REPORT OF DEPARTMENTAL STUDY ON OT COMPLEX

OBJECTIVES
1. To study the location of O.T. in relation to access to patients
2. To study the design of O.T. and its functioning.
3. To study and understand the significance, structure and function and
organisation of an OT complex.

INTRODUCTION
An operation theatre complex is the "heart" of any major surgical hospital. An operating
theatre, operating room, surgery suite or a surgery centre is a room within a hospital within
which surgical and other operations are carried out. Operating theatres were so-called in the
United Kingdom because they traditionally consisted of semi-circular amphitheatres to allow
students to observe the medical procedures. The Old Operating Theatre in London is one of
the oldest, dating back to 1822 (Oxford English Dictionary and Wikipedia.com).
The patient is the centre point of a functioning OT complex. He/she is in isolation for
varying times, away from his near and dear ones and is physically sick. Efforts are directed
to maintain vital functions, prevent infections/and promote healing with safety, comfort and
economy.
The establishment and working of the operation theatre (O.T.) need specialised planning and
execution and are not simple civil engineering work. A
"civil-mechanical-electrical-electronic- biomedical" combo effort driven and coordinated by
the needs, preferences and safety of the medical/ surgical team forms the basis for starting
and maintaining an operation theatre. Anesthesiologists, by virtue of their knowledge of the
intricacies of physiology, physics and biomedical aspects of medicine and constant
proximity to the operation theatre should preferably be involved from the early stages of
planning of operating theatres.
On average, operation theatres cater to 50% of the needs of total healthcare seekers.

Content

Ideal Department

Comparison of ideal and actual OT

Recommendations

IDEAL DEPARTMENT
PURPOSE OF OPERATION THEATRE COMPLEX
OT complexes is designed and built to carry out investigative, diagnostic,
therapeutic and palliative procedures of varying degrees of invasiveness. Many
such setups are customised to the requirements based on the size of the hospital,
patient turnover and maybe speciality-specific. The aim is to provide the
maximum benefit for the maximum number of patients arriving at the operation
theatre. Both the present as well as future needs should be kept in mind while
planning.

LOCATION OF OPERATION THEATRE

Objective is to keep the OT area free of traffic and in close proximity to surgical
wards, intensive care units (ICU), accidents and, Radiological department (X-Ray)
should be closely related and access is also required to Sterilizing and disinfecting
unit (or CSSD) and laboratory facilities. OT is designed so as to make it suitable
and comfortable for administrators, surgeons, anaesthetists, surgical nurses, OT
technicians, and other concerned staff over long and tense working hours.
Low rise buildings limited to two or three-storey‟s high are preferred because of
the maximum advantage of natural light and ventilation as appropriate can be
derived. The location of operation complex in a multi-storey building is planned
on the first floor, connecting to surgical and other wards on the same floor. An
adequate electric lift is planned for vertical movement from casualty on the ground
floor and ENT, Orthopedics, Ophthalmology & other wards on the floors above.
Otherwise, OT can be planned strategically on any floor. Zone wise distribution of
the area is necessary, so as to avoid criss-cross movements of men & machines.
Adequate & appropriate space allotment as per the utility of the area is necessary.

DESIGN & STRUCTURE:

DIFFERENT ZONES OF OT COMPLEX
The location and flow of the patients, the staff and the materials form the three
broad groups to be considered during all stages of design.
Four zones can be described in an OT complex, based on varying degrees of
cleanliness, in which the bacteriological count progressively diminishes from the
outer to the inner zones (operating area) and is maintained by a differential
decreasing positive pressure ventilation gradient from the inner zone to the outer
zone.
(1) Protective zone: It includes
● Change rooms for all medical and paramedical staff with conveniences
● Staff lockers and Toilets
● Rooms for administrative staff
● Stores & records
 ● Reception – Control room
● Transfer bay for patient, material & equipment
● Pre & post-operative rooms
● Emergency lab (Frozen section)
● Classrooms and Conference rooms
(2) Clean zone: Connects protective zone to aseptic zone and has other areas also like
● I.C.U. and P.A.C.U.(Post anaesthesia care unit)
● Stores & cleaner room
● Equipment store room
● Maintenance workshop
● Kitchenette (pantry)
● Firefighting device room
● Emergency exits
● Service room for staff
● Close circuit TV control area
● Sterile supply storage area
● Flash steriliser area
● Plaster room if necessary
(3) Aseptic zone: Includes
● Operation rooms (sterile)
● Anaesthesia induction room
● Scrub areas
(4) Disposal zone: Disposal areas from each OR & corridor lead to disposal zone
● Dirty utility storage

Pre-operative check-in area

This is important with respect to maintaining privacy, for changing from street clothes to
gown and to provide lockers and lavatories for staff. Separate area for male and female
staff. It should have direct entry from outside and before entry to a clean area.

Holding area
This area should have a stretcher station of 80 sq. ft. with 4 ft. on the sides. It
is planned for preoperative examination, IV line insertion, preparation,
catheter/gastric tube insertion, the connection of monitors, & shall have O2 and
suction lines. A facility for CPR should be available in this area. Each bed
should have 8-10 electric points. Pre-operative area with a reception with a
separate designated area for paediatric patients is desirable.

Induction room(Anaesthesia room)

It should have all facilities as in OT, but there is controversy as to its need.
One for each OT is required; ideally, each is a duplicate of the other on each
floor. The anaesthetic room will provide a more tranquil atmosphere to the
patient than the OT. It should provide space for anaesthetic trolleys with
circulation corridors. Equipment should be located with direct access to
 circulation corridors and ready access to the operating room. It will also allow
cleaning, testing and storing of anaesthesia equipment. It should contain
workbenches, sink(s) and racks for the cylinder. It should have sufficient
power outlets and medical gas panels for testing of equipment.

Post anaesthetic care units (PACU)

Preferably adjacent to the recovery room. These should contain a medication
station, hand washing station, nurse station, storage space for stretchers,
supplies and monitors, equipment and gas storage area, suction outlets and
ventilator. Additionally, 80 sq ft (7.43 sq m) for each patient bed, clearance of
5 ft (1.5 m) between beds and 4 ft (1.22m) between patient bedsides and the
adjacent wall should be planned.

Recovery room
One nursing station per recovery room with a chatting facility. It should
contain a medication cabinet, hand steriliser per bed, storage space for
stretchers, clinical sink, bedpan cleaning space, supplies and monitors,
equipment and gas storage area, gas & suction outlets and ventilator.
Additionally, 80 sq ft (7.43 sq m) for each patient bed, clearance of 5 ft (1.5 m)
between beds and 4 ft (1.22m) between patient bedsides and the adjacent walls
should be planned.
Isolation rooms for infectious patients should be planned.

Staff room
Separate areas for men and women dress change from street cloth to OT attire;
lockers, shower and lavatory are essential amenities; restroom TV, etc. are
desirable. It should have an entrance from the outside. One washbasin and one
western closet (WC) should be provided for 8-10 persons. Shower and their
number is a matter of local decision. The inclusion of toilet facilities in
changing rooms is not acceptable; they should be located in an adjacent space.

Medical gas storage

The anaesthesia gas/cylinder manifold room/storage area should be designated.
It should be in a cool, clean room that is constructed of fire-resistant materials.
Conductive flooring must be present but is not required if non-inflammable
gases are stored. Adequate ventilation to allow leaking gases to escape, safety
labels and separate places for empty and full cylinders should be allocated.

Offices
For staff nurses and anaesthesia staff - The office should allow access to both
unrestricted and semi-restricted areas as frequent communication with the
public is needed.

Restrooms
Pleasant and quiet rest for staff should be arranged either as one large room for
 all grades of staff or as separate rooms; both have merits. Comfortable chairs
and sofas, one writing table, a bookcase etc., may be arranged.

Laboratory
Small laboratory with a refrigerator for pathologists for preparation and
examination of the frozen sections should be arranged.

Seminar room
Since the staff cannot leave an OT complex easily, it is better to have a
seminar room within the OT complex. Intra-departmental discussions,
teaching and training sessions for staff (with audio-visual aids) may be
conducted here.

Storeroom
This is designed to store large but less frequently used equipment in the OT.
There should be storage space for special equipment after cleaning.

