operating Theatre Standard No 11 Standard: Incident Reporting Standard Statement: All staff members are responsible for the identification and documentation of accidents and incidents within the department. Method: All staff must ensure they have received training on the responsibilities of the employer and the employee in relation to health and safety, and be familiar with the following policies; o Health and Safety and Environmental Policy (Introduction & Responsibilities for Health & Safety) o Policy for Risk & Incident Management o Serious Adverse Incident Policy & Procedure Staff must take an active part or be aware of the need and necessity of updating policies. All accidents to, or all incidents involving staff/and or equipment/ adverse incidents/ breaches of protocol or any issues pertaining to patient care and the running of the theatre lists must be reported to the co-ordinator and the relevant paperwork completed i.e. Incident report forms.
All staff, if necessary, should seek medical assessment of any injury sustained. The person responsible for co-ordinating the department should sign the incident report form. One copy remains in the department and the other is sent to Risk Management for assessment whereby the level of risk can be ascertained. 100% None NATN Principles of Safe Practice in the Perioperative Environment. Trust Policies as detailed above
Operating Theatre Standard No 12 Standard: Issue of Controlled Drugs, Holding Controlled Drugs Keys and Ordering of Controlled Drugs. Standard Statement: All controlled drugs will only be issued or ordered within the Operating theatre department, in accordance with the Misuse of Drugs Act (1971) Controlled drugs keys will only be held by Registered Nurses and delegated ODPs as detailed below. Regular controlled drugs checks will be carried out and recorded in a daily logbook held in each controlled drug cupboard. Method: Under the Misuse of Drugs Act (1971), the accountability for safe custody and issue of controlled drugs lies with the Registered Nurse within the operating theatre. Responsibility for the issue of controlled drugs and for holding the keys may be delegated by the Registered Nurse to an ODP within the theatre. Delegation of responsibility can only be to an ODP of D grade or above. The identified delegate must only be an ODP permanently employed by the RUH Trust, i.e. it is not permissible for Agency ODPs to hold the drugs keys or to issue drugs. The accountability for all controlled drugs remains with the Registered Nurse even when access is delegated to an ODP. An ODP reserves the right to refuse responsibility for holding the drugs keys. Agency nurses whose registration has been confirmed with the N.M.C. may be delegated to hold the keys and issue controlled drugs. Controlled drugs keys will be kept centrally in a locked cupboard until they are required. The key to this cupboard is held with Theatre Ones keys, which are held by the senior nurse on duty until delegated to an appropriate member of Theatre Ones team. Controlled drugs checks will be carried out prior to commencement of each days operating list and at each change over of staff. The controlled drugs will again be
checked at the end of the days operating session before the keys are returned to the central holding cupboard. Two members of staff of which one must be a registered nurse must carry out each drug check. The other member of staff may be any member of the theatre team who has received the appropriate training and has been assessed as competent in this skill. Each check must be recorded in the checking logbook kept in each anaesthetic room. Both parties who carry out the drugs check must sign the logbook. Controlled drugs must be issued in accordance with the Misuse of Drugs Act 1971. All drugs must be signed for in the controlled drug register by the person issuing or checking the drug and by the person administering the drug. Ordering of controlled drugs may only be undertaken by registered nurses, whose signature is held on file in the pharmacy department. Controlled drugs must be received from pharmacy sealed within a red transfer bag. These drugs must only be entered into the register and put into the controlled drug cupboard by a registered nurse. If a controlled drug is found to be missing, all efforts must be made to locate it. If it is not possible to discover where the discrepancy has occurred, the Theatre Coordinator for the shift must be informed and an incident form completed. 100% None Misuse of Drugs Act 1971 RUH. Trust Administration of I.V. Drugs Manual
See also Theatre Standard Incident Reporting Operating Theatre Standard No 13 Standard: Opening of sterile trays and packages. Statement Standard: All sterile items to be used during an operative procedure will be opened in a manner so as to avoid any possible contamination, and therefore minimise the risk of cross infection to the patient. Method: All members of staff will be given training regarding the safe opening and of equipment, and will have been assessed as competent before undertaking this unsupervised. Staff must check that the pack to be opened is intact i.e. no visible tearing of either paper or drape.
Any packaging that feels damp or contains moisture is not fit for use, and must be discarded. Staff must be aware that all packaging has a shelf life and must therefore examine each item before opening to check the expiry date has not been exceeded. Any tray or package that has auto-clave tape must be checked to ensure that the tape has turned brown indicating the item has been through a correct autoclaving process. A lot of items are now purchased pre-sterilised and will have been sterilised by irradiation. These items have a longer shelf life, but still carry an expiry date, which must be checked. Auto-clave tape must be peeled upwards, care being taken not to tear the outer packaging in the process. When an item is packaged in a bag staff must run their fingers along the gulleys on either side in an upward motion so the inner package emerges from the top. Trays must be opened in a manner whereby the unscrubbed circulating person does not lean over any part of the sterile inner drapes. Items must not be dropped onto the scrub trolley without the scrub persons consent and knowledge as to what the item actually is. Sutures must be peeled open and presented for the scrub person to take. Items must be presented to the scrub person from the edge of the sterile field. Staplers and disposable pre-packaged items should have the paper peeled off the top of their packaging, from the semi-peeled point, so as the scrub person can take the item from within the sterile plastic packaging. Prostheses and other implants must be opened according to manufacturers instructions and must not be opened until both the surgeon and scrub person have identified them as the required item. If staff touch, or suspect they touched a sterile item, then it must be discarded and a fresh one introduced. Any sterility stickers or implant/ prostheses labels must be removed and placed in the patients notes, and if appropriate on the reordering sheet.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment 1998. The Royal Marsden Hospital Manual Of Clinical Nursing Procedures.
See AlsoTheatre Standards: Aseptic Technique Theatre Documentation Trolley Preparation for Surgical Intervention
Operating Theatre Standard No 13A Standard: Handling of Prostheses and Implants
Standard Statement: All staff will ensure that any implant or prosthesis is minimally handled to reduce the risks of both cross infection and the mishandling and dropping of the item, thereby reducing cost to the trust in treatment of post operative infection, and cost to the department in wasted implants/ prostheses. Method: The implant/ prostheses must not be opened until the scrub person and the surgeon have checked the item and requested its delivery to the sterile trolley. The item should be opened carefully according to the manufacturers guidelines and should be taken directly by the scrub person. The item must not be dropped on to the sterile surface to prevent both damage to the item, accidental contamination, and wastage if the item should fall. The scrub person having taken the item should identify a sterile receiver, if appropriate, or a safe area of the sterile trolley, that is away from the working area, for storage of the item, until it is actually required. Where the item is provide sealed within another layer of packaging, the scrub person should leave this packaging intact as long as possible, to reduce possible cross contamination. When the surgeon requests the item, the packaging may be opened on a clutter free sterile area of the trolley ensuring adequate drop space around the item. The item should be kept as close to the surface of the trolley as possible, in case the item is accidentally dropped. Transfer of the item wherever possible should be either, within the opened sterile packaging provided, or in an identified safe receptacle, such as a receiver. Where the item has its own specific delivery instrument or impaction device, the item, where possible should be mounted by the surgeon who is undertaking the procedure. Once mounted the whole should be placed very carefully on a flat sterile surface, of sufficient area, free from any other swabs or instruments. The surgeons themselves should then pick up the item as required. Where there is no other option but to hand the item from scrub person to surgeon, this must be done directly and never through a third party, such as assisting surgeon, or trainee scrub person to reduce the risk of wastage and cross contamination. Any traceability stickers or prostheses/implant details must be recorded in the patients notes and on the Stores sheet for reordering. In the event of a prosthesis or implant being dropped or contaminated, the item must be discarded and a fresh sterile item sourced. It is not acceptable to decontaminate any implants or prostheses using Little Sister Autoclave or Chemical e.g. Perisafe forms of decontamination. If in doubt contact a senior member of the theatre team for advice. Compliance: 100% Ref 416/2009 Status: Final
Exceptions: References:
None RUH Infection Control Policies NATN Standards and Recommendations for Safe Perioperative Practice Oct 2004
See Also Operating Theatre Standards: Handling of Instruments Aseptic Technique Opening of Sterile Trays and Packages Theatre Documentation Operating Theatre Standard No 14 Standard: Pharmacy delivery and stock rotation Standard Statement: All staff are responsible for putting Pharmacy items away and ensuring correct stock rotation. Method: All staff will receive training on how to put Pharmacy away correctly. Staff must ensure that they are familiar with the location of all drugs in case of an emergency. Every item of Pharmacy delivered to the department, whether fluids or ampoules, must be checked off the order list provided, so we have a record of everything received. The Pharmacy order check lists, must be signed by the person putting the Pharmacy away, and kept in the bottom of the pharmacy cupboard. All items must be stock rotated, i.e. new stock placed at the back and older stock brought forward to ensure items are used in date order, to prevent drugs passing their expiry date and wastage of resources. Once emptied, the Pharmacy boxes should be returned to Theatre Reception. General pharmacy requirements are fulfilled twice a week by pharmacy technicians on a top up basis. Controlled Drugs are ordered by Registered Nurses as required by each individual theatre. Special one off items may be ordered as required using the yellow pharmacy order sheets kept in each Anaesthetic room. ( Not controlled drugs) Compliance: 100% Exceptions: None
Operating Theatre Standard No 15 Standard: Photography and Video Standard Statement: Staff will ensure that prior to any photographs are taken or video equipment is used, the appropriate consent has been obtained. Method: Patients have the right to refuse permission for any photographs to be taken, or any video equipment to be used during their surgery. It is essential that anyone wishing to use photographic or video equipment has obtained the necessary permission from the patient prior to their use. Any photographs taken of patients are the copyright of the Secretary of State for Health and may only be used subsequently if further permission is gained from the patient. When outside agencies have been given permission to film or photograph within the operating department, staff should be reminded of their role in patient advocacy and standards of professional conduct. Media personnel should not be permitted into the Perioperative Environment without the Trust Administrations permission. Compliance: 100% Exceptions: None Reference: NATN Principles of Safe Practice in the Perioperative Environment 1998
Operating Theatre Standard No 16 Standard: Preparation of personnel within the perioperative environment. Standard Statement: All member of staff working within the theatre environment should present a professional appearance and conduct themselves in a professional manner at all times. Method: All personnel must be familiar with and adhere to the R.U.H. Trust Code of Expectations, the Trust Uniform policy, the Theatre Departmental Expectations, and the Theatre Policy; Preparation of Personnel within the Operating Theatre Environment. All staff must receive yearly mandatory training in infection control, including good hand washing techniques and the need for good personal hygiene. Finger nails should be kept short, clean and free from nail polish and artificial nails.
All cuts and abrasions should be kept covered with a clean waterproof dressing. Jewellery must be kept to a minimum i.e. a plain wedding ring may be worn along with one pair of plain stud earrings and a plain neck chain only. All personnel who enter the restricted areas of the theatre environment must be appropriately attired in clean freshly laundered theatre wear in good repair. Theatre wear must be changed when it becomes soiled or wet. Footwear is provided to all staff working within the restricted areas. All footwear must be kept clean and in good repair, exchanging for new when appropriate. Clean headwear must be worn within the restricted areas and all head hair should be kept within the confines of the headwear provided. Several styles of headwear are available within the changing areas to allow for differing hairstyles to be accommodated. Disposable facemasks must be worn by all staff entering Orthopaedic areas. Personal discretion and preference may be used in other specialties, but it is recommended that staff working in close proximity to bodily fluids should wear masks for their own protection. Masks must be changed when they become soiled, and every two hours where possible. Masks should be removed entirely when leaving the restricted areas. Visor and laser masks are provided for additional protection as required. Disposable gloves are provided throughout the department and must be worn when dealing with any contaminated items. Latex free gloves are provided for staff with latex allergy, these must be stored separately from those gloves containing latex. Disposable gloves are single use items and must be disposed of into an appropriate clinical waste receptacle after use. Wearing of gloves does not negate the requirement for good hand washing before and after use. If it is necessary for a member of staff wearing theatre blues to leave the department, a clean buttoned up white coat must be worn over theatre wear. All hats and masks must be removed, and theatre footwear exchanged for staff members own outdoor shoes.
Compliance: 100% Exceptions: References: Nil
R.U.H. Trust Code of Expectations R.U.H. Uniform Policy R.U.H. Trust Universal Infection Control Precautions Policy NATN Principles of Safe Practice within the Perioperative Environment 1998 R.U.H. Theatre Departmental Expectations 2004 R.U.H. Theatre Policy Preparation Of Personnel within the Operating Theatre 2004
Operating Theatre Standard No 17 Standard: Personal Protective Equipment Standard Statement: Staff must ensure that they are familiar with and utilise appropriate types of personal protective equipment available for use within the operating department, to minimise the risk of infection or accidental contamination to patients, self and fellow colleagues. Method All staff must ensure that they are familiar with the different types of personal protective equipment available, relevant to the operative procedure they are undertaking, before commencing any procedure that may expose themselves or others to contamination with either body fluids, cleaning fluids or other material controlled by C.O.S.H.H. i.e. Control of Substances Hazardous to Health. All staff will receive mandatory training in Infection Control issues and in C.O.S.H.H. This training is undertaken at Trust Induction and should then be updated yearly. If this training has not been completed or kept up to date all staff have a duty to inform their manager. All staff should be familiar with the RUH Trust Infection Control Policies: Protection Against Infection, Hand Decontamination and Protection Against Infection with Blood Borne Viruses. Also COSHH recommendations. Disposable aprons and gloves are available in each clinical area, together with a variety of surgical masks for all types of surgery. Specialist laser masks must be worn together with appropriate eye protection whenever the Laser is being used. External door signs must be clearly displayed on all entrances to minimise the risk of accidental exposure to laser beams. Only Laser trained personnel are permitted to operate the Laser, and the Laser key holder must be present during use. Alternative forms of eye protection are available in each clinical area. An appropriate type must be selected on an individual basis depending on the risk encountered. It is strongly recommended that all staff members who are in close proximity to the operative field wear some form of eye protection to prevent accidental eye splashes or contamination with diathermy plume. Types of eye protection available: 1. Surgical masks 2. Visor masks 3. Laser masks 4. Single use visors with holders 5. Eye goggles 6. Laser goggles Disposable gloves must be worn when dealing with any contaminated items to minimise the risk of cross infection. Appropriate sized gloves should be donned onto freshly washed and dried hands. Gloves should be changed when contaminated, between each patient intervention and prior to leaving the operating theatre.
Hands must be washed on removing gloves and a moisturiser used as appropriate, to prevent cracking or chapping of dry skin thereby reducing the risk of cross infection. Various types of disposable and surgical gloves are provided within the department, including latex free forms of both types. Freezer gauntlets are provided for dealing with the freezer unit containing the Orthopaedic Bone Bank All members of the theatre team should wear disposable aprons where there is a high risk of contamination with either body fluids or cleaning materials. Disposable aprons must be removed before leaving the operating theatre and a fresh one applied between each patient intervention. Aprons should be removed with gloved hands and disposed of into an appropriate clinical waste receptacle, prior to the removal of gloves ensuring hands are kept protected for as long as possible. Lead gowns and thyroid protectors are provided for all staff involved in operative procedures where there may be exposure to radiation. See Radiation Protection Standard no.17a Freshly laundered supplies of theatre scrub suits are available in each staff changing area. Scrub suits must be changed daily or as soon as visibly contaminated. Scrub suits should not be stored in lockers prior to use. All staff who work in the operating theatre environment are supplied with appropriate footwear. It is the individuals responsibility to keep these clean and appropriately stored when not in use. If footwear becomes damaged, a new pair should be sourced. Footwear should be enclosed at the front to prevent accidental injury to toes, and if of the clog variety, have a back strap applied to prevent injury when forced to walk backwards e.g. when escorting patients on beds or trolleys.
Compliance: 100% Exceptions: None References: RUH Trust Policies: Operating Theatres Visitors to the Peri-Operative Environment Operating Dress Laser Safety Radiation Safety C.O.S.H.H. Health, Safety and Environment Infection control Policies: Universal Precautions Protection Against Infection with Blood Borne Viruses Hand Decontamination
NATN Standards and Recommendations for Safe Perioperative Practice October 2004
See Also Theatre Standards: Preparation of Personnel Scrubbing Gowning and Gloving Aseptic Technique Sharps Disposal Radiation Protective Operating Theatre Standard No 17a Standard: Radiation Protection Standard Statement: All staff members have a responsibility to protect the patient, themselves and others. They will ensure that they do not knowingly expose themselves or others to more radiation than is necessary. Method: Only authorised personnel who are trained and assessed may use the X-Ray equipment. Patients undergoing procedures where X-Ray is deemed necessary should be protected wherever possible. Radiation doses and exposure should be kept to a minimum. Only essential staff should remain in the theatre whilst X-Ray is in use. All staff remaining in the immediate vicinity must be protected with appropriate lead garments. Protective lead garments must be safeguarded from damage, cleaned after use and examined frequently. They must be stored hanging freely on the provided racking system. Any member of staff known to be pregnant should not be present in theatres when X-Ray is being deployed. When X-Ray is in use it is essential that access to the area is restricted in order to prevent accidental exposure, with notices being displayed wherever possible. Details of any radio-opaque contrast used must be recorded in the perioperative documentation. Radio-opaque contrast must be used with extreme caution in any patient with known iodine allergy. Compliance: 100% Exceptions: Reference: None NATN Principles of Safe Practice in the Perioperative Environment 1998 R.U.H. Trust Radiation Safety Policy
Operating Theatre Standard No 18 Standard: Receiving patients into theatre. Standard Statement: All patients will be received into theatre and greeted by name by the staff involved in their care, and their identity checked with the operating schedule. All patients will receive their surgery in a safe and controlled environment, and be treated with dignity and respect at all times. Method: The theatre team will greet the patient by name, introduce themselves and identify their roles. The theatre team will assist in the safe transfer of the patient from bed to theatre table. A member of the theatre team will accompany the patient until anaesthesia is give to provide support to the patient. The Anaesthetic assistant will communicate any relevant information regarding allergies, restrictions of movement and any other specific patient requirements. The theatre team will ensure that patient dignity is maintained at all times and that exposure is kept to a minimum. The theatre team will ensure a safe environment is maintained for the patient. The scrub person will again check the consent form before surgery commences and confirm the patient details with their identity bracelet.
Compliance: 100% Exceptions: NCEPOD Category 1 patients who require immediate resuscitation concurrent with surgery, who may not have been formally identified or be able to sign a consent form NATN Principles of Safe Practice in the Perioperative Environment. NCEPOD guidelines
References:
Operating Theatre Standard No 19 Standard: Scrubbing , Gowning and Gloving Standard Statement: All staff that take part in operative procedures will be able to scrub, gown and glove effectively to ensure asepsis is maintained in order to reduce the risk of cross infection to the patient.
Method: All staff that need to take part in operative procedures will be trained and assessed as competent in these skills before undertaking them unsupported. All staff will be in appropriate theatre attire before commencing, wearing a freshly donned mask, correctly positioned over the nose and mouth, with all hair covered by a surgical hat. Fingernails must be clean, short and free from polish or artificial nails. All jewellery must be removed, except a plain wedding ring, which may be worn if extra care is taken to clean under and around it when scrubbing. Protective eyewear is advised for all invasive procedures. Any spectacles or microscopic lenses should be securely positioned prior to scrubbing. Skin on hands and arms should be intact. Protective clothing such as lead gowns or aprons should be donned and comfortable. In order to minimise contamination during scrubbing staff should ensure the following; o Taps are operated using the elbows only once the scrub sequence has begun o The water is of a comfortable temperature and steady flow. o The hands are above the level of the elbows o Care should be taken not to splash theatre clothing o Rinsing is performed from fingertips to elbows using the water flow not the hands. o Approximately 5ml of scrub solution is dispensed onto the hands at each application using an elbow operated device. Scrub solution is worked into all areas of the hands paying particular attention to the nails and between the fingers, and then worked down the arms to the elbows. o A nailbrush should be used for the first scrub of the operating session. o Only the nails should be brushed, brushing of other areas of the fingers and hands has been shown to be detrimental to the skin, causing abrasions and bringing organisms to the surface. o The first scrub of the day should last for 5 minutes, subsequent scrubs need only be of 3 minutes duration, alcohol hand rub may be used between short cases e.g. oral surgery, E.N.T. etc. if no visible contamination is present. o Care should be taken to keep the hands up and allow cleansing solution to run off the elbows. o A separate disposable paper towel should be used to dry each hand, with drying commencing at the fingertips and finishing at the elbows. o A dabbing motion should be used for drying, vigorous rubbing must be discouraged as it disturbs skin cells. All gowns used should be presented in a good state of repair, any gown found not to be processed to a high standard must be discarded. o The practitioner touches only the inside of the folded gown, and inserts both arms into the sleeves of the gown at the same time. o The circulating person will assist the scrubbed person by securing the back ties.
o The gown should be of the wrap around variety and this should be secured with the assistance of another scrubbed person. o Disposable gowns are provide for use within the orthopaedic operating theatres, to prevent contamination with lint from linen drapes Closed gloving is the method of choice, i.e. donning of gloves with hands tucked inside the cuffs of the gown so that no outer part of the glove is touched with bare hands. Different varieties of gloves are available for different purposes, also latex free varieties are available for those with latex sensitivity. Double gloving is recommended for all cases to minimise the risk of contamination in the event of an accidental sharps injury. It is advised that a pair one size larger is placed underneath the usual sized outer glove to optimise wearer comfort. Double gloving is essential for all Orthopaedic cases, as the incidence of puncture of the outer glove is high. Whilst double gloving does not prevent sharps injury it has been shown to effect up to a six-fold decrease in inner glove puncture. In the event of percutaneous injury, the volume of blood transmitted may also be reduced due to the enhanced wiping effect of two layers of glove Double gloving is also essential in any known or suspected patients with blood borne viruses such as Hepatitis B & C and HIV, also patients who are thought to be in other high risk groups as defined by the RUH Trust Policy for Protection Against Infection with Blood Borne Viruses. If it is necessary to change gloves during a procedure, the closed method remains the method of choice if possible. It is essential that the practitioner understands that their area of sterility is from fingertips to elbows, and from below nipple line to waist. The hands must be kept at or above waist level at all times. When not involved in a sterile procedure the scrubbed person should stand with their hands together in front of their lower chest. At the end of the procedure the practitioner should remove firstly the gown over gloved hands and then the gloves, to minimise skin contamination, then disposing of them into the appropriate receptacle i.e. yellow clinical waste bin or bag. Hands should then be rewashed and dried. It is recommended that a hand moisturiser is used at frequent intervals to prevent chapping or cracking of skin, to minimise the risk of infection.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment. RUH Trust Universal Infection Control Precautions Policy RUH Policy for Protection Against Infection with Blood Borne Viruses
See also Theatre Standards: Aseptic Technique Disposal of Waste Refuse and Linen Preparation of Personnel Personal Protective Equipment Operating Theatre Standard No 20 Standard: Sending For Patients Standard Statement: All patients who are listed for surgery will be sent for in a timely manner to ensure smooth running of theatre lists and maximisation of the operating theatre availability. Method: Elective operating lists will be compiled in advance by the appropriate booking coordinator, in consultation with senior members of the theatre staff wherever possible. Elective lists should be available the day prior to surgery, to allow theatre staff to plan instrumentation, prostheses and staffing appropriately. Specific instrument or prosthetic requirements that need to be arranged in advance, must be notified to the Senior Theatre Practitioner responsible for that specialty as far in advance as possible. On the morning of surgery, theatre reception will phone to ensure that bed space is available for all patients, confirm ward allocation and inform the relevant theatre of any problems. The first patient of each operating session will be sent for automatically according to the planned start time for each list. Should there be any delay to the projected start time for afternoon sessions, theatre staff will inform reception to prevent the patient being sent for inappropriately. Subsequent patients are requested as required, via theatre reception. Emergency patients are done in order of clinical priority and are sent for directly by the Emergency Theatre Coordinator, who will phone the ward in advance to ensure that each patient is ready for collection. Cases must not be sent for after 3pm without the prior consent of the Theatre Coordinator. The Theatre coordinator must be informed of any additions to scheduled operating lists, and of any other problems arising. Only the Theatre Coordinator has the authority to cancel patients due to lack of operating time. Compliance: 100% Exceptions: None
Operating Theatre Standard No 21 Standard: Sharps/ needle stick injury, mucous membrane contamination. Standard Statement: All sharps/ needlestick injuries, contamination of mucous membranes or conjunctiva, bites or scratches which draw blood, or contamination of minor cuts, abrasions and other open skin lesions, must be reported and dealt with in accordance with the R.U.H. Occupational Health Sharps Injury Action Pack. Method: All staff must be familiar with the Occupational Health Sharps Injury Action Pack (copy available in each theatre) Immediate care includes running the site of exposure/ injury under warm water, encouraging bleeding, washing the site liberally with soap and water but avoiding scrubbing. If there is a puncture wound, free bleeding should be encouraged but the wound must not be sucked. Exposed mucous membranes or conjunctiva should be irrigated copiously with water. With the patients consent, a blood sample for hepatitis B, C and HIV should be taken in a yellow-topped clotted bottle. The staff member involved should have a 1st storage blood sample taken using a yellow-topped clotted bottle. If there is concern about exposure to HIV during working hours telephone the needlestick hotline on ext 1001. out of hours contact switchboard and ask for the Physician on call for HIV PEP All incidents must be reported by telephone to Occupational Health as soon as possible. o 8.30 17.00 hrs Mon Thurs 8.30 16.00 hrs Friday, telephone the Needlestick hotline ext. 1001 o Other times inc. Bank Holidays ext.1001 leave a message on the ansaphone, this will then be dealt with as soon as possible. o If further advice is required out of hours, contact the on-call Virologist via switchboard. An incident/ accident form must be completed as soon as possible and forwarded to the theatre coordinator for the shift.