Theatre sterile supply unit (TSSU)

Within this area, the following are desirable
Temperatures between 18o - 22o C, the humidity
of 40%•-50% is the aim. Air-conditioned with
10-12 air exchanges per hour
Storage of sterile drapes, sponges, gloves, gowns and
other items ready to use. Option to store from one side
and remove from the other side.
Safety inventory stock.

Scrub room
This is planned to be built within the restricted area. Elbow, knee operated or
infrared sensor operated hot and cold water source with minimum water
splashing is ideal. It is steel scrub essential to have non-slippery flooring in
this area. It should have minimum travel from scrub to OT in order to
eliminate the chances of contamination.

TYPES OF OT COMPLEX:
There are three main categories of operation theatres:
1. The single theatre suite with OT, scrub-up and gowning, anaesthesia room,
trolley preparation, utility and exit bay plus staff change and limited ancillary
accommodation.
2. The twin theatre suite with facilities similar to 1st, but with duplicated ancillary
accommodation immediate to each OT, sometimes sharing a small post
anaesthesia recovery area.
3. OT complex of three or more OT‟s with ancillary accommodation including
post anaesthesia recovery, reception, sterile store and staff change.
PRINCIPLES TO BE TAKEN INTO CONSIDERATION WHILE
PLANNING AN OT (PHYSICAL / ARCHITECTURAL):
It is observed that out of all surgical beds of the hospital 50% of patients are
expected to undergo surgery. Thus for 100 beds with an average length of stay of
10 days for each patient, 10 operations per day can be performed. In general,
multi-use OTs, instead of multiple OTs, offer advantages of efficient manpower
utilisation, economical maintenance and better training of supporting staff.
Thus, in a 300 bedded hospital (with 150 surgical beds), one OT complex with 3
OTs for General Surgery, Gynecology, Orthopedics/ENT, one for Endoscopy and
one for Septic is required. OT will be required with 8 hours a day working
duration.
The number & size can be as per the requirement but the recommended number is
1 OT for 11/2 -2 ICU & 1 operating table for 50 surgical beds. Recommended size
is 6.5 m x 6.5m x 3.5 m. Glass windows can be planned on one side only.

Doors:
Main door to the OT complex has to be of adequate width (1.2 to 1.5 m). The
doors of each OT should be spring-loaded flap type, but electrically operated
sliding doors are preferred as no air currents are generated. All fittings in OT
should be flush type and made of steel.

Floor:
The surface/flooring must be smooth, slip-resistant, strong, impervious &
seamless with minimum joints (e.g. mosaic with copper plates for antistatic effect)
or joint less conductive tiles/terrazzo, linoleum etc. The recommended minimum
resistance is 1m Ohm and a maximum of 10m Ohms. Presently the need for
antistatic flooring has diminished as flammable anaesthetic agents are no longer in
use.
Recommended floor area except storage and cabinet in a normal OT 360 sq. ft.
(18ft * 20ft), major OT 480 sq. ft. (24ft * 20ft) & specialty OT is 600 sq. ft (24ft *
25ft).

Walls & Ceilings:

Laminated polyester or smooth paint provides a seamless wall as tiles can break
and epoxy paint can chip out. Walls should be water and stain-proof, easy to clean
and fire-resistant. Collusion corners to be covered with steel or aluminium plates,
the colour of paint should allow reflection of light and yet soothing to eyes. Light
colour (light blue or green) washable paint will be ideal. A semi-matt wall surface
reflects less light than a high gloss finish and is less tiring to the eyes of the OT
team. The Walls and ceilings must be covered each other and to the floor to
decrease the infection.

Operation table:
There should be one operation table per OT. In the case of transplants, two OTs
should be linked by a service window to transfer organs etc. from the donor side to
the recipient side. The surface should be easy to clean and stain proof.

X-Ray illuminators:
There should be X-ray film illuminators preferably recessed into the wall having
space for at least two films.

Corridors:
Corridors should not be less than 2.85 m in width for easy movement of men,
stretchers & machines. Separate corridors for dirty utility other than going into
OT.

Gas & suction (control, supply & emergency stock):

For all OTs & areas where patients are retained, Oxygen gas and suction pipe to be
connected with the central facility and standby local facility should also be
available.

Water supply:
Besides the normal supply of available water at the rate of 400 L per bed per day,
a separate reserve emergency overhead tank should be provided for operation
theatre. Elbow taps have to be 10 cm above the washbasin.

Drainage system:
Proper drainage system should be planned. Drainage pipes above the ceiling of OT should be
avoided.

Fire safety:
Safety in the place is essential. Fire extinguishers have to be planned in the
appropriate zone. Fire fighting systems water sprinklers or steam sprinklers can be
planned with ionisation and optical fire detectors. Fire exit routes must be well
defined and checked periodically.

Ventilation:
Ventilation should be on the principle that the direction of airflow is from the
operation theatre towards the main entrance. There should be no interchange of air
movements between one OT and another. Efficient ventilation will control
temperature and humidity in OT, and dilute the contamination by microorganisms
and anaesthetic agents.
There are two types of air conditioning systems: re-circulating and non-recirculating.
Non-recirculating systems heat/cool the air as desired and convey it into the
operating room with ideally 20 air exchanges per hour. Air is then exhausted
outside. Anaesthetic agents in the OT air are also automatically removed. These
are thus ideal but expensive.
The circulating system takes some or all of the air, adjusts the temperature and
circulates air back into the room.
The broad recommendations include
● 20-30 air exchanges/hour for re-circulated air.
● Only up to 80% re-circulated air to prevent the build-up of anaesthetic and other gases.
● Ultraclean laminar airflow - the filtered air delivery must be 90% efficient in
removing particles more than 0.5mm.
● Positive air pressure system 5 cm H2O from the ceiling of OT downwards and
outwards, to push out air from OT.
● Relative humidity of 40-60% to be maintained.
● Temperature between 20o - 24oC. The temperature should not be adjusted for
the comfort of OT personnel but for the requirement of the patient, especially
in paediatric, geriatric, burns, & neonatal cases etc.
● Air should not contain detectable clostridium spores of coagulated +ve staphylococcus.
● Aerobic culture should not indicate ˃35 bacteria carrying particles in 1m3 of
air. During surgical operations, the concentration of bacterially - contaminated
airborne particles in the operating theatre averaged over any 5 minute period
should not exceed 180 per m3 (5 per ft 3), and special types of surgical
operation, e.g., orthopaedic and transplantation procedures, higher standards of
air cleanliness must be ensured.

Positive Pressure:
There is a requirement to maintain a positive pressure differential between OT and
adjoining areas to prevent outside air entry into OT. The minimum positive
pressure recommended is 15 Pascal (0.05 inches of water) as per ISO 14644 Clean
Room Standard.

Air Filtration:
The AHU (Air Handling Unit) must be an air purification unit and air filtration
unit. There must be two sets of washable flange type pre-filters of capacity 10
microns and 5 microns with aluminium/SS 304 frame within the AHU as per
NABH 2010 amendments. The necessary service panels are to be provided for
servicing the filters, motors & blowers. HEPA filters may be provided in the AHU.
The AHU of each OT should be a dedicated one and should not be linked to the air
conditioning of any other area. During the non-functional hours, the AHU blower
will be operational round the clock (maybe without temperature control). VFD
devices may be used to conserve energy.

Pendant services:
Two ceiling pendants for pipeline services should be designed; one for the surgical
team and one for the anaesthetist. Anaesthetic pendants should be retractable and
have limited lateral movement and provide a shelf for monitoring equipment. It
should have oxygen, nitrous oxide, four-bar pressure medical compressed air, a
medical vacuum, scavenging terminal outlets and at least four electric sockets.

Media Bridge:
Media Bridge is a replacement for pendants. It is not only better ergonomically by
providing 360-degree access but it also helps in maintaining the class of
cleanroom specified as there is no obstruction in the Laminar Flow of air.

Piped gases:
Automatic/semi-automatic fail-safe manifold rooms should be designed. Two
outlets for O2 and suction and one for N2O is a minimum in each OT. Pipeline
supply systems should have provision to cut off from the mainline if the problem
occurs anywhere along with the delivery hosing/tubing.

Laminar Air Flow:

Laminar airflow is designed to move particle free air over the aseptic operating
field in one direction. It can be designed to flow vertically or horizontally and is
usually combined with high-efficiency particulate air (HEPA) filters. HEPA filters
remove particles > 0.3 micron in diameter with an efficiency of 99.979%.

Electrical:
All electrical equipment in the OT needs proper grounding. In the past, isolated
power systems were preferred when explosive agents were being used. They have
the advantage of a transformer using grounded electricity and there is no risk to
the patient or machines if a machine gets faulty. The grounded systems as used at
homes offer protection from macro shock but devices may lose power without
warning. Life support systems, if in use, could be disturbed.

The following criteria are ideal with respect to electricity in OT complex:

● Use of Ground Fault Interrupters is desirable if there is an overload or ground fault.
● Power line of 220 Volts.
● Suspended ceiling outlets should have locking plugs to avoid accidental
disconnection.
● Insulation around ceiling electrical power sources should withstand
frequent bending and flexing and should not develop cracks. Wires inside
rigid or retractable ceiling service columns can help to some extent.
● Wall outlets should be installed 1.5 m above ground.
● Use of explosion proof plugs.
● Multiple outlets from different electrical line sources should be available.
● Electrical load calculation should be based on equipment likely to be used
and appropriate current-carrying capacity cords to be used.

Emergency power:
OT electrical networks need to be connected to the emergency generators with an
automatic two-way changeover facility. Power back up for life-saving equipment
and OT light is necessary. UPS of adequate capacity should be installed after
considering OT light, anaesthesia machine, monitors, cautery etc. until the backup
generator takes over.

Lighting:
Some natural daylight is preferred. Wherever possible, high-level windows can be
considered in the OT for a visual appreciation of the 'outside world'.

General lighting:
Colour corrected fluorescent lamps (recessed or surface ceiling mounted) to
produce even illumination of at least 500 Lux at working height, with minimal
glare are preferred. Means of dimming may be needed during endoscopies. To
minimise eye fatigue, the ratio of the intensity of general room lighting to that at
the surgical site should not exceed 1:5, the preferred is 1:3. This contrast should be
maintained in corridors and scrub areas, as well as in the room itself so that the
surgeon becomes accustomed to the light before entering the sterile field. The
Colour and hue of the lights should be consistent also. Adequate illumination with
shadowless lamps of 70,000-120,000 Lumens intensity (2000 Lux) is required for
assessing patient colour and tissue visibility. White and glistening/shiny body
tissues need less light than dark and dull tissues.

Operating area:
Overhead light should be shadowless and glare-less with 27,000 – 1, 27,000 Lux
of light (50000 to100000 Lux at the centre and at least 15,000 Lux at the
periphery). About 10 - 12 inches of focus of light gives adequate illumination both
at depth as well as on the surface of the body. Lights should be freely movable
both in horizontal and vertical ranges. Pendant systems are preferred. OT light
should produce the blue-white colour of daylight at a spectral energy range of
50000 K (35000-67000 Kelvin acceptable). Halogen lights produce less heat and
hence are preferred. OT light should not produce more than 25000 mw/cm2 of
radiant energy. Elimination of heat by diachronic reflectors (cold mirrors) with
heat-absorbing reflectors or filters should be available along with the luminaries.
An auxiliary light for a second surgical site is often beneficial.
In endoscopic OTs, reduced lighting is sometimes recommended. A grazing light
over the floor can be helpful.

Noise:
Noise, defined as any unwanted or undesirable sound, is a known environmental
pollutant and health hazard. Recommended sound levels during the entire surgical
procedure are less than 25-35 decibels and a reverberation time below 1sec.

Anaesthesia equipment and monitoring needs:

At least one anesthesiologist should be in the team involved in planning an OT. It
is imperative that certain mandatory considerations with respect to the anaesthetic
equipment and monitors be planned during the planning and design stage itself.
Personal, practice and cost preferences may influence the plans.
Communications:
Telephones, intercom and code warning signals are desirable inside the OT. One
hands-free phone per OT and one exclusively for use of anaesthesia personnel is
desirable. An intercom to connect to the control desk, pathology and other OTs, as
well as the use of paging receivers (bleeps), is also ideal. A code signal, when
activated, signals an emergency state such as cardiac arrest or need for immediate
assistance.

Hatch Box:
A hatch is provided in each OT to remove waste materials from the operation
theatre to the dirty linen area just adjacent to OT. Each hatch is equipped with two
doors and the doors are electronically interlocked i.e. the hatch is designed in such
a way that only one door is opened at one time. The UV light is installed so that it
is kept on while both the doors are closed. This UV light automatically turns off in
case of opening of either of the doors. There are indicators on both sides of the OT
so that the door open/close status can be monitored from both ends.

Control Panel:
Every OT must be equipped with a control panel. It indicates the following:
a. Time Day Clock
b. Time Elapsed Clock
c. General Lighting System
d. Medical Gas Alarm Panel
e. Hands-Free Telephony set with memory
f. Temperature and humidity indicator with controller
g. HEPA filter status module
h. Room Pressure indicator

OT Storage unit
The storage unit is ergonomically designed and 1.50 mm thick E.G.P. Zinc coated
steel panels homogeneously filled with polyurethane foam. The doors of the
storage cabinet house vacuum insulated glass, these doors are installed on the
storage units with the help of imported fittings allowing an opening allowance of
160 degrees. The storage unit is divided in 2 equal parts and each part has
individual doors with a locking system. Each part is provided with steel racks
which are completely detachable.

Cleaning:
The construction materials selected for the OT complex should aim to minimise
maintenance and cleaning costs.
Provision for expansion of the OT complex should be borne in mind during the planning
stages itself.
Data management:
Customised network connections should be put in place or a conduit should be
planned. A well-designed system can provide automated records, materials
management, quality improvement and assessment, laboratory tracking, etc. The
software for OT management is costly and hospitals are generally slow to adapt to
 changes. Customised OT software can be designed for individual needs.

Operating theatre satellite pharmacy:

Access to the OT areas and outside should be possible. It should have a
refrigerator for blood storage and a warmer space for drug storage, locked
containers for controlled substances, a computer, and a desk area for paperwork
and pharmaceutical literature. Special kits for specific surgeries may also be
arranged. The pharmacy may open for 1 to 24 hours based on need but it is
desirable that an after hour system is planned.

Statutory regulations
The design and planning of an OT complex will need compliance with mandatory
regulations related to local administration such as Municipal Corporation,
Government, Pollution Control Board, Fire Safety Department, Water supply and
Drainage department etc.

The authority for standardisation

Recommendations is available in various surgical, anaesthesia and nursing
manuals with regard to the planning and establishment of operation
theatres/complexes. The hospital can get accredited by the Joint Commission on
Accreditation of Healthcare Organisations (JCAHO) or the National Accreditation
Board for Hospitals and Healthcare providers (NABH), a professionally sponsored
program that stimulates a high quality of patient care in health care facilities.
There is also an accreditation option that is available for ambulatory surgery
centres (Accreditation Association for Ambulatory Healthcare - AAAH).
STANDARD OPERATING PROCEDURE
The consequences of serious infection following surgery are catastrophic and can
lead to increased morbidity, death or loss of graft or eyesight. A low incidence of
infection depends on operating theatre design, meticulous surgical technique and
rigid aseptic discipline within the operating theatre suite. The risk of postoperative
infection is multi-factorial; it is determined by pre-operative bacterial
contamination of the wound, the virulence of the organism, the amount of tissue
trauma and the body‟s ability to resist contamination. However, much depends on
the skill of the surgeon in handling tissues and preventing wound contamination,
the duration of the procedure and the administration of prophylactic antibiotics in
appropriate cases. The theatre environment and conduct of operating staff also
play a part in reducing contamination of the air and the environment. The
adherence to infection control theatre discipline by all staff is therefore essential to
minimise postoperative infection.

TRAFFIC CONTROL
a. Traffic must be controlled since activities in these areas and a number of
people influence the burden of microorganisms in the environment.
b. Controls must be in place to limit the number of people in attendance at any
operation to the minimum required. Observers must be limited to one for an
operation to keep the
c. A number of people attending to within 6 people.
d. Theatre doors must be kept closed.
Restricted Areas
a. Redlines or other barriers may be used to create demarcation of areas that can
or cannot be crossed. However, while they assist in maintaining discipline,
they are unlikely to reduce infection.
b. Adhesive mats should not be used.
c. Transfer Zones
d. Patients should be transferred on trolleys with fresh laundered sheets and
blankets that should be changed between patients.