References:
Occupational Health Sharps Injury Action Pack See also Theatre Standards: Incident/ Accident Reporting Sharps Use and Safe Disposal Universal Precautions and Infection Control
Operating Theatre Standard No 22 Standard: Sharps use and safe disposal. Standard Statement: All sharp items used during procedures must be handled and disposed of safely to protect self, colleagues and patients. Method: All staff will receive mandatory yearly training and updates on infection control. All staff will receive training on the correct handling and disposal of sharps. All staff will be familiar with the various types of sharps containers within the department and be aware of their appropriate use. All staff will be familiar with the policy regarding the reporting of and dealing with needle stick injuries. During surgery all sharps must be kept contained within an appropriate receptacle, e.g. handle and blade in a receiver, sutures in their packets until required, then secured on an adhesive sharps pad. The scrub person is responsible for their sharps at the end of any procedure and must not allow anyone else to dispose of them. All sharps will be disposed of into an appropriate sharps container, either secured to an adhesive pad or disposed of directly into the sharps bin. The container must not be overfilled, and replaced as required. Personnel disposing of the full item must ensure that the lid of the container is fully secure, and that the outside is labelled with the location and date. Compliance: 100% Exceptions: References: None R.U.H Trust Universal Infection Control Precautions Policy Reporting of N.S.I. policy Occupational Health Sharps Injury Action Pack NATN principles of Safe Practice in the Perioperative Environment 1998
Operating Theatre Standard No 23 Standard: Skin preparation and draping

Standard Statement: Theatre staff will ensure that the patients skin is prepared for surgery in a safe and aseptic manner, exposing the patient as little as possible. Staff will ensure that sufficient quantities of sterile drapes are applied, in order to maintain an adequate sterile field around the site of surgery. Method: Routine preoperative hair removal should be avoided if possible. If it is necessary, it should be done with a surgical hair clipper with a disposable blade, immediately prior to prepping and draping. Surgical preparation should not commence until all non-sterile personnel are clear of the operative field. All lotions should be checked for contamination, content and date of expiry. A suitable skin lotion will be chosen depending on the site of surgery, surgical preference and taking into account any known patient allergies. Aqueous based solutions should be used on all sensitive areas, such as mucous membranes, genitalia and pre-existing open wounds. Alcohol based solutions may be preferred for tougher skin areas such as for abdominal or limb surgery. Preparation swabs should be positioned on the holder in such a way as to allow adequate take up of the chosen solution, whilst ensuring the ends of the holder cannot traumatise the patient accidentally. Particular care must be taken when the end of the holder may not remain visible e.g. vaginal prepping. Only sufficient solution should be applied, taking great care to avoid excess solution running on to the diathermy grounding plate or pooling under the patient. Care must also be taken to prevent seepage underneath tourniquet cuffs. Cleansing should begin at the intended site of the incision and continue outward in a rectangular or spiral motion. The swab should not be brought back across the incision site, as this will return micro organisms to the area. A large enough area of skin surface should be prepared in order to allow a safe extension of the incision to be made if this should prove necessary during a surgical procedure. It is recommended that prep solutions be allowed to dry naturally, maximising their effectiveness, prior to applying the drapes. This is particularly beneficial when using alcohol based prep solutions. The way in which the patient is to be draped should be agreed with the surgeon prior to draping commences, to give the best possible access to surgery whilst maintaining as small an area of exposed skin as possible. In order to prevent contamination during the draping procedure, scrubbed personnel should ensure that; o The drapes are intact o The drapes are unfolded carefully at waist height. o Gloved hands are protected from accidental contamination by folding the leading edge around the hands. o The distal edges of the drapes are allowed to fall naturally. When the sterility of the draping procedure has been compromised, complete redraping is advised. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 87 of 131
It is recommended that non-adhesive drapes are held into place by towel clips. These should never be allowed to pierce the patients skin, and atraumatic towel clips should be used if available. Where it is necessary to attach the drapes to the patients skin, it is recommended that a non-absorbable suture material such as Silk is used. Care must be taken to ensure that all such sutures are removed in their entirety at the end of the procedure, and that all staff involved in the operative procedure are reminded not to pull the drapes off at the end of the procedure until all the sutures have been removed. If available, it is recommended that adhesive drapes are used instead of attaching drapes to the skin by other methods. Where adhesive drapes are used, checks must be made of the patients sensitivity to adhesives, and skin condition must be assessed following removal of the drapes at the end of the surgical procedure. Drapes must remain in place until the dressing has been applied to reduce the risk of post-operative infection. The scrub person should be considered the most appropriate person to dispose of all the drapes into the appropriate bag, whilst they are still protected with a gown and gloves.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment RUH Trust Infection Control Linen Policy
See also Theatre Standards: Aseptic Technique Disposal Of Waste and Linen Scrubbing, Gowning and Gloving Use of Electro surgical Equipment Application of Tourniquets See also Anaesthetic Standard: Patient Positioning Operating Theatre Standard No 24 Standard: Stocking up of Theatres. Standard Statement: All staff are responsible for ensuring that the operating theatres are adequately stocked at all times, and ensuring correct stock rotation.
Method: All staff must ensure that the theatres are left stocked ready for use at the end of each operating session. All areas should be checked including cupboards and shelves in preparation rooms and fluid warming cabinets as well as the trolleys in theatres. If this is not achievable because of pressure of work, the coordinator for the shift must be informed, so other staff can be directed to fulfil this requirement during any other quieter periods. Staff must ensure that when placing new stock into theatres, older stock is brought forward to ensure it is used in date order. All expiry dates must be checked prior to the stock being placed into theatres and again before use. Each theatre has required stock levels for each item they hold, and these should not be exceeded. Staff should ensure that stock items are stored neatly to reduce damage to items. If a final item is removed from a box, staff must ensure the box is disposed of and that there is a new box of the item available for use. Any items noted to be in short supply, must be notified to the Stores person on duty Bleep7215 or extension 5756. Also noted on the white board outside the main storeroom. The stores team monitor the stores levels on a daily basis, but welcome any information regarding reduced levels, any increased usage in a particular item that will be sustained, should be notified to the Stores person so that stock levels can be increased accordingly. Items that are unwanted or unused must be returned to their appropriate storage area. Items should not be removed from the main storage area as this is a receiving and distribution area only and items may not have been processed completely. Staff should only use other theatres stock as a last resort, if the particular item required is out of stock. Any labels on stock items must be attached to the patient notes for traceability purposes. Any prostheses or implants used should also have labels attached to the reorder sheets in each theatre and patients operation note. Ordering of non stock items can only be authorised by the senior team leaders in each speciality. Compliance: 100% Exceptions: References: None See other Theatre Standards: Pharmacy Delivery and Stock Rotation Theatre Documentation
Operating Theatre Standard No 25 Standard: Swab and instrument counts Standard Statement: All staff will adhere to the R.U.H. Theatre Policy regarding the counting and recording of swabs, instruments and additional items in order to provide a safe environment for the patient to undergo surgical procedures. Method: All staff will receive training before undertaking any counts, and will achieve the required level of competency before undertaking these unsupported. All counts are undertaken audibly, with two competent practitioners, one of whom must be a registered nurse or O.D.P. The scrub person will undertake a count of all instruments with a competent check person prior to the equipment being used, using the D.S.D.U. check sheet for each tray. Any discrepancies between the D.S.D.U. check sheet and what is actually present will be recorded. All swabs and additional disposable items such as sutures, hypodermic needles, blade etc. will be counted and recorded clearly on the theatre dry wipe board in accordance with hospital policy. Any additional instruments will be checked prior to use and recorded on the D.S.D.U. check sheet for the principal tray. This may then be referred to at closure. All swabs should be counted in fives and recorded as such on the theatre board, allowing for swabs to be counted down as appropriate during the case. (See hospital policy) At closure of any cavity or at the first primary closure of a wound, a complete swab and instrument count will take place. A verbal statement of a correct count must be made to the surgeon and a response achieved. A final count of all swabs and instruments will take place prior to closure of the skin layer. Any scrub person may choose to undertake other counts, as and when they deem necessary. Any discrepancies must be reported immediately to the surgeon in charge of the case, and surgery should be halted until the missing item is accounted for. If despite extensive searches an item remains missing, the Theatre Coordinator should be informed and a request for on table X-Ray with the image intensifier made to determine if the missing item is inside the patient. If an item remains unfound, an incident report must be completed, and the incorrect count together with details must be recorded in the perioperative document, and in the theatre register. Following a correct final count, both the scrub person and the count checker must sign the theatre register, and have their names recorded on the perioperative document. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 90 of 131
If scrub personnel are required to change over during a case, a complete instrument and swab count must take place prior to hand over and any discrepancies noted. All items of equipment, instruments, rubbish and linen used during an operative procedure must be retained inside the theatre until the final swab and instrument count has been completed. If instruments are required for further cases, they may be removed prior to the final count, with the consent of the surgeon and scrub person, following completion of the initial swab check to facilitate rapid turnaround in D.S.D.U. The scrub person is responsible for disposal of all sharp items from the trays.
Compliance: 100% Exceptions: References: None NATN Principles of Safe Practice in the Perioperative Environment
Addenda to Swab and Instrument Counts Standard No 25 No 25a: Swab and Instrument count for Obstetric Emergencies. Method: For all caesarian sections follow Standard No25 as detailed above. For other obstetric cases ie. Trial of Forceps, Retained Placenta, Suturing of Tears etc. It remains the scrub side trained member of staffs responsibility to check all the instruments and swabs prior to the start of the case and again at the end of the procedure. This may be carried out with the surgeon responsible for the case or another member of the theatre team. All counts must include any equipment, swabs and packs that are part of the equipment supplied for the surgical intervention by the Central Delivery Suite, e.g. Delivery Packs All counts must be recorded and signed for on the appropriate documentation, i.e. in the perioperative document and in the operating record book.
Operating Theatre Standard No 26 Standard: Theatre Documentation. Standard Statement: All perioperative documentation will be completed as accurately and promptly as possible to ensure patient safety and optimum communication. Method:
Perioperative Documentation Theatre staff will ensure that all sterility processing stickers are attached to the reverse side of the Patient check sheet, or to the patients notes if the check sheet is unavailable. Adhesive labels from prostheses or implants used will be placed in the patients surgical notes. Each patients details will be entered into the Theatre register. The register will be completed by the scrub person at the end of each case and signed by both the scrub person and the circulating count checker. All patients are allocated an unique theatre database number (ORSOS) All details will be completed as fully and accurately on the theatre computer by all staff involved in the patients care, with any additional information recorded as necessary. The scrub person is responsible for checking that the theatre database has been completed and for providing PACU with a printout for the patients records. The scrub person will confirm the accuracy of the printout and sign it once handover to PACU has taken place.
Sterile Services Unit Documentation The circulating person will ensure that all tray check sheets are attached together with the principle tray sheet on top. The circulating person will ensure that the principle tray sheet is completed with date, patient and theatre numbers, and that the scrub person and count checker are identified. Any discrepancies discovered between the check sheet and the tray contents on preliminary count must be recorded on the appropriate tray sheet. Any items requiring repair or replacement must be identified and recorded on the sheet. Any additional instruments used during a procedure must be recorded on the principle tray sheet and replaced on this tray at the end of the case. All tray sheets must be returned to DSDU with the used trays at the end of the case. Any surplus documentation which is produced and on which, patient details can be identified, must be destroyed in accordance with RUH Trust Policy on Confidential Information, and Theatre Standard, Disposal of Confidential Information. Compliance: 100% Exceptions: References: None RUH Trust Policy on Confidential Information
See also Theatre Standards: Disposal Of Instruments Swab and Instrument Counts Transfer of Patients To PACU Disposal of Confidential Information Operating Theatre Standard No 27 Standard: Theatre Etiquette Standard Statement: All staff will endeavour to maintain a professional demeanour within the department at all times, treat their colleagues with courtesy and respect, and provide the best possible care for all patients who enter the department. Method: All staff are expected to be changed and ready for duty at their allocated start time. Talking outside of the anaesthetic rooms and theatres must be kept to a minimum to avoid disruption. The use of mobile phones is restricted staff must familiarise themselves and comply with the theatre standard regarding the use of mobile phones in the department. Staff must be familiar with and adhere to the existing Operating Theatre Standards. Staff must be familiar with and adhere to the Operating Theatre Philosophy. Staff must be familiar with and adhere to the dress policy as outlined in the Preparation of Personnel Operating Theatre Standard. Staff must ensure that entitlement to lunch and breaks is not exceeded. The morning coffee break will be granted by the team leader and is for fifteen minutes. Lunch breaks are not to exceed half and hour unless permitted by the team leader in mitigating circumstances. The afternoon tea break is discretionary and will be granted, when possible, by the theatre team leader. Smoking is not allowed in the RUH Trust except in designated areas. Staff may leave the department to visit these smoking areas in their allotted drink and meal breaks only. Help and support is available from Occupational Health for staff members who wish to give up smoking. To prevent disruption of air flows and minimise the risk of cross infection staff must restrict their movement in and out of each theatre environment. Staff should address members of the theatre team by their appropriate title unless invited to do otherwise, especially in front of awake patients. Patients should be addressed by Mr or Mrs/Ms/Miss (except for paediatric patients) unless they have given prior consent to be address by their given name. Details of preferred form of address should be indicated on the theatre check list. If it is necessary to speak to a member of the surgical team during an operative procedure, it is essential that this is initiated through the scrub person. Compliance: 100%
Exceptions: None References: RUH Operating Theatre Standards 2004; Preparation of Personnel Use of Mobile Phones in Theatre Operating Theatre Philosophy RUH Policy Dress Code Operating Theatre Standard No 28 Standard: Tourniquet application. Standard Statement: All staff will ensure that tourniquets are applied safely and securely without risk of injury or damage to the patient or staff. Method: All staff who need to apply and monitor tourniquets will be trained appropriately and assessed as competent before carrying out this task unsupported. All staff applying tourniquets must be conversant with the equipment and the manufacturers guidelines regarding maintenance and checking of the equipment. o All pipes, tourniquets and connectors must be in good working order. o There should be 2 x 12 cuffs, 2 x 24 cuffs and 2 x 34 cuffs. o The connection of the machine to the compressed air outlet should be checked. o The controls should be set to 150mmHg, and each cuff connected and inflated to check for leaks. Ensure the cuff is tightly wrapped prior to inflating. o The Rhys-Davies exsanguinator should measure 18 in diameter, if not inflate or deflate appropriately. o Any damaged or leaking equipment must be removed from service, reported to the Theatre Coordinator and sent for repair. It remains a surgical decision whether to use a tourniquet, always ask, never assume. All tourniquets must be applied as far up the limb as possible, checking for preexisting skin damage in the area. The upper part of the limb must be wrapped with sufficient padding to prevent skin damage. The appropriate sized tourniquet should be selected allowing sufficient overlap when wrapped around the limb. The tourniquet must be wrapped firmly over the padding ensuring no skin folds or genitalia are trapped. The pressure on the control box should be set to 100mmHg above the patients systolic blood pressure for arm tourniquets and 150mmHg above for leg tourniquets. Always check the inflation pressure with the surgeon prior to inflation, and confirm the pressure achieved once inflation has taken place.
Please ask the surgeon regarding pressures if tourniquets are to be used on children. Check that the surgeon is ready to start before inflating the tourniquet in order to minimise the time the tourniquet remains inflated. A clean plastic bag should be placed over the limb to be exsanguinated. Exsanguination may be by use of the Rhys Davies exsanguinator, elevation or Esmarch bandage. o To use the Rhys Davies exsanguinator, roll the exanguinator up your own arm first and grasp the patients foot or hand, ensuring all the patients digits are lying flat in your palm. Then roll the exsanguinator down your arm and over the patients limb in one movement. Holding the Rhys Davies exsanguinator as far up the limb as possible, turn on the tourniquet machine, wait until the required pressure is achieved before releasing the exsanguinator. o When elevating a limb to exsanguinate, the limb should be held upwards as vertically as possible to aid blood return. o Gentle massage in the direction of the heart may also be used to assist exsanguination, depending on the skin condition. o Elevation should continue for a minimum of 5 minutes before the cuff is elevated. o When using an Esmarch bandage, ensure that the bandage is stretched before you wrap it around the limb. Starting at the distal end of the limb wrap the bandage tightly around the limb, moving towards the tourniquet cuff, ensuring an overlap as you go. Inflate the cuff to the required pressure, remove the Esmarch bandage and check the patients skin condition. Once the tourniquet has been inflated, the time must be noted and recorded in the theatre register and on the theatre database. The stop clock in theatre may be used as a secondary reminder, if there is no counter on the tourniquet machine, and the inflation time should also be clearly recorded on the dry-wipe board in theatre. The surgeon must be informed of the duration of the tourniquet at regular intervals, the first reminder at 60 minutes, then at 90 minutes, then every 15 minutes thereafter. It is the surgeons decision how long the cuff may remain inflated. If required a cuff may be re-inflated providing at least 10mins has elapsed to allow sufficient perfusion of the limb. The anaesthetist must always be informed prior to the tourniquet being deflated as there may be a drop in blood pressure as perfusion of the limb occurs. Also waste products such as CO2 and lactic acid build up in the tourniqued limb, which are then released into the circulatory system. If bi-lateral cuffs are used, each cuff must be deflated separately allowing sufficient time for the blood pressure to stabilise before deflating the second. After deflation the tourniquet and padding must be removed immediately to prevent venous congestion and arterial stasis. The skin condition must be assessed following removal and the limb assessed for full perfusion prior to the patient being transferred to PACU. Any doubt about the quality of capillary return in the digits must be reported immediately to the surgeon. Ref 416/2009 Status: Final
The method of exsanguination, inflation, deflation and total tourniquet times must be recorded on the perioperative theatre database, and in the theatre register. Caution must be exercised in the use of tourniquets in patients with the following conditions; o Blood diseases e.g. sickle cell anaemia o Localised infection of the limb o Regional infections e.g. cellulitis o Peripheral vascular disease o Severe bone trauma Soiled tourniquets must be washed with warm water and detergent and dried thoroughly.
Compliance: 100% Exceptions: References: None ODP Level 3 Standards NATN Principles of Safe Practice in the Perioperative Environment 1998
See also Theatre Standards: Theatre Documentation Operating Theatre Standard No 29 Standard: Transfer of patients from operating theatre to Post Anaesthetic Care Unit (PACU.) Standard Statement: Staff will ensure the safety and dignity of the patient during the transfer from theatre to PACU post operatively, and ensure all relevant information is communicated to PACU staff. Method: A Qualified theatre practitioner will accompany the patient and anaesthetist on transfer. The side restraints on the trolley or bed must be in the upright position during transfer to ensure patient safety. An adequate supply of oxygen must be available for all transfers, and an appropriate oxygen delivery system e.g. Hudson mask, T-bag, or ambubag. The patient must remain covered to protect dignity at all times during the transfer process. Theatre staff will ensure that the exit route from the theatre is clear to facilitate rapid transfer and minimise risk of injury to staff members. On arrival in PACU an appropriate bay will be located. The bed or trolley will be positioned to allow free access to the head of the bed, and the brakes applied.
Theatre staff will assist PACU staff with the transfer of the oxygen delivery system and the application of monitoring. Anaesthetic handover will take place to the PACU staff member responsible for the patients recovery period. The scrub person for the case, or designated trained member of staff, will ensure the theatre database is fully completed and printed out. Using the printout, theatre staff will hand over to PACU all relevant details i.e. operation performed, skin closure, dressings, drains, catheters, any local anaesthetic given, and any items left in situ requiring later removal. Other relevant patient care details such as pressure area problems, known skin breaches or adverse reactions must be recorded in the perioperative printout and handed over to PACU for communication to the ward staff. The theatre staff will sign the printout on completion of handover.