CHANGE ROOM
a. Street clothes are to be stored in lockers (lockers are not general-purpose
storage cupboards)
b. Street shoes to be covered before entering the theatre suite and removed to
change to OT slippers before entering scrub/surgery areas.
c. The door to the main corridor is to be closed at all times.
d. No foodstuff is allowed in the theatre area.

STERILE PREPARATION ROOM

a. Staff working in this area must wear theatre clothes and gowns, masks and
sterile gloves when necessary.
b. Clean and sterile supplies should be taken to the operating room from a
reprocessing or supply area outside the theatre suite on a covered trolley.
c. Soiled items should be taken in covered containers from the operating room to
the decontamination area.
d. Soiled items must be contained and stored separately from clean items.
Sterilising instruments/equipment
a. A separate room should be designated for processing, and autoclaving instruments and
equipment.
Equipment
b. Equipment such as suction equipment and ventilators must be fitted with
bacterial filters and decontaminated appropriately.
c. Used instruments should be counted, handled minimally and then sent for
reprocessing and sterilisation.

SURGICAL TEAM PREPARATION FOR SURGERY

Theatre Staff - Wearing of Jewellery
a. Necklaces, earrings, wrist jewellery and rings with stones should be removed.
If necessary rings can be worn by scrub and non-scrubbed staff, although
surgeons may be advised to remove these, particularly if working with metal
prostheses.
b. Scrub staff must not wear false fingernails.
Preoperative Hand Hygiene
a. Remove jewellery.
b. Keep nails short and do not wear artificial nails or polish.
c. Adjust water to warm temperature and wash hands and forearms to remove dirt and
transient flora.
d. Clean under each fingernail and around the nail bed with a nail cleaner prior to
performing the first surgical scrub of the day. Do not use nail brushes to scrub
the skin.
e. Holding hands up above the level of the elbow, apply the antiseptic agent to
hands and forearms up to elbows.
f. Scrub hands for 3-5 minutes pre-operatively with chlorhexidine detergent scrub or
g. Aqueous povidone-iodine.
h. Rinse each arm separately, fingertips first, holding hands above the level of the elbow.
i. Dry hands with a sterile towel.
j. Keep hands above waist level and do not touch anything before putting on a
sterile gown and sterile gloves.
k. Alcohol hand rubs solutions are an acceptable alternative for those with
allergies to antiseptics. Soap and water may be used, followed by an alcohol
hand rub.
Gloves
a. Wear well-fitting sterile gloves to protect the patients against hand contamination.
b. Change gloves between patients and when contaminated, after touching a
non-sterile field and if their integrity is compromised.
Masks
a. The scrub team should wear masks to protect the wearer. Masks should be
changed frequently and between patients and if deemed contaminated or damp.
b. Masks should not be worn hanging around the neck.
c. Filter type masks must be worn for patients with suspected TB.
d. Fluid shield masks must be worn when splashing with blood or body fluids is
anticipated.
Eye Protection
a. Eye protection must be worn to protect the eyes, mouth and nose from splashes of blood
and body fluids.
Theatre Caps
The scrubbed team must wear disposable headgear.
Theatre Footwear
Special footwear must be worn in the theatre and regularly cleaned.
Plastic overshoes should not be worn.
Scrub Suits
a. Scrub suits must be worn as protection against penetration of blood. Scrub
suits must be changed when visibly soiled.
Dress when leaving Theatre Cover Gowns/Coats
Staff must change theatre clothes before leaving. Cover gown over theatre suits is not
recommended.
Dress for Visitors to the Operating Theatre
a. If appropriate, maintenance staff may wear a gown over their clothes to enter the theatre.
b. Visitors to the operating departments do not need to wear theatre attire, a cover
gown is sufficient. But visitors entering the operating room should change into
theatre suits, hats and shoes.
c. Visitors should wear appropriate name badges and introduce themselves to the in-charge.
PREPARATION OF THE PATIENT
Preoperative Stay
a. Keeps hospitalisation to a minimum while allowing for adequate preparation of the
patient.
Standard Precautions and Risk Assessment
a) Standard precautions should exist for all surgical procedures, with
additional risk assessment of each patient to determine if extra and specific
precautions may be necessary.
Patients' Personal Clothing
a. Patients must remove clothing and wear disposable paper gowns and caps.
Patients Jewellery
a. Patients‟ rings or other jewellery must be removed if they are in the operative
or anaesthetic field. Jewellery should be taped if remaining on the patient.
b. Remove body jewellery as a precautionary measure when using diathermy/cautery.

Shaving
a. Avoid shaving if at all possible and only shave the incision area
b. Ideally use depilatory cream and if this is not possible, use clippers.
c. Only shave if other options are not possible.
d. If shaving is necessary, shave pre-operatively in theatre, either around the site
for surgery or before applying a diathermy pad on the patient.

Patient Showering
a. Patients should shower at least the night before the operation for hygiene purposes.
b. Showering with a chlorhexidine detergent scrub (Hibiscrub) may be advised for
Methicillin-resistant Staphylococcus aureus (MRSA) patients.

Skin Preparation before operation

a. Thoroughly wash and clean the operative site to remove gross contamination
before performing the skin preparation.

Order of Patients on the Operating List

a. MRSA and other infected patients, as well as patients requiring special decontamination
procedures,
e.g. hepatitis B, C,D, must be placed last on the list unless emergency surgery
is necessary. This is to facilitate adequate cleaning and disinfection. If such a
patient is an emergency, it is important that adequate cleaning and disinfection
of the environment take place prior to further use.

SURGICAL TECHNIQUE
Meticulous attention to asepsis, controlling bleeding and handling tissue is
necessary to minimise infection.
Sterile Operating Field
a. Theatre gowns and drapes must be made of waterproof, disposable material.
b. Place only sterile items within the sterile field
c. All items introduced to the sterile field must be opened, dispensed or
 transferred by methods that maintain sterility.
d. The sterile field must be constantly monitored.
e. All personnel movements must be conducted to maintain the sterility and integrity of the
sterile field.
f. Moisture in the sterile field must be avoided.
g. Consider an item below the level of the draped client to be unsterile.
h. Staff in sterile gowns, etc must not stretch over an unsterile field.
Movement in the Theatre
a. There is a risk of infection to the patient from the patient‟s own skin flora,
from the surgeon‟s hands and from airborne bacteria. Therefore to reduce
airborne bacteria, traffic in and out of theatre must be restricted.
Skin preparation at Operation
The ideal antiseptic should possess the following properties:
a. The spectrum of activity should be broad, with rapid and persistent effects
against Gram-negative and Gram-positive bacteria (and against fungi and
viruses which are resistant to some antiseptics).
b. It should be resistant to inactivation by organic materials, such as blood and faeces
c. There should be no toxicity or allergic reaction
d. Cosmetically acceptable
Gross contamination at the site of the incision should be removed before the
antiseptic skin preparation. The antiseptic skin preparation should be performed in
concentric circles moving away from the proposed incision site to the periphery
allowing sufficient prepared area to accommodate an extension to the incision or
new incisions or drain sites to be made. The application of the skin preparation
may need to be modified according to the condition of the skin (e.g. burns) and the
location of the incision site (e.g. face). Sufficient time must be allowed for
alcohol-based skin preparation to dry thoroughly before commencing the
procedure to ensure that all combustible ingredients have evaporated.

Blood/Body Fluid Spillage

For blood/ body fluid spillage, wear gloves and a plastic apron, and cover the area
with cotton or paper towelling. Pour Klorsept solution 10,000ppm (2 tabs/1 litre
water) over the paper towel and leave for 10 minutes. Wipe up the entire spill with
fresh paper towelling and dispose of all waste in a clinical waste bag (yellow).
Wash the area with water and detergent and dry the area as per infection control
policy.
Minimising Sharps Injury
a. Adopt procedures to minimise „sharps‟ injury and subcutaneous exposure to blood/body
fluids.
b. Dispose of „sharps‟ carefully in Sharps containers as per hospital guidelines.
c. In the event of injury or exposure, follow the hospital guidelines.
Linen
a. Linen must be minimally handled and placed in appropriate linen bags (adhere to I C
Policies).