References: See Theatre Standards: Theatre Documentation Patient Safety and Dignity See Anaesthetic Standards Safe Transfer of Patients from Operating Table to Bed Operating Theatre Standard No 31 Standard: Trolley Preparation for Surgical Intervention. Standard Statement: The preparation of sterile instrument trolleys for surgical intervention is a skilled and precise procedure that requires adherence to a strict aseptic technique throughout. Staff will prepare and maintain a sterile field at all times to minimise the risk of cross infection to the patient. Staff will ensure the patients safety throughout the procedure. Staff will ensure appropriate use of resources and minimise waste. Method: All staff involved in the preparation of trolleys for surgical intervention will have received training appropriate to their level of participation and have been assessed as competent. Staff will ensure that sufficient trolleys, mayo stands and bowl stands are available for the planned surgical procedure, and that they are in a good state of repair and have been cleaned thoroughly prior to use. Staff will collect together all items expected to be required for each procedure in advance of surgery. Any items not available must be detailed to the surgeon in
charge of the case prior to start of anaesthesia, to allow the surgeon to make an informed decision regarding whether to continue. All items to be used must be inspected for sterility and damage. Trolleys must be prepared immediately prior to each individual surgical intervention in accordance with the planned operative procedure and individual patient needs. Trolleys must only be laid up in an area that affords sufficient space to open packs and maintain a sterile field. There should be minimal movement of personnel within this area during preparation of the trolley. For Orthopaedic surgery, trays and packs must not be opened until the patients position on the operating table is finalised, including catheterisation, and the ward bed has been removed from the operating theatre. All trolleys must remain within the boundaries of the Laminar Flow. All doors within the operating theatre must remain closed wherever possible to maintain correct airflow changes. A minimum of two personnel are required to prepare sterile trolleys. It is essential that one member is scrubbed, gowned and gloved, and strictly follows the principles of the aseptic technique. All trolleys should be covered with a minimum of two layers of sterile drapes. The drapes should be large enough to cover the horizontal plane of the trolley, and long enough vertically to avoid contamination. Sterile equipment must be presented to the scrub person from the edge of the sterile field and received in such a way as to prevent glove contamination on the unsterile wraps. It is recommended that wherever possible items are handed directly to the scrub person. Where this is not possible, items may be delivered directly to the sterile field, but it is recommended that a separate area is identified for this purpose, away from the work area to minimise the risk of contamination. Items must only be delivered to the sterile field at the request of the scrub person. Although anticipation of needs by the circulating person is appreciated, they must not open additional items prior to a request being made, to ensure best possible use of resources. Once prepared the trolley must be attended at all times. Standard basic layout of trolleys should be followed in order to facilitate continuity of patient care and safety in the event of a sudden change of scrub personnel during the operative procedure. Trolleys must be placed correctly around and above the patient depending on the planned operative procedure. Care must be taken to ensure there is no undue pressure on any part of the patients body or limbs. All instruments must be returned to the trolley or mayo stand in order to prevent accidental injury to the patient or members of the surgical team. Any breach of aseptic technique must be acknowledged and acted on immediately. Contaminated equipment must be removed from the sterile field. Re-gloving, gowning and draping should be carried out as required. The disposal of equipment drapes and sharps must be carried out in accordance with Hospital Policies and Theatre Standards. Ref 416/2009 Status: Final
Compliance: 100% Exception: References: None NATN Principles of Safe Practice in the Perioperative Environment 1998 R.U.H. Universal Infection Control Precautions Policy
See also Theatre Standards for: Aseptic Technique Disposal of Equipment Disposal of Waste and Linen Safe Handling and Disposal of Sharps Scrubbing Gowning and Gloving Swab and Instrument Counts Operating Theatre Standard No 32 Standard: Universal Precautions Standard Statement: All staff must ensure that universal precautions are adhered to, in order to protect themselves from the spread of blood borne viruses, such as HIV/ Hepatitis B & C and other harmful microorganisms that may be present in blood, saliva and other body fluids. It is not always possible to tell who has an infection, so all patients must be treated as potentially infected. This ensures that patients with known infection are not discriminated against as every one is treated the same. Method: All staff must be educated in the principles of Universal Precautions, and receive mandatory yearly updates in Infection Control. All blood/saliva and body fluids must be treated as infected. Principles of good hand hygiene must be adhered to, hands must be washed before and after all patient contact and after removing gloves. Any blood or body fluid splashes are removed immediately with soap and water. Any broken skin areas must be covered with a clean waterproof dressing. Any staff members with chronic skin lesions to the hands or forearms should avoid invasive procedures and seek the advice of the Occupational Health Department. Gloves must be worn when making contact with any patients. Gloves should be discarded after each episode of care/procedure. If gloves become punctured they must be removed, hands washed and fresh gloves donned. Protective clothing must be worn when dealing with body fluids. Where there is a low risk of splashing, gloves and a gown or apron should be worn. Where there is a high risk of splashing, eye protection and masks should also be applied. Principles of safe practice must be adhered to when using and disposing of sharps.
Ensure that body fluid spillages are dealt with correctly. Staff must be aware of and adhere to RUH Trust policies for Disposal of Waste and Linen.
Compliance: 100% Exceptions: References: None UK Health Departments (1998) Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-borne Viruses. RUH Trust Infection Control Policies Disposal Of Waste & Linen
See also Theatre Standards: Dealing with Non Hazardous Spillages Disposal of Waste Refuse and Linen Sharps/ Needlestick Injury Sharps Safe Use and Disposal
Operating Theatre Standard No 33 Standard: Use of mobile phones in the operating theatres Standard Statement: The inappropriate use of mobile phones in the operating theatre department is strictly prohibited. Method: Staff must be familiar with the trust policy regarding the use of mobile phones in the hospital. Staff are only to use their mobile phones in the coffee room whilst on their designated breaks, or for essential Trust business use. Mobile phones must be switched off or on silent mode in the restricted areas i.e. Prep room, Anaesthetic room, Operating Theatre and Sluice. Sending text messages and receiving calls whilst in the theatre is strictly prohibited when patients are present. The Trust accepts no responsibility for loss, damage to, or breakage of staff members mobile phones. The use of picture phones, by any staff member or visitor, is strictly prohibited in theatre. Compliance: 100%
Exceptions:
On call Surgeons who are unable to divert emergency calls whilst operating.
Operating Theatre Standard No 34 Standard: Use of Electro surgical Equipment. Standard Statement: Staff will ensure that all patients whose surgery requires the use of diathermy, will be protected from the risk of burns. Method: All personnel using diathermy equipment will receive the appropriate training and have been assessed as competent. They must be fully conversant with the safe use of the equipment and understand the principles of electro surgery. Diathermy machines will be checked prior to the start of every list, in accordance with the manufacturers guidelines. Yearly maintenance and testing of equipment must take place by MEMS to ensure its safety, any faulty or damaged items must be removed from use immediately and reported for repair. Application of diathermy grounding plates is only done by competent practitioners in accordance with the manufacturers instructions, ie. Applied to a clean, dry, hair free, muscular area, as close to the operation site as possible, away from any pre-existing metal work in the patient. Diathermy grounding plates must be kept clean and dry, and preventative measurers taken to ensure the plate does not become soiled with prep. Solutions or body fluids. The scrub person must check diathermy forceps and leads prior to use, to confirm intact insulation and good connections between components. The scrub person must keep the diathermy forceps/ blade etc. within a suitable insulated receptacle during surgery, to prevent accidental burns to the patient or members of the surgical team. Scratch pads may be used to clean the tips of monopolar diathermy, to ensure good contact with bleeding vessels is maintained, to prevent sticking, and to prevent possible tissue damage from excessive charring on forcep ends. Scratch pads must never be used on bi-polar forceps as they remove the non-stick properties and render the instrument useless, a damp swab should be used to remove charred tissue All staff must be aware of any patient contraindication to the use of monopolar diathermy e.g. pacemaker, prior to commencement of surgery. Staff will be educated regarding the use of visor masks to prevent inhalation and eye contamination with diathermy plume. Ref 416/2009 Status: Final
The diathermy machine must be switched off or set to standby before connecting or disconnecting live electrodes, and the surgeon informed of the power settings before commencing use. Single use return electrodes (grounding plates) must never be reused. The return electrode must be in direct and complete contact with the patient throughout their surgery. If the patient position is changed after application of the plate, the site must be rechecked. Patient skin condition must always be checked after removal of the grounding plate, and the site and skin condition recorded on the perioperative documentation. The patient must be shielded from metal objects to prevent a short circuit bypass of the grounding plate.
Compliance: 100% Exceptions: Reference: None Principles of Safe Practice in the Perioperative Environment. ODP Level 3 Standards
Operating Theatre Standard No 35 Standard: Visitors to the Operating Theatre Standard Statement: Staff will ensure that only visitors who have obtained the relevant permission for definitive supportive and/ or educational purposes, are present in the operating theatre whilst the patient is undergoing surgery. Method: Patients have the right to confidentiality unless they have consented to have information divulged. Patients have the right to refuse the presence of visitors during their perioperative phase. The number of visitors permitted in the perioperative environment must be kept to a minimum. All visitors must have gained appropriate consent prior to arrival, report to Theatre reception to sign in and be identified to the Theatre Coordinator. All visitors must be provided with the appropriate apparel and instruction given as to their use. All visitors must be clearly identified and wear an identity badge. All visitors must be made aware that all procedures carried out within the perioperative environment are confidential in nature, and that any information, discussions, technical data or documentation must be treated in confidence. All visitors must be made aware of theatre etiquette, and they should be introduced to all staff working in the area they will be attending. It is essential that visitors be chaperoned at all times during their stay in theatres.
Visitors must be made aware of the procedure should they feel faint or unwell during their stay. All medical, nursing and technical personnel who are not employees of the trust, but intend to participate in patient care during their visit, must have their professional qualifications verified prior to admission to the department. (Currently under review is the appropriateness of the presence of work experience students in the perioperative environment.)
Compliance: 100% Exceptions: Reference: None
NATN Principles of Safe Practice within the Perioperative Environment 1998 See also Theatre Standards: Preparation of Personnel Photography and Video Operating Theatre Standard No 36 Standard: Wound, drain and catheter dressings. Standard Statement: The Theatre Team will ensure that an appropriate dressing is applied to the patient according to surgery, surgical preference and known patient allergies. Method: Theatre personnel will ascertain any patient allergies. An appropriate dressing for the type, size and site of surgery will be selected. The dressing will be delivered to the scrub person at the end of the procedure using an aseptic technique. If plain gauze swabs are to be used, these should not be delivered to the scrub trolley until the final swab count has been completed. The scrub person or the surgeon will apply the dressing to a clean dry surface using clean-gloved hands. The drapes must not be removed from the patient until the dressing has been applied to minimise the risk of infection. All dressings must be detailed in the perioperative record. Especially any packing material such as ribbon gauze, Sorbasan etc. detailing quantity and type, to facilitate complete removal at a later date. Compliance: 100% Exceptions: Cases where no dressing is deemed necessary such as E.N.T., Maxillofacial etc. Ref 416/2009 Status: Final
Reference:
NATN Principles of Safe Practice in the Perioperative Environment 1998
Operating Theatre Standard Number 37 Standard: The insertion of rectal suppositories. Standard Statement: All staff in the department must be aware of the correct way to insert rectal suppositories as prescribed by the anaesthetist. Method Check that the patient has consented for the suppositories to be inserted. The person inserting the suppositories must be a trained nurse. Ensure the suppositories being given have been prescribed by the anaesthetist or surgeon check prescription. Move the patient into the required position for administering the suppositories i.e. on left side or with knees flexed. Wash hands and don gloves prior to the procedure. Lubricating jelly may be applied to the blunt end of the suppository prior to insertion. The insertion of suppositories must always be witnessed by another member of the multi disciplinary team. Remove gloves and wash hands.
Compliance: 100% Exceptions: None References: Manual of Clinical Procedures. The Royal Marsden Hospital Operating Theatre Standard No. 38 Standard: Protocol for Sentinel Node Biopsy Theatre Procedure Standard Statement: All staff involved with the sentinel node procedure will be aware of the protocol involved so as to limit risk to both patients and staff. The Technetium 90 @ 40 Mbq will be performed on the ward or in the radiology department either the day before surgery or the morning prior to the afternoon theatre list. The patient is brought to theatre and anaesthetised in the usual way. Ref 416/2009 Status: Final
2mls of Patent blue dye diluted with 2mls of sterile saline is injected by the surgeon before the patient is prepared and draped in the normal way. The Patent V dye used is prescribed to each patient and will be brought to theatre by either the surgeon or the patient. A large disposable patient drape and three utility drapes are required, plus, two disposable gowns. The sentinel node will then be sought by dissection to locate the blue dye and the Navigator Gamma Guidance System (GGS) equipment to monitor the radio activity over the axillary nodes. The primary lesion may then be removed by either mastectomy or wide local excision. Specimens may be dry or in formalin dependent on the surgeons preference. Specimens are placed in their containers then in a plastic bag. The histology form is stuck to the plastic bag and radiation stickers attached must be attached. Sentinel node specimens must be clearly marked as such. Swabs, instruments, sharps and dressings can be handled normally during this procedure. Following the procedure all clinical waste is placed in yellow bags and marked with date, time, theatre of origin and the consultants initials. The waste is placed in a burn bin (also marked with the time, date and theatre number), the burn bin is closed when sufficiently full i.e. more than one patients waste may be placed in it. The bins are then taken to Nuclear Medicine; the orderlies will transport them there when alerted. They will be stored there for twenty four hours prior to disposal. Radioactivity stickers must not be applied to waste bins. As the majority of radioactivity is removed from the theatre in the pathological specimens, no special cleansing is required in between cases. Dirty trays will be handled as usual. PACU must be informed that the patient has had Patent V when handover takes place.
Compliance 100% Exceptions: None References: Cardiff & Vale NHS Trust Operating Theatre Standard No. 39 Standard: Practice for Operating Department Orderlies Long Distances or Heavy Patients.
Standard Statement: On all long distances (especially those with inclines and declines) there must be two Operating Department Orderlies to a bed, ie PAW, William Budd Ward. If there are no other Operating Orderlies available to assist, eg night shifts, a member of the theatre staff must assist if required. If an Operating Department Orderly feels that a patient is heavy/large, he has the right to ask for assistance either from another Operating Department Orderly or theatre staff member. This is now standard, with the exception of emergencies where the situation dictates one ODO. Compliance 100% Exceptions: None Operating Theatre Standard No 40 Standard: Action to be taken in the event of a breakdown of the ultra low temperature bone bank freezer Standard Statement: All staff will understand the processes that need to be undertaken in the event of a malfunction of the bone bank freezer to ensure that the integrity of the stored bone is not compromised. Method: All theatre staff will be able to recognise the sound of the freezer alarm and the freezer monitor alarm The ultra low freezer alarm will sound if the temperature exceeds -65 deg C and the monitor alarm when the temperature exceeds -59 deg C. Staff need to be aware that this will also happen if the freezer lid is kept open for an extended period of time while bone is being taken out of or put into the freezer. Frozen human bone must at all times be stored in a continually monitored freezer, at a temperature not exceeding -20 deg C Staff will follow the process below when a problem is identified: 1. If there is no power to the freezer, check the supply- any interruption to the power will trip the power breaker switch, e.g. regular generator testing. Reset the power breaker switch. 2. If there is no power to the plug, telephone Facilities on 4141 and ask them to contact the Electrician urgently. 3. The freezer alarm can be silenced by using the mute button on the bottom panel at the front of the freezer.
4. The monitor alarm can be silenced by using the mute button on the panel on the wall above the freezer. 5. If the electrician is unable to restore power to the freezer, or the freezer itself is faulty, contact Pathology Blood Bank on ext 4735 in hours or Bleep 7555 out of hours and request space in their -40 deg C freezer. 6. Arrange suitable packaging to transfer the processed frozen human bone to the blood bank freezer. 7. Arrange for a Theatre Orderly to transport the frozen bone immediately to the Blood Bank Freezer in Pathology. 8. Ensure a record is kept of the code numbers on the frozen bone that is sent to pathology. 9. Ensure that a senior orthopaedic member of staff and the Theatre Coordinator are notified as soon as possible that transfer has taken place. 10. Facilities will ensure that an appropriate engineer is called to repair the freezer as soon as possible. In the event of bone being required during surgery whilst the bone is stored in the Pathology Blood Freezer, staff will request the bone required by code number to be removed from the freezer by the Pathology staff and arrange a Theatre orderly to collect the bone immediately from pathology and deliver to the appropriate theatre. Staff will ensure that only the required amount of bone is requested to avoid wastage. All checking and recording procedures of bone used must be adhered to as per Theatre standard No 41.
Compliance: 100% Exceptions: None References: EU Directive for Cells and Tissue (2004/23/EC) Guidelines for the Blood Transfusion Service in the United Kingdom (7th Edition) See also Theatre Standard No 41: Ordering, Receiving, Storage and Use of Human Frozen Bone Operating Theatre Standard No 41 Standard: Process for ordering, receiving, storage and use of Frozen Human Bone. Standard Statement: All staff will ensure that they follow the correct procedures for the ordering, receipt, storage and use of frozen human bone supplied by NHS Blood and Transplant Tissue Services.
Method: The RUH has elected not to apply for a Tissue licence for the continued storage of Frozen Human Bone, therefore we may only store bone in the freezer for a maximum of 48 hours. Ordering: The surgeon notifies the Orthopaedic theatre staff of any possible requirement for frozen bone, using the request form available in the Pre admission clinic, giving as much notice as possible The forms are returned to the Orthopaedic Administrator (currently Emma Tee), or to the Bone Bank link member of staff (currently Maria Francis) or to any senior member of the orthopaedic team. A member of the stores team raises an order number for the requisition Liverpool Tissue services are contacted by telephone 01515527078 to give details of quantity required, date required by, patient name and registration number and order number. A Tissue Services order form is then completed with the above information and faxed through to 01515527124 A confirmation fax is received back from Tissue Services All copies of paperwork are filed in the Bone Bank file, kept on shelf outside of Theatre 3
Receipt: Bone is delivered by courier complete with paperwork, and is received into the department by a member of the orthopaedic team conversant with the procedures for handling the bone. Cont. All paperwork received is checked for correct details and is filed in the Bone Bank file for traceability purposes. The time of arrival from courier is noted on the paperwork as Tissue Services may ring to gain this information for integrity Audit purposes. The quantity of bone delivered is recorded on the laminated sheet on the front of the bone freezer, together with the date. All details are entered into the Blue Bone Bank record book kept by the freezer, including the Code number from the product, the product expiry date and date of arrival A competent practitioner will open the bone freezer using the protective equipment provided and place the bone securely inside. This will be carried out as swiftly as possible to prevent the temperature inside the freezer from rising above acceptable limits.
Use: N.B. At time of surgery, a member of the team who has been assessed as competent removes the required amount of bone from the freezer, using the protective equipment provided. The container will be checked for integrity and against the appropriate entry in the blue bone bank record book, using the code number printed on the side of the container. The expiry date is verified with the scrub person. The circulating person will sign the used bone out of the blue record book and complete the patient recipient details recording patient name, date of birth and hospital registration number. The paperwork provided with the donated bone is completed and one copy is filed in the patients records and the other in the Bone Bank file together with the copies of corresponding order forms and faxes to allow traceability. The circulating person will open the outer container and deliver the inner container to the sterile field using aseptic techniques. The scrub person will open the inner container and place the frozen bone in warm saline to hasten the defrosting process. A bone mill may be used to prepare the bone, or the surgeon may wish to cut pieces using a saw or osteotomes, so these will need to be available. The laminated sheet on the front of the freezer should be updated to accurately reflect its contents.
Any fresh frozen bone that is ordered but not used within the 48 hour window should be discarded from the freezer. Alternative synthetic and freeze dried bone substitutes are available within the department for emergency use. Neither synthetic nor freeze dried bone is covered by the requirement for a tissue licence, so these may be stored for as long as the product expiry date allows. The bone freezer must not be used for storage of anything other than the bone ordered and delivered from the Tissue Services.
Compliance: 100% Exceptions: None References: EU Directive for Cells and Tissue (2004/23/EC) Guidelines for the Blood Transfusion Service in the United Kingdom (7th Edition) See also Theatre Standard No 40: Action to be taken in the event of Freezer breakdown Operating Theatre Standard No 42 Standard: Handling wound drains.
Standard Statement: Wound drains must be handled and attached maintaining an aseptic technique and following Infection Control guidelines. Method: Staff must be aware of the content of and have access to the Trusts Infection Control Policy. Staff must have a good understanding of the mechanics of the different types of wound drains. They must have been taught how to correctly assemble the drains, ensuring that the relevant clamps are closed to prevent spillages. The Surgeon can insert the drain trochar and ensure that the sharp end is effectively protected. The drain receptacles must be kept in the bag and put to the side to prevent contamination. At the end of the case, at an appropriate time, the top gloves (when two pairs are worn) must be removed. An extra pair (when only one pair is worn) must be added. Clean gloves MUST be donned prior to handling. The drainage receptacle can then be attached maintaining an aseptic technique.
Compliance: 100% Exceptions: References: None RUH Trust Universal Infection Control Precautions Policy. NATN Principles of Safe Practice in the Perioperative Environment.
See also Theatre Standards: Dealing with Hazardous Spillages Personal Protective Equipment SECTION C POST ANAESTHETIC CARE UNIT STANDARDS ORSOS Layout of PACU Standards Of Care Maintenance of temperature 5 Breathing 1 + 2 Maintenance of circulation 3 Pain relief Sleep & Rest 7, 8, 9 + 12 Preventing infection 15, 15a, 15b
High Dependency Care 16 + 17 Communication 10 Transferring a patient to the ward 18 Number 5 Standard of Care :- Temperature All patients following admission into PACU will have their temperature recorded within 15 minutes of arrival. Patients who are cold will be given extra blankets. If patients are too warm appropriate action will be taken immediately. Patients will feel warm and comfortable during their admission.
Method
Staff will undergo training on how take an accurate temperature. The patients temperature will be recorded on the post-operation documentation. Patients will be asked if they feel comfortable. Staff will understand the implications of being either too warm or too cold. Staff will take the appropriate action to maintain a patients normal temperature. 100% None
Compliance Exceptions
Interventions If a patient is cold, extra blankets are applied. Appropriate use of the Bear Hugger blanket. Warm fluids through the IV fluid warmer. If a patient is too warm, remove blankets. Administer appropriate medication if indicated. Use fan to cool. If drinking, offer cold drinks. If hyper pyrexia, consult anaesthetist. Consider cause. Consider ice packs, in extreme conditions. Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications
PACU Standard No 1 Standard of Care Maintenance of airway in the unconscious / semiconscious/ conscious patient. On admission each patient in PACU will have their airway, respiratory rate and oxygen saturation level monitored until the patient is able to safely maintain their own airway without intervention. Method Head lift, chin lift and jaw thrust Oropharyngeal airway (Guedal airway). Laryngeal mask airway. (LMA) Nasopharyngeal airway. Compliance 100% Exceptions None Interventions Look for chest and abdominal movement. Listen and feel for air flow at the mouth and nose. Monitor saturations. Monitor respiratory rate and rhythm. Administer oxygen. Recognise airway obstruction. Noisy breathing is obstructed breathing. If required suck out mouth and pharynx. Yanker sucker. Wait for the patient to remove his own airway. If the patient coughs or gags on the mask remove it for him. Take care not to pull the LMA past the teeth, this may cause damage. Check to see no residual secretion remains in the pharynx. Place the oxygen mask onto the patients face. Reference Hatfield A & Tronson M. 3rd edition (2003). The Complete Recovery Room Book. Oxford University Press
PACU Standard No 2 Standard of care Monitor the breathing of the postoperative patient. On admission into PACU all patients will be monitored with a pulse oximeter and will have an O2 saturation reading of > 96% with or without oxygen, with a normal respiratory rate and pattern.
Methods Place oximeter on patients finger on admission into PACU. Count respiratory rate on admission into PACU. Note the rhythm of patients respirations on admission into PACU. Listen to the patients breath sounds as soon as a problem is identified.
Compliance 100% Exceptions Interventions Administer oxygen as required by the patients condition. Use suction catheter if required to remove excess secretions. Watch airway and chest movement. Look for signs of cyanosis and hypoxia. Listen to the patients chest. Record respiratory rate and rhythm. Encourage your patient to cough and expectorate. Position your patient in an upright position to help their breathing. Position your patient in a high side lying position to promote plural drainage. Administer medications as per prescription chart. Known underlying disease process.
Reference Hatfield A & Tronson M. 3rd edition (2003). The Complete Recovery Room Book. Oxford University Press PACU Standard No 3 Standard of Care Cardiovascular System. All patients will be monitored according to their individual requirement. They will have their cardiovascular status maintained by appropriate measures. Patients should have an adequate stock of cross matched blood and blood products according to their individual needs prior to being admitted for surgery. Patients will be cardiovasculary stable when discharged to the ward.