Waste
a. Waste must be disposed of with minimal handling (adhere to Waste management
guidelines).
b. The theatre porters are responsible for the emptying of all the waste bins and
 the removal of sealed sharps bins.
c. Preoperative Antimicrobial Prophylaxis
a. Use antibiotics for procedures in which use has been shown to reduce
postoperative infection as per the antibiotic policy of the hospital.
Management of Infected or Colonised Surgical Personnel
Staff who have a communicable disease or are colonised with a pathogen
capable of transmission to a patient during surgery should be excluded until
well or as directed by the Consultant Microbiologist or Occupational Health
Physician.
Environmental Sampling of the Theatre
Routine microbiological sampling of the air or surfaces in the theatre is not
recommended because the results are only valid for the time period and for the
location sampled. Instead, such sampling should be limited to
recommendations from the infection control team, investigation of clusters or
to validate the changes in the ventilation system, (e.g. installation of a new
system).

STERILISATION OF INSTRUMENTS
a. The processing and sterilisation of instruments and equipment should take
place in a designated CSSD conforming to current standards.
b. The autoclaves should be set at commissioning and following major repairs or
modifications.
Testing of Autoclaves
a. Conduct tests as outlined for the Steam and steriliser at the start of each day on
each autoclave and steriliser as specified. Maintain a logbook of each cycle
and conduct weekly, quarterly, and yearly tests, faults, repairs, and
maintenance as outlined in the policies.
b. Adhere to the policies in the event of a failed cycle or faults in the autoclave.
Do not use autoclaves until faults are rectified.
Planned Maintenance
a. A planned maintenance programmer and provision for a breakdown service
should be drawn up with the suppliers at the time of purchase for each
autoclave, preferably by means of a fixed contract in writing (i.e. that is
legally binding).
b. A planned programmer for regular maintenance of all equipment, autoclaves,
air conditioning, and ventilation must be in place.
c. Records should be kept of maintenance.
d. Records must be kept of faults and their rectification.
e. Traceability System for Instrument/Equipment
f. There should be a traceability system to trace all reusable instruments.
g. The Theatre Superintendent is responsible for ensuring that there is adequate
documentation of the sterilisation cycle and of each autoclave together with
results on commissioning, re-commissioning following annual tests, and
details of maintenance, repairs etc.

CLEANING OF THEATRES
A clean environment is an essential background to good standards of hygiene and
asepsis. For guidance, this cleaning section is divided into cleaning for known
infected cases, daily routine and for regular cleaning.
Cleaning after Infected Patients in Theatre
a. Infected surgical cases should be placed last on the theatre list, and the theatre
nurse manager or the deputy informed of the case.
b. All unnecessary equipment should be removed from the theatre, if this is not
practical the equipment must be covered with disposable drapes to avoid the
risk of contamination.
c. On arrival at the theatre the patient is transferred directly into the operating theatre.
d. Standard precautions must be observed for all surgical patients.
e. The theatre requires a thorough terminal cleaning using a hypochlorite (e.g.
Klorsept 87) when the patient has left the theatre (for suspected bacterial
contamination please check with the infection control manual or CNS
Infection Control).
f. A hypochlorite solution i.e. Klorsept 87 (2 tablets/1 litre water) must be used
for cleaning after suspected blood borne virus contamination.
g. All clothes used for this cleaning purpose should be discarded after use.
h. The patient is recovered in the theatre environment and not transferred to the recovery
unit.
Daily Cleaning
a. Daily cleaning at beginning of list:
i. The theatre nursing staff cleans all flat surfaces with water and
detergent at the beginning and end of each shift. The nursing OIC/
manager for the theatre area is responsible for ensuring that this is
carried out.
b. Daily cleaning between operations:
i. Clean the theatre immediately if spillage occurs and after infected patients.
c. Daily cleaning at end of list:
i. The theatre nursing staff damp dust with water and detergent, all the
horizontal surfaces and any equipment in the theatre or in the set up
room, i.e. drip stands, the theatre operating table, window sills etc.
When completed, discard the clothes used.
ii. The theatre lighting is damp dusted at the end of each theatre list by the theatre
porters.
iii. The Household staff cleans with water and detergent after the last case
on the list. Use a floor buffer at the end of each day to scrub the floors.
iv. The Household staff wear the appropriate theatre attire i.e. theatre
scrub suits, theatre clogs and theatre hats. They should not wear
jewellery.
Cleaning Procedure
a. One of the household staff hover all the theatre suites, the corridors, the store-
room, the scrub area, and the set up area, the offices, the toilets, and the
recovery area. As many items of equipment as possible should be removed and
the floor space behind these areas cleaned.
b. The other contract household staff follows, and washes all of these surfaces
with a diluted solution of water and detergent. A swivel head mop with a
disposable cloth must be used. The water must be changed after each theatre is
cleaned and the water disposed of. All of the theatre floors are then buffed on a
weekly basis.
c. All of the scrub sinks and their splashbacks are cleaned with cream cleaner or
general purpose cleaner and rinsed with hot water.
 d. The toilets and the sluice are cleaned with a toilet cleaner.
e. The lids of all the waste bins inside and out should also be cleaned in the same
manner. All of the clothes used for cleaning should be disposed of on a daily
basis.
f. A damp dusting of all railings, and horizontal surfaces is carried out on a daily
basis. The fire hydrants should also be damp dusted in the same manner. All of
the brass handles on the doors are cleaned daily with brass and copper polish.
g. If the theatre is used after hours it is then cleaned first thing in the morning by
the household staff as per protocol.
Regular Cleaning of Theatre
a. The theatre walls are cleaned on a six-monthly basis by the household staff.
b. If there are obvious splashes these should be cleaned as they occur.
c. The theatre blinds are cleaned on a six-monthly basis by the Household staff.
d. Any cleaning that is required in the theatres of electrical appliances is also
carried out by the Technical Services Company.
Responsibility for Cleaning
a. The Household supervisor, the household staff, the theatre nurse managers, the theatre
nursing staff, The theatre auxiliary staff and the theatre porters are all responsible for the
implementation of the theatre cleaning guidelines. The cleaning schedules are drawn up by
the household supervisor, theatre superintendent and the Infection Control Team.

MANAGEMENT
Managers are responsible for ensuring that all staff are educated and aware of the
guidelines for theatre including sterilisation and reprocessing of equipment.
Managers are responsible for the implementation of the guidelines. A regular audit
is necessary.
Regular analysis of OT data is essential to monitor efficiency and correct
deficiency. OT efficiency is maximised by adherence to several basic
principles:
1. The number of OTs available should be matched to the number required to achieve good use.
2. Nurses and anesthesiologists rather than attending surgeons should control access to the
surgical schedule.
3. Surgeons should be allowed to follow themselves.
4. Block time should be provided to surgeons.
5. Systems should be established to enable and enforce efficient turnover between cases.
The distinction between efficiency and effectiveness is important. Measures of
effectiveness relate achievements to goals. Measures of efficiency relate
achievements to cost. The OT must be both efficient and effective.
Data must be both available and rapidly accessible. Automation of OT data is
critical and must integrate with the institutional health information system (HIS).
Hospital-wide data regarding work flow, staffing, referral patterns, and even
parking may yield useful information for improvements in OT efficacy and
efficiency.

OT SCHEDULING
OT scheduling systems should be designed to track all of the operational aspects
of the OT, including patients, resources, rooms, and staff. They should be fully
integrated into the institutional HIS while also interfacing with key elements
located in other parts of the hospital (or ambulatory centre), including finance,
materials management, electronic medical records, radiology, pathology, nursing,
the emergency room, labour and delivery, the blood bank, and the pharmacy. One
of the most important purposes of a good OT scheduling system is to allow
informed case substitution. Informed case substitution is critical because surgical
scheduling must contend with frequent last-minute case cancellations. Different
specialities differ widely in their scheduling practices. An understanding of these
practices allows the OT to use resources to maximum efficiency.
Information systems that predict and fill unexpected openings already exist in
the transportation and manufacturing industries. In the future, such
technology may be a useful adjunct to computerised OT scheduling.

QUALITY IMPROVEMENT
The key to increased OT efficiency is increased productivity. Standardisation of
internal procedures reduces bottlenecks. Computerization speeds the flow of
information so that continuous improvement of the system becomes possible.
Before the desired improvement can be implemented, the proposed change must
be tested quickly so that its effect can be determined, ideally through a
small-scale pilot implementation. This requires a collaborative effort, in which
the group involved in the change learns how to 'plan, do, check, and act.' Such
teams remain the key to a safe, efficient, and effective OT.
ACTUAL DEPARTMENT STUDY

Introduction
The Hospital is dedicated to be the best in patient care and customer service - from
the pursuit of this aim, stems the passion to excel. The modern state of the art 352
bedded Cancer care hospital, offers affordable and comprehensive healthcare
services/facilities to the patients under one roof at the BHU campus Sundar
bagiya, Varanasi.
The strength of the hospital comes from an eminent panel of medical
professionals, many of whom are leaders in their respective fields along with the
highest level of diagnostic services with the latest state of the art equipment
including double.

A view of general and Minimal Access Surgery

The department offers comprehensive and dedicated care for almost all Solid
cancers. The hospital has a team of well trained and experienced surgeons
providing specialist care for the Benign and Malignant Diseases in the following
DMGs
1. Head And Neck
2. Paediatric
3. Gastroenterology
4. Gynaecology
5. Urology
6. Neurology
7. Breast
8. Thoracic
9. Bone and Soft Tissue
10. Adult Hematolymphoid

Salient features of Operation theatre complex:-

​ State of the art operation theatres
​ Advance surgical instruments & equipment
​ Fully trained team comprising surgeons, anaesthetists, bariatric staff nurses,
paramedics, dieticians, physiotherapists and psychologists.
​ Pre-operative counselling with video visual sessions with the patients & relatives.
​ Interaction with operated patients.
​ Working hours:- Monday to Saturday: 8.00 am-5.00 pm
​ 24 hours emergency services.
ORGANOGRAM FOR OT COMPLEX

Location of operation theatre

Multi Speciality OT (MSOT) of this hospital is situated on the fourth floor away
from the traffic and in close proximity to Surgical S.I.C.U. , PAC clinics,
Radiological department (X-Ray) are easily accessible by lifts. Central Sterile
Supply Department (CSSD) is one floor below with Special Dumb-waiter access
(non-operational due to technical issue). OT is designed so as to make it suitable
and comfortable for administrators, surgeons, anaesthetists, surgical nurses, OT
technicians, and other concerned staff over long and tense working hours.
LAYOUT:-

The OT complex of this hospital comprises 9 OTs. Each OT is modular and can be
equipped for any Surgery from any of the DMG. There’s a sub-sterile area
between two OT‟s used as instrument Parking in the corridors.
There are three scrub bays in each corridor for six scrub bays, for a maximum of
nine OT‟s. There’s an entrance from the lift and staircase where one has to
cover/take off the shoes at the first step. Then one has to change to OT slippers
before entering the OT complex. The straight corridor leads to a pre-operative area
with a facility of three patient beds. The same passage is used to transport waste
from OT to outside. The pre-operative area is equipped with O2, suction, nurse call
 bell etc. and all facilities of CPR in case of emergency. From the preoperative
area, there‟s a way to the OT, a dirty utility room and soiled linen washing area.
The pre-operative area has a holding area also. From here the patient is transferred
to OT. Every OT has one entrance; one from the corridor for patients, same from
the sub sterile area for entry of sterile staff, doctors and anaesthetists. From here
the patient is transferred to the post-op area through the main corridor and then
stepped down to the recovery room. The same corridor is used for circulating
sterile instruments from CSSD to OT and clean instruments for sterilisation from
OT to CSSD.

OT Scheduling Guide

OT Monday Tuesday Wednesday Thursday Friday Saturday

OT 1 UGIT(LAP)/ UGIT(LAP)/ UGIT(LAP)/ UGIT(LAP)/ UGIT(LAP)/ UGIT(LAP)/

Breast Breast Breast Breast Breast Breast

OT 2 HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC
(LAP) (LAP) (LAP) (LAP) (LAP) (LAP)

OT 3 HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC HPB/ CRC
(LAP) (LAP) (LAP) (LAP) (LAP) (LAP)

OT 4 Uro /Gynae Uro /Gynae Uro /Gynae Uro /Gynae Uro /Gynae Uro /Gynae

OT 5 HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS

OT 6 HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS

OT 7 HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS HN/PRS/NS

OT 8
Pediatrics/ Pediatrics/ Pediatrics/BS Pediatrics/ Pediatrics/ Pediatrics
BST BST T BST BST /BST

DESIGN:
Different zones of OT complex
The location and flow of the patients, the staff and the materials from the three
broad groups is as follows in this hospital

Protective zone: It includes

 ​ Change rooms for all medical and paramedical staff with conveniences
​ Staff lockers and Toilets
​ Rooms for administrative staff
​ Transfer bay for patient, material & equipment
​
Clean zone: Connects protective zone to aseptic zone and has other areas also like
​ Control room
​ Stores & records
​ Pre-operative room
​ Stores & cleaner room
​ Equipment store room
​ Firefighting device room
​ Emergency exits
​ Service room for staff
​
Aseptic zone: Includes
​ Operation rooms (sterile)
​ Scrub bay
​
Disposal zone:
There was no separate disposal area. The waste removal area coincides
with the patient pathway.

Four zones in an O T complex, based on varying degrees of cleanliness. The

bacteriological count progressively diminishes from the outer to the inner zones
(operating area), and should have been maintained by a differential decreasing
positive pressure ventilation gradient from the inner zone to the outer zone. The
first three zones were well separated from each other, but the fourth zone did not
exist.
The recovery room or post-operative care room was just outside the OT complex,
which was accessible from both the Major OT corridor and Minor OT corridors

Subareas (excluding OT place)

Pre-operative check-in area or Holding area.
This is the first contact point of the patient with the OT complex. This area
of 730 sq. ft. had three beds with 6plug points for the facility of CPR, 1 O2 supply,
one suction point, nurse call bell, 1needle disposer, and 1 table and hand sanitiser
per bed. The circulation area, including the nurse station, was around 30-40% of
the total area. Ft. It is provided with a lavatory and a change room for the patient.
This area had a holding capacity for stretchers of 40 sq. ft. It is planned for
preoperative examination, IV line insertion, preparation, catheter/gastric tube
insertion, and the connection of monitors, O2 and suction lines.

Induction room(Anaesthesia room)

There was no separate anaesthesia room. Anaesthesia is given in the OT itself.
Recovery room
The area is 500sq. ft. was dedicated to a recovery room with one
nursing station and charting facility. It had a medication cabinet, hand
steriliser per bed, storage space for stretchers, clinical sink, bedpan
cleaning space, supplies and monitors, gas & suction outlets and ventilator.
An isolation room for infectious patients was planned in the ICU on the
other side of the OT complex.

Staff rooms
Separate area for men and women staff separated by their trades as well as
Donning and doffing room from street cloth to OT attire; lockers, shower and
lavatory were provided in protective zones. It had an entrance from the outside
with a shoe change before entering the OT complex. One washbasin, one western
closet (WC) and one lavatory were provided in each change room.
Senior Consultant Rooms
Junior consultants Rooms
Nurses’ Lounges
Housekeeping Lounges

Restrooms
Both male and female staff, as well as doctor change rooms, have adequate
space provided for sitting, resting and lockers.

Frozen Section:
Frozen section is provided in the OT complex. Samples for the frozen
section have to be sent to the laboratory for analysis by a transporter, but
currently, it was not in use.

Storeroom
Large Storerooms for various items like Sterle storage, Consumable storage etc were
provided for equipment storage and other purposes.
Empty or unused Major OTs were used as storage for other large items.

Scrub Bay:
Hand and elbow operated hot and cold water sources with minimum water splashing
are provided. There are three steel scrubs in every corridor. It has minimum travel
from scrub to OT to eliminate contamination chances.

Doors:
Main door to the OT complex has adequate width. The door of each
Major OT is an electrically operated sliding door. However, Minor OTs have
spring-loaded Flap Doors.

Floor:
The surface/flooring are smooth, slip-resistant, strong, impervious &
seamless with minimum joints or joint less conductive tiles. The floor area except
for storage and cabinet in a normal OT is approx 500 sq. ft.
Walls & Ceilings:
Walls are smoothly painted, seamless and Vinyl-covered up to 10 ft.
Covering of walls makes it water and stain proof, easy to clean and fire-resistant.
Collusion corners are not covered or covered. Light cream colour. Washable paint
is ideal in OT. A semi-matt wall surface which reflects less light than a high gloss
finish makes it less tiring to the eyes of the OT team.

Operation table:
One operation table per OT.

X-Ray illuminators:
There are X-ray film illuminators recessed into the wall having space for at least two
films in each OT.