Method All staff will have training in the equipment currently used. Staff will have an increasing understanding of the patients post operative conditions. Staff able to recognise any abnormality in patients condition.
Check that there are cross matched units of blood for the patient through TPATH if required.
Compliance 100% Exceptions None Interventions Vital signs are measured according to the patients individual need and as their condition dictates. Ensure the correct blood pressure cuff size is used. The bladder size should be 40 50% of the upper arm circumference. The bladder length should encircle 80% of the arm. If required attach the 3 lead ECG. If arrhythmias are detected the doctor should be informed and the patient treated accordingly. 12 lead electrocardiograph should be taken in the event of chest pain or arrhythmias to detect serious ECG changes. Aseptic technique used at all times when changing or removing intravenous lines. Monitor fluid balance closely. Use Doppler to detect a pulse which is difficult to palpate following vascular surgery. Note the colour and heat of the limbs following distal vascular surgery. Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications PACU Standard No 4 Standard of Care Cardiovascular System. All patients will be monitored according to their individual requirement. They will have their cardiovascular status maintained by appropriate measures. Patients should have an adequate stock of cross matched blood and blood products according to their individual needs prior to being admitted for surgery. Patients will be cardiovasculary stable when discharged to the ward. Method All staff will have training in the equipment currently used. Staff will have an increasing understanding of the patients post operative conditions. Staff able to recognise any abnormality in patients condition. Check that there are cross matched units of blood for the patient through TPATH if required.
Compliance 100% Exceptions None Interventions Vital signs are measured according to the patients individual need and as their condition dictates. Ensure the correct blood pressure cuff size is used. The bladder size should be 40 50% of the upper arm circumference. The bladder length should encircle 80% of the arm. If required attach the 3 lead ECG. If arrhythmias are detected the doctor should be informed and the patient treated accordingly. 12 lead electrocardiograph should be taken in the event of chest pain or arrhythmias to detect serious ECG changes. Aseptic technique used at all times when changing or removing intravenous lines. Monitor fluid balance closely. Use Doppler to detect a pulse which is difficult to palpate following vascular surgery. Note the colour and heat of the limbs following distal vascular surgery. Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications PACU Standard No 5 Standard of Care Haemodynamic Monitoring Those patients who require continuos monitoring will have their vital signs invasively monitored until they are discharged to the Intensive Therapy Unit to continue their High Dependency Care or until they are fully recovered and able to return to a ward. Staff monitoring HDU patients will work within an agreed criteria set out by the anaesthetist. The patient will suffer no ill effects from being invasively monitored. Method All staff will have training in the use of invasive monitoring. New staff will be introduced to the invasive monitoring systems. An awareness of the possible complications of being invasively monitored will be understood by all staff. Equipment is regularly checked and maintained. Adequate stocks of sundries, e.g. blood gas syringes. All staff will demonstrate their ability to use these devices. Ref 416/2009 Status: Final
Staff must undertake extra training in the management of Central Venous Catheter Monitoring and use in IV workbook, they must be passed as competent. Compliance 100%
Exceptions None
Interventions
Prepare the patient for the insertion or removal of the monitoring equipment. Ensure that the arterial line is secure and correctly zeroed. Ensure the Central Venous Catheter is x-rayed if new and that the x-ray is checked prior to use. Keep arm with arterial line visible to ensure continuous observation. Oxygen saturation monitored continuously. 3 lead ECG monitoring. Respiratory rate and rhythm monitored. Hourly urine measurements. Regular inspection of wound sites and drains.
Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications PACU Standard No 6 Standard of Care Fluid Balance The patient in PACU will have an accurate record of their fluid balance and adequate fluids prescribed for their discharge to the ward. The patient should be neither dehydrated nor overloaded with fluid. Urine output should in the average adult be a minimum of 0.5 ml/kg/h. The patient will not experience any deterioration of their kidney function.
Method
All IV fluids will be recorded when set up on the fluid balance sheet. Oral intake will be monitored and recorded. NG output will be monitored and recorded. Urine out put will be measured either hourly or four hourly as the patients condition dictates. Staff will have training to ensure they understand the signs and symptoms of fluid overload and dehydration. All output form indwelling drains will be measured and monitored. The fluid balance sheet must be maintained to show a running total of fluid balance for the patient.
Compliance 100% Exceptions None Interventions Take a base line measurement of urine. Check urinary catheter is draining and not blocked. Label any drains for ease of reference. Ensure they are not clamped. Follow procedure for trans cell drain and document appropriately. Check patency of all IV cannula on a regular basis. Remove IV cannula if it is not patent or looks infected. Check all IV infusion lines are patent and intact. Label all IV infusion lines. Fluid being infused and date. Follow hospital policy for the infusion of blood and blood products. Adhere to an aseptic technique at all times. Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications PACU Standard No 7 Standard of Care: Pain Control The patient will have effective pain relief which will be continuously monitored and evaluated in the recovery area. A patient should experience no more than moderate pain and no ill effects of analgesia can be observed.
Method
Adequate supplies of analgesic drugs. Policy covering the prescribing of drugs. Distribution of protocol sheets with patient, on transfer to ward. Adequate supplies of syringe driver pumps and a system for reclaiming these pumps from the ward when discontinued. Anaesthetic advice available at all times.
Compliance 100% Exceptions Interventions Ensure staff order and maintain sufficient supplies of analgesic drugs, and also keep accurate records of administration. Staff aware of the details on protocols sheet. Pain and sedation scoring of patients having sophisticated pain control techniques. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 117 of 131 None
Systems for regular maintenance and repair of syringe driver pumps. Record of pump whereabouts when transferred with patient. Training for new staff in the use of epidural and intra-venous opiates infusions. Staff trained to assess, monitor and evaluate the effects of pain relief. Regular updating of staff and encouragement to participate in pain relief research. Staff trained to recognise side effects when administering specialised pain control and able to take appropriate action.
Acute Pain Service Bill Palastre or Jane Armston or Pain Anaesthetist. Bleep 7113 Reference: Acute Pain Service. RUH Policy. PACU Standard No 8 Standard of Care Administration of medications to patients in PACU. On admission into PACU all patients will have a current medication chart, with appropriate medications to better control their post operative symptoms. This must have the correct patient information, be prescribed, signed and dated by the doctor in charge of their care. The correct administration of medications will be carried out by the nurse in charge of their care, a designated nurse or a nurse in further training under direct supervision of the nurse in charge of that patients care. The administration of symptom controlling medication will take place within 10 minutes of the symptom being identified. Method Give medication according to the symptom and medication chart. I.e. :- PO, PR, IV, IM or S/C. Give to the right patient. Check name bands, medication chart, anaesthetic chart, prescription, route and drug dose. Compliance 100% Exceptions Drug incompatibilities, known patient allergies and if the drug previously administered to the patient. was
Interventions Assess the patients pain score, and if the patient is suffering from nausea.
Choose from the medication chart an appropriate drug and route to control the patients symptom/s. Look at the anaesthetic chart for any premedication already given. Check for patient allergies and always monitor for drug related reactions. Note drug incompatibilities, whenever possible, administer drugs separately. When administering drugs keep patient safety in mind. Check patient identity bands against patient s own medication chart. Sign the chart when the drug has been given, not before. Explain to the patient what you intend to give and why. Assess patients respiration rate and blood pressure, before, during and after the administration of the drug. Follow the RUH Hospital policy for the administration of medications. If you are unsure during any stage of the procedure, seek advice. Refer to the RUH administration of drugs policy. BNF. IV work book. References RUH Drug Administration Policy. RUH IV Drug Administration Manual. British National Formulary. PACU Standard No 10 Standard of Care Communication Patients and their relatives / carers will receive clear, accurate and relevant information whilst in PACU. They should feel free to seek advice and express their needs and feelings. Method All staff will be proficient in communication skills and receive training as appropriate. All staff will ensure they are friendly and approachable at all times. Communication with all patients will commence on admission into PACU, regardless of conscious level. PACU staff will gather information from theatre handover and patient documentation to ascertain the patients preferred name, communication abilities and needs (e.g. Sight, hearing, comprehension, verbal abilities, special needs etc.) All bed areas will have an accessible, working emergency call bell. Clocks will be visible to all patients to aid orientation to time. Lights will be dimmed at night and noise kept to a minimum at night. Ensure main carer is known to all staff and where appropriate, involved with decisions affecting patients care. Patients understanding of new information will be verified All staff to be aware of patients need for privacy for communication where possible. All documentation should be clear, accurate and complete, whether hand written or computerised and signed by the appropriate staff.
Compliance 100% Exceptions None
Interventions Ensure up to date liaison between all health care staff. All relatives and carers will be prepared for entering the recovery environment, both psychologically and with regard to their and others safety. Patient will have anxieties dealt with by reassurance, information, with access to relatives or specialist staff as needed. Nurses may give specific counselling as they feel able or ensure patients are referred to the appropriate services. Specific communication needs will be addressed quickly by appropriate means (e.g. Hearing aid, spectacles, carers involvement etc.) Reference Roper.N., Logan.W. and Tierney.A. (1996) 4th edition The elements of nursing Churchill Livingstone PACU Standard No 10a Standard of Care: Privacy and Dignity. All patients when admitted into PACU will have their privacy maintained, they will be treated with dignity by all staff members at all times regardless of their race, gender or medical condition. The patient will know who their nurse is as soon as they are conscious and able to understand where they are. Method Introduce yourself to the patient when the appropriate time arises. Orientate the patient to time and place. Ensure that all medical notes are kept with the patient in a folder. Receive patient handover from other members of the MDT. Always consider the patients feelings when interventions of a personal nature are required. Try to announce your arrival to a private bed space. (Curtains pulled around)
Compliance 100% Exceptions Interventions

None
Introduce yourself, tell the patient where they are and reassure them. Speak to the patient in a clear voice with respect and understanding. Be sympathetic of the patients medical condition and how it affects them. Always explain any procedure to the patient before you act. Always fully enclose the bed space to promote privacy. Never expose the patient unnecessarily. Always answer any questions honestly. Keep the patient informed of your intentions.
Reference Roper.N., Logan.W. and Tierney.A. (1996) 4th edition The elements of nursing Churchill Livingstone PACU Standard No 10b Standard of Care: Last Rites In the event of a death of a patient in PACU the patient will be treated with dignity and compassion. The ward and their relatives will be informed of the event immediately. The family may if they wish to, view their loved one, after the patient is laid out, provision for this will be arranged.
Method
Note the time of death. Inform the Doctor. The Doctor should certify the patients death and document this in the notes. The PACU nurse should document the events in the patients notes. Check the patients name band is correct.
Compliance 100% Exceptions

Interventions
None
Stop all infusions. Leave all cannula in place and capped off. Leave (but document any jewellery) with the patient. Wash, dry and place the patient into a shroud. Put dentures into the patients mouth if possible. Cover with a sheet. If leaking or an infection risk place the body into a mortuary bag, seal and label as an infection risk. The labels from the mortuary box should be completed. a) Attach to body b) Attach to sheet the body is wrapped in. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 121 of 131
c) d)
Attach to the mortuary bag if used. Put a copy into the patients notes. Send patients notes and belongings to patient affairs. Give RUH Bereavement booklet to family of the deceased and advise them to contact patient affairs. If a post mortem is required the doctor will discuss this with the family of the deceased. Call the general porters for the removal of the body to the mortuary.
Reference RUH Bereavement Policy PACU Standard No 11 Standard of Care: Elimination All patients in PACU will have their toilet needs met with prompt and appropriate methods of elimination. They will be treated with dignity and be given privacy to conduct their toilet needs. They will be offered the appropriate assistance in order to achieve a satisfactory outcome without deterioration or complications post operatively.
Method
Ask the patient if they need to use the toilet. Adequate numbers of staff to ensure patients are not experiencing a delay when they require assistance. Adequate toileting devices are available.