Corridors:
Corridors are at least 2.50m width for easy movement of men, stretchers
& machines. No separate corridor is provided for dirty utility other than going into
OT.

Gas & suction (control, supply & emergency stock):

For all OTs, pre-operative area & post operative care units where patients
are retained, Oxygen gas and suction pipe are connected with the central facility
and Mobile Oxygen Cylinders are available in the SICU.

Water supply:
Provision for adequate & continuous water supply is in place.

Fire safety:
Safety in the workplace is essential. Fire extinguishers are planned in the
appropriate zone. Fire fighting systems water sprinklers with ionisation fire
detectors are planned. Fire exit routes are well defined and checked periodically.
Emergency exit route plan is well defined and communicated to all the employees,
and the same is mounted on the wall for use in case of emergency. Fire drills are
conducted periodically, and fire safety classes are taken periodically.

Ventilation:
Direction of air flow is from the operation theatre towards the main
entrance. Every OT has its separate Air Handling Unit (AHU). Efficient
ventilation controls temperature and humidity in OT, dilutes the contamination by
microorganisms and anaesthetic agents which helps in controlling infection.
Non recirculating systems cool the air as desired and convey it into the
operating room with ideally 20 air exchanges per hour. Air is then exhausted
outside. Anaesthetic agents in the OT air are also automatically removed. These
are thus ideal but expensive.
These include:
​ 20-30 air exchanges/hour.
​ Ultraclean laminar air flow - the filtered air delivery is 99% efficient in
removing particles more than 0.5mm.
​ Positive air pressure system 5 cm H2O from ceiling of OT downwards and
 outwards, to push out air from OT.
​ Relative humidity of 40-60% can be controlled through Control panels in each OT.
​ Temperature between 17o - 24oC. Temperature is regulated for the comfort of
OT personnel but for the requirement of patients, especially in paediatric,
geriatric, & neonatal cases etc by a central temperature control unit.
​ Air should not contain detectable clostridium spores of coagulated +ve
staphylococcus. Aerobic culture should not indicate ˃35 bacteria carrying
particles in 1m3 of air. During surgical operations the concentration of
bacterially - contaminated airborne particles in the operating theatre averaged
over any 5 minute period should not exceed 180 per m3 (5 per ft 3), and
special types of surgical operation, e.g., orthopaedic and transplantation
procedures, higher standards of air cleanliness must be ensured. Culture for
every OT is taken every week after the cleaning of OT. Reports should be
collected before the opening of OT on Monday. In case culture is positive, OT
is re-washed and cultures are again taken by microbiologists. Until then OT is
not used.
​
Air Filtration:
The AHU (Air Handling Unit) is an air purification unit and air filtration
unit. The necessary service panels are provided for servicing the filters, motors &
blowers. HEPA filters are provided in the AHU. The AHU of each OT is common
linked to air conditioning of other areas.

Pendant services:
Two ceiling pendants for pipeline services are designed; one for the
surgical team and one for the anaesthetist. Anaesthetic pendants are retractable
and have limited lateral movement and provide a shelf for monitoring equipment.
It has 2 oxygen, 1 nitrous oxide, 1 four bar pressure medical compressed air, 1
medical vacuum, 1 scavenging terminal outlet and four to eight electric sockets
per pendant.

Piped gases:
Two outlets for O2 and suction and one for N2O are a minimum in each OT.
Pipeline supply systems have provision to cut off from mainline if the problem
occurs anywhere along with the delivery hosing/tubing.

Electrical:
OT electrical network is connected to the emergency generators with an
automatic two-way changeover facility. Power back up for life-saving equipment
and OT light is provided. UPS of adequate capacity has been installed for OT
light, anaesthesia machine, monitors, cautery etc. until the backup generator takes
over.

Lighting:
Some natural daylight is preferred by the windows in OT. Wherever
possible, high-level windows are installed in the OT for a visual appreciation of
the 'outside world'. Five of the nine Major OTs have large 5ft x 5 ft windows for
allowing natural light to illuminate the table
General lighting:
To minimise eye fatigue, the ratio of the intensity of general room lighting
to that at the surgical site is 1:5. This contrast is maintained in corridors and scrub
areas, as well as in the room itself, to make the surgeon become accustomed to the
light before entering the sterile field. Adequate illumination with shadowless
lamps of 70,000-160,000 Lumens intensity (3000 Lux) is provided for assessing
patient colour and tissue visibility.

Communications:
There’s a landline phone set in the OT complex for communication.
Intercom to connect to the control desk, pathology and other parts of the hospital
is given by landline at the manager control desk and pre-op area. A code signal for
an emergency state such as cardiac arrest can be planned.

Hatch Box:
No hatch box is planned. Waste material is transported from the main OT
entrance and is transported outside by the patient way.

Control Panel:
No control panel is there in any OT except Ortho OT. But all the
parameters are recorded on different panels e.g. time on the wall clock, the
temperature on the thermometer etc.

Catering:
Food is banned in the OT complex’s except the Protective area. No Food
(lunch & tea) is served in the OT complex to staff, doctors and nurses. The staff is
allowed to eat and drink in the changing room.

Data management:
HMIS is used for indenting medicines, equipment, requests for
investigations etc. OT booking and scheduling is done manually and on paper and
then entered into the system. The doctor’s also use the HMIS to enter the surgery
nots using their given ID and Passwords from any of the terminals from around
the Hospital intranet.

Operating theatre satellite pharmacy:

No dedicated Pharmacy was available for the OT complex, the central
pharmacy store acted as the common point for all medical as well as surgical
purchases and the attendants sometimes bring their own medicines.
The nursing staff maintains a small emergency stock of about a week,
which is replenished from the new stock that patient attendants brings.

Statutory regulations:
The design and planning of an OT complex is in compliance with
mandatory regulations related to local administration such as Municipal
Corporation, Government, Pollution Control Board, Fire Safety Department,
Water supply and Drainage department etc.
Staffing:-
Operation theatre complex begins at 8:00am (sometimes sooner) and ends at
5:00pm. It consists of following man power. The work timings for various
staff of the OT are shown below.
​ OT Manager: Single Shift from 9:00 am to 5:00 pm
​ Nurses & Technician have 3 shifts 8:00 am to 4:00 pm
1:00 pm to 9:00 pm
9:00pm to 9:00am

Pre-Surgery patient flow

Post surgery patient flow
TECHNOLOGY IN OT COMPLEX OF HOSPITAL:-

S.NO. INSTRUMENT
1. Anaesthesia machine
2. Surgical stool
3. Neonatal warmer care system
4. Bp apparatus
5. Glucometer
6. X-ray view box
7. Patient warmer
8. Monitor
9. Cautery machine
10. Vaporizer
11. Suction machine
12. OT light
13. Operating interoscope
14. Phacoemulsification system
15 Light source
16 Camera console
17 OT table
18 Shadow less mobile OT lamp
19 Optical light source
20 Camera
21 Defibrillator
22 Harmonic scalpel
23 Incubator
24 Ultrasonic washer
25 Insufflators
26 Syringe pump
27 Shaver
28 Automated coagulation timer
29 Fluid warming system
30 Oven
31 Fibrillator
32 IABP
33 Glucometer
34 TRS drill
35 Battery charger for TRS drill
36 Bone cutting drilling and reaming system
37 TPS
38 Tourniquet
39 Neuro microscope
40 Constant current peripheral nerve stimulator
 41 Nerve stimulator for plexus anaesthesia
42 Arthroscopy pump
43 Pneumatic drill
44 Endourology instruments
45 Weighing scale

Recovery room inventory equipment list

S.no Name Of Items

1 Bed Remote With Iv Stand

2 Cardiac Table

3 Bed Locker

4 O2 Flow Metre

5 Suction Jar

6 Infusion Pump

7 Cardiac Monitor With Spo2

8 Ambu Bag With Mask

9 Glucometer

10 Stethoscope

11 Kidney Tray

12 Measuring Jar

13 Dressing Drum

14 Writing Pad

15 Plastic Scale

16 Aed Machine

17 Emergency Tray

18 Steel Stool

19 Stapler

20 Punch Machine

21 Telephone

22 Syringe Pump
23 Barcode Reader

24 Computer With Keyboard

25 Portable Suction Machine

26 Ampule Cutter

27 Manual Sphignometer

28 Laryngoscope A/P

29 Bouge A/P

30 Hot Water Bag

31 Gcd Tray

32 Tube Changes

33 Lancet

34 Bucket And Mug

35 Pneumatic Casted Container

36 Blanket

RECORDS MAINTAINED IN OT COMPLEX:-

1. OT booking register
2. OT in-out record register
3. Microbiology register
4. Crash cart checks register
5. Indent book
6. Linen cook
7. Daily consumption I.V fluids register
8. Pathology sample register
9. Cytology register
10. Anesthesia machine checklist book
11. Biomedical round register
12. Neuro inventory book
13. Uro inventory book
14. BST inventory register
15. Pediatric inventory register
16. Narcotic drug register
17. Blood book register OT room wise
18. Recovery inventory
19. Recovery death register
20. Staff attendance register
Cleaning checklist for OT