Compliance 100% Exceptions None Interventions Observation of bladder, bowel / stoma function. Ensure privacy and dignity for the patient at all times. Ensure toilet devices are available. Ensure the infection control policy is adhered to when dealing with waste products. Note any abnormalities in appearance of urine or stool, report to doctor if concerned. Note volume and quantity. Record appropriately on fluid chart. Ensure an aseptic technique is used when catheterising or dealing with an indwelling catheter. Hourly urine measurements if appropriate. Reference Mallett.J & Bailey. C (1996) The Royal Marsden NHS Trust Manual of clinical Nursing Procedures 4th edition Blackwell Science
PACU Standard No 12 Standard of Care: Fluid Balance The patient in PACU will have an accurate record of their fluid balance and adequate fluids prescribed for their discharge to the ward. The patient should be neither dehydrated nor overloaded with fluid. Urine output should in the average adult be a minimum of 0.5 ml/kg/h. The patient will not experience any deterioration of their kidney function. Method All IV fluids will be recorded when set up on the fluid balance sheet. Oral intake will be monitored and recorded. NG output will be monitored and recorded. Urine out put will be measured either hourly or four hourly as the patients condition dictates. Staff will have training to ensure they understand the signs and symptoms of fluid overload and dehydration. All output form indwelling drains will be measured and monitored. The fluid balance sheet must be maintained to show a running total of fluid balance for the patient.
Compliance 100% Exceptions Interventions Take a base line measurement of urine. Check urinary catheter is draining and not blocked. Label any drains for ease of reference. Ensure they are not clamped. Follow procedure for trans cell drain and document appropriately. Check patency of all IV cannula on a regular basis. Remove IV cannula if it is not patent or looks infected. Check all IV infusion lines are patent and intact. Label all IV infusion lines. Fluid being infused and date. Follow hospital policy for the infusion of blood and blood products. Adhere to an aseptic technique at all times. None
Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications
PACU Standard No 13 Standard of Care: Post operative nausea and vomiting. To prevent or reduce post operative nausea and vomiting. For patients in PACU to remain comfortable and free from post operative nausea and vomiting. For patients to remain safe from the effects of nausea and vomiting. Method The education of staff in the management of post operative nausea and vomiting. An awareness of the infection control issues surrounding body fluids. Adhere to the policy for passing a NG tube. Adhere to the drug administration policy. Ensure adequate equipment at each bed space. All hygiene needs are met. Compliance 100% Exceptions None
Interventions Continued education for all staff in the management of post-operative nausea and vomiting. Staff will use gloves and aprons when dealing with body fluids. All staff will be able to pass a NG tube safely and demonstrate its patency. Antiemetic drugs will be administered according to hospital policy. Use acupressure if appropriate. The pressure point is in the midline on the anterior aspect of the left forearm, about an inch above the proximal skin crease of the wrist. The patient will if allowed sit up to avoid aspiration and to promote orientation. Strict fluid balance will be adhered to, ensuring dehydration does not occur.
Reference Hatfield. A.& Tronson. M. (2001) The complete recovery room book. 3rd Edition Oxford Press. PACU Standard No 14 Standard of Care: Hygiene Patients in PACU will have their hygiene needs met within 15 minutes of being identified, or at a time which is clinically convenient. For patients to feel clean and comfortable.
Method
Wash patients skin with soap and water. Provide clean linen and gown if necessary. Offer mouth care to patients. Give eye care wherever appropriate. Perform catheter care when needed.

Interventions
None
Be aware of the patients medical condition. Be aware of the patients temperature. Ensure that the patient understands the intervention. Always provide privacy. Always treat the patient with dignity. Allow the patient to help if possible. Ensure the safe disposal of soiled laundry. During intervention assess your patients skin.
Reference Roper.N., Logan.W. and Tierney.A. (1996) 4th edition The elements of nursing Churchill Livingstone Mallett. J & Bailey. C. (1996) The Royal Marsden NHS Trust. Manual of Clinical Nursing Procedures 4th edition. PACU Standard No 15 Standard of Care: Infection Control All patients who are admitted into PACU will be protected from hospital acquired infection.
Method
All PACU nurses will keep their statutory infection control updated by attending the appropriate course. PACU nurses will put into practice the RUH infection control policy guidelines. Compliance 100% Exceptions None
Interventions
Good hand hygiene. Universal blood and body fluid precautions. Cleaning, disinfection or sterilisation of equipment, instruments and surfaces. Correct use of disinfectants. Ref 416/2009 Status: Final
Aseptic technique. Safe disposal of waste, sharps and linen. Isolation precautions when patients have a known or suspected infection.
Reference Royal United Hospital Infection Control Policy Mallett. J & Bailey. C. (1996) The Royal Marsden NHS Trust. Manual of Clinical Nursing Procedures 4th edition. PACU Standard No 15a Standard of Care: Prevention of Pressure Sores Patients will have their pressure area needs assessed on admission into PACU. Patients will have their pressure areas inspected and assessed by a PACU nurse within 15 minutes of becoming conscious or as soon as they are able to tolerate being moved. To promote healthy intact skin. Method Assess pressure area risk by using the Waterlow score. Continued and further training for all staff in the safe moving of patients. Equipment available for moving patients and training in its use. Appropriate mattress for patient needs. Adequate staffing levels to allow good pressure area care at all times. Updated knowledge of staff with RUH pressure area prevention policy. Plan care and implement plan.

Interventions
None
Roll patient on admission and assess skin condition. Plan pressure area care whilst in PACU. Document skin condition. If incontinent wash and dry to prevent skin breakdown. Position patient for optimum pressure area care. Support vulnerable areas adequately. Avoid shearing and friction by using slide sheets when moving patients. Treat any existing pressure sores, using research based practice.
Reference RUH Pressure Ulcer Prevention And Management Mallett. J & Bailey. C. (1996) The Royal Marsden NHS Trust. Manual of Clinical Nursing Procedures 4th edition. Document Name: Theatre Practice Policy Ref 416/2009 Issue Date: September 2009 Status: Final Page 126 of 131
PACU Standard No 15b Standard of Care: Wound Management Wounds will be inspected within 10 minutes of the patient being admitted into PACU. The wound will be assessed for signs of infection and blood loss. Measurements form drains will be recorded at this time and further assessment of the wound and drains will follow at regular intervals. Method Aseptic technique will be adhered to at all times by all staff. Staff trained in the management of drains. Staff trained in the management of wounds. Stoma will be assessed for profusion. PACU staff will be trained to recognise any complications. Compliance 100% Exceptions Interventions Demonstration by staff of aseptic technique. Infection control protocol adhered to. Staff training updates. Assessment of wounds and drains along side observations. Demonstrate ability to manage drains. Ability to change a stoma bag. None
Reference Mallett. J & Bailey. C. (1996) The Royal Marsden NHS Trust. Manual of Clinical Nursing Procedures 4th edition. PACU Standard No 16 Standard of Care: Haemodynamic Monitoring Those patients who require continuous monitoring will have their vital signs invasively monitored until they are discharged to the Intensive Therapy Unit to continue their High Dependency Care or until they are fully recovered and able to return to a ward. Staff monitoring HDU patients will work within an agreed criteria set out by the anaesthetist. The patient will suffer no ill effects from being invasively monitored.
Method
All staff will have training in the use of invasive monitoring. New staff will be introduced to the invasive monitoring systems. An awareness of the possible complications of being invasively monitored will be understood by all staff. Equipment is regularly checked and maintained. Adequate stocks of sundries, e.g. blood gas syringes. All staff will demonstrate their ability to use these devices. Staff must undertake extra training in the management of Central Venous Catheter Monitoring and use in IV workbook, they must be passed as competent.
Compliance 100% Exceptions Interventions Prepare the patient for the insertion or removal of the monitoring equipment. Ensure that the arterial line is secure and correctly zeroed. Ensure the Central Venous Catheter is x-rayed if new and that the x-ray is checked prior to use. Keep arm with arterial line visible to ensure continuous observation. Oxygen saturation monitored continuously. 3 lead ECG monitoring. Respiratory rate and rhythm monitored. Hourly urine measurements. Regular inspection of wound sites and drains. None
Reference Adam. SK and Osborne. S. (1999) Critical Care Nursing Oxford Medical Publications
PACU Standard No 17 Standard of Care: Recovery from anaesthesia. Patients admitted into PACU will all expect to recover from their anaesthetic in a safe environment and a controlled manner. Method: PACU trained nurses will care for these post anaesthetic patients. Anaesthetists will co-ordinate and plan the patients post operation care. The PACU nurse will monitor the patient and act according to the post operative plan.
The PACU nurse will seek advice from the anaesthetist if there are any problems during the recovery period. Compliance 100% Exceptions None
Interventions Check the bed space equipment is ready and appropriate to admit a patient safely. Take handover from the anaesthetist and theatre nurse. Ensure you are aware of the complications of the patients surgery. Understand the post operative plan. Observations according to the patients history and post operative condition. Interventions according to the patients condition and post operative plan. Complete all care plans, record all changes in condition and consult with anaesthetist if required. Ensure that the patient is ready for a safe transfer to the ward before discharge, according to the PACU standards. A Airway. B Breathing. C Circulation. D a). Drain. b). Drip. c). Drugs. E Elimination. Complete ORSOS. Contact the ward and ask for a trained nurse to collect your patient from PACU. Give a full handover to the ward nurse, outlining the patients past medical history, operative complications, post operative complications and post operative plan. Reference Hatfield A & Tronson M. 3rd edition (2003). The Complete Recovery Room Book. Oxford University Press PACU Standard No 18 Standard of Care: Transferring a patient to the ward All patients can expect a safe transfer to another department within 30 minutes of being assessed ready for discharge from PACU. The patient should not experience any undue delay in their discharge. Method Full assessment from the PACU nurse and or multidisciplinary team involved in the patients care.
1) 2) 3) 4) 5) 6) 7) 8) 9)
Patient meets the standards required for discharge. Patient maintains airway. Protective reflexes returned. Respiratory rate between 8 - 25 Cardiovascular system stable. Temperature > 35.5 Pain score < 3. Patent drips and drains. If in doubt about anything clinical, consult your patients anaesthetist for advice. Inform your patients anaesthetist when you intend to discharge to the ward if appropriate. 10) Contact ITU 10 minutes before discharge to the unit. The patient is aware of their transfer. The receiving ward is informed that the patient is ready for discharge form PACU. Compliance 100% Exceptions Interventions Staff in PACU fully trained in recovery of post operative patient care. Full recovery from anaesthesia. Good organisation of the PACU nurse. Documentation completed. Notes, care plans and X rays. Good communication between PACU and ward staff. Full handover of the patient to receiving ward staff. Identification of problems / issues affecting the patients care. Safe storage of equipment during transfer. Staff trained in the use of emergency equipment. Dr to help with the transfer if necessary. Theatre orderly informed of the transfer and ready to escort the patient back to the ward. None
Reference Cosgrove. J & Kilner. A. (2003) Transfer of the critically Ill Patient. Care of the critically ill. Vol19 NO 2.
CONSULTATION CHECKLIST Author, please attach this to each copy of the policy being sent to a meeting for comments. Dear Chairman, please would you review this policy at your committee and return any amendments / comments to ____________________________ by _____ / _____ / __ Title of meeting Date of meeting Name of policy Name of author ______________________________________ ______________________________________ ______________________________________ ______________________________________ Yes Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. ___________________________________ Is the policy referenced? Does the policy include a training plan? If you are the appropriate forum, have the necessary resources been agreed to implement this policy? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? Other comments from meeting. No N/A
Policy accepted without further comment. (Please circle) Policy needs further amendment. (Please circle) Name of Chair __________________________ Signature ______________________________ For Human Resources Policies only Name of Staff Side ______________________ Signature ______________________________
Yes / No Yes / No
Date _____ / _____ / _____
Date _____ / _____ / _____ Ref 416/2009 Status: Final

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THEATRE PRACTICE POLICY

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