Replace All Extra Items

Cabinet Door Cleaning

Chair Stool, Step Stools

Computer

Electronic Communication Device

Suction Jar

Equipment Suction, Cautery

Equipement Cart

Floor

High Touch Surfaces (E.G Door Light Switches)

Linen Hamper

Instrument Trolly

I.V Stands

Or Light & Handle

Back OT Table

OR Table Including Controls, Mattress, Side Rails, Table Straps,Positioning, And

Transfer Device

Regulator

Suction Regulator Remove

Waste Bucket

Walls And Ceilings

Vents/Grills For Return Air

Supply Carts

Scrub Sink

Replaced All Consumables Items

 Cancellation reason for surgery

Reason
Month

Scan/consultant OT comorbidity Time COVID PAC Fitness

Availability Availability (HTN/DM/raised constraint
HGT/ low spO2 )

April 8 6 1 110 0 0
27 April-1april

March 5 8 2 79 0 0
31march-1march

February 0 5 0 123 0 1
28feb-1feb
January
31 jan- 1 jan 1 56 2 93 3 5
MAJOR OT
Gynaecol
Month Breast Head &Neck Gastrointestinal Pediatric ogy Urology Throacic Bone & Soft-tissue Adult Haemolymphoid Neuro total
Jan-21 41 74 31 2 9 9 4 17 0 0 187
Feb-21 53 100 46 8 18 17 3 17 0 0 262
Mar-2
1 48 97 60 6 23 9 5 22 0 0 270
Apr-21 48 100 33 2 11 8 4 5 0 2 213
May-2
1 52 92 40 11 17 11 3 19 0 3 248
Jun-21 38 101 73 14 18 8 10 21 0 2 285
Jul-21 49 120 77 7 19 16 6 20 0 6 320
Aug-2
1 32 106 83 13 33 18 5 27 2 1 320
Sep-21 54 109 70 17 39 24 8 22 0 11 354
Oct-21 95 119 64 18 17 26 3 19 0 3 364
Nov-2
1 84 95 56 18 24 17 8 22 0 5 329
Dec-21 76 99 75 18 26 26 4 22 0 9 355
Annua
lly 670 1212 708 134 254 189 63 233 2 42 3507
MINOR OT

Minor OT

Gynaecol
Month Breast Head &Neck Gastrointestinal Pediatric ogy Urology Throacic Bone & Soft-tissue Adult Haemolymphoid Neuro total
Jan-21 38 135 41 0 22 26 15 13 0 0 290
Feb-21 91 206 61 4 62 49 32 21 9 0 535
Mar-2
1 93 217 68 7 72 52 34 40 7 0 590
Apr-21 83 190 54 1 51 35 26 20 5 0 465
May-2
1 79 234 58 3 36 42 28 19 1 0 500
Jun-21 154 367 84 5 100 69 43 19 10 1 852
Jul-21 148 310 78 5 66 94 34 28 6 2 771
Aug-2
1 138 289 82 12 74 74 30 25 4 0 728
Sep-21 176 290 57 6 61 77 42 45 9 0 763
Oct-21 141 228 69 7 42 98 29 31 4 0 649
Nov-2
1 112 211 53 6 31 108 33 26 4 0 584
Dec-21 130 251 64 11 23 92 29 41 3 2 646
Annua
lly 1383 2928 769 67 640 816 375 328 62 5 7373
 Comparison Analysis Of OT Infrastructure Of Hospital With Ideal OT Infrastructure
IDEAL MPMMCC
● OT area free of traffic and with close 1)OT is close to S.I.C.U. , and Radiological
proximity to surgical wards, intensive department (X-Ray) and easily accessible
care units (ICU), accident and by lifts. CSSD is connected with a dumb
emergency department (A & E), waiter but not in use currentely.
Radiological department (X-Ray),
LOCATION 2)It is on the fourth floor, which provides
Sterilising and disinfecting units (or
OF less traffic and a comfortable environment
CSSD) and laboratory facilities.
OPERATION to the department
THEATRE
● Low rise buildings limited to two or
three storey‟s high are preferred
because of the maximum advantage of Location is appropriate for patient, doctors
natural light and ventilation. and staff flow.
● The location is planned on the first
floor.

DESIGN & STRUCTURE

ZONING
● Change rooms for all medical and ● Change rooms for all medical and
paramedical staff with conveniences paramedical staff with conveniences
● Staff lockers and Toilets ● Staff lockers and Toilets
● Rooms for administrative staff ● Rooms for administrative
● Stores & records staff
● Reception Control room ● Transfer bay for patient, material &
● Transfer bay for patient, material & equipment
equipment ● Postoperative recovery room
Protective ● Pre & post-operative rooms
zone ● Emergency lab (Frozen section)
● Classrooms and Conference rooms
Connects protective zone to aseptic zone and has ● Control room
other areas also like ● Stores & records
● I.C.U. and P.A.C.U.(Post ● Pre-operative room
anaesthesia care unit) ● Stores & cleaner room
● Stores & cleaner room ● Equipment store room
Clean zone ● Equipment store room ● Firefighting device room
● Maintenance workshop ● Emergency exits

● Kitchenette (pantry)
● Firefighting device room
● Emergency exits
● Service room for staff
● Close circuit TV control area
● Sterile supply storage area
● Flash steriliser area
● Plaster room if necessary
 ● Operation rooms (sterile) ● Operation rooms (sterile)
● Anaesthesia induction room ● Scrub areas
● Scrub areas
Aseptic zone

Disposal areas from each OR & corridor lead to There was no separate disposal area. The
disposal zone waste removal area coincides with the
Disposal zone ● Dirty utility storage patient pathway.

Four zones in an O T complex, based on

varying degrees of cleanliness. The
bacteriological count progressively
diminishes from the outer to the inner zones
(operating area). The first three zones are
well separated, but the fourth zone does not
exist at all. The recovery room and
post-operative care room were just
outside the OT complex, which was
accessible from both
inside and outside the OT complex

SUB AREAS IDEAL MPMMCC

This is important concerning maintaining This is the first contact point of the patient
privacy, for changing from street clothes to with the OT complex.
gown and providing lockers and lavatories for ● This area of 730 sq. ft. had 3 beds with
staff. Separate area for male and female staff. It 5plug points for the facility of CPR
should have direct entry from outside and before ● 1 O2 supply
entry to a clean area. ● 1 suction point
● nurse call bell
● 1needle disposer
● 1 table and hand sanitizer per bed.
The circulation area, including the nurse
Pre-operativ station. It is provided with a lavatory, a
e check in patient's change room, and a dirty utility
area room.
(reception) This area had a holding capacity for
stretchers of 40 sq. ft. It is planned for
preoperative examination, IV line insertion,
preparation, catheter/gastric tube insertion,
and the connection of monitors, O2 and
suction lines.
 This area should have a stretcher station of 80 sq. This area coincides with the
ft. with 4 ft. on sides. It is planned for pre-pre-operative area.
preoperative examination, IV line insertion,
preparation, catheter/gastric tube insertion,
connection of monitors, & shall have O2 and
suction lines. Facility for CPR should be
available in this area. Each bed should have 8-
10 electric points. Pre- operative area with
Holding area reception with separate designated area for
paediatric patients is desirable.
It should have all facilities as in OT, but there is There was no separate anaesthesia room.
controversy as to its need. One for each OT is Anaesthesia is given in the OT itself.
required; ideally, each is a duplicate of the other
Induction
on each floor.
room

are Preferably adjacent to the recovery room. Here, this area is the same as the recovery
Post These should contain a medication station, hand area adjacent to the minor OT’S and
anaesthetic washing station, nurse connects to the main OT corridor.
care station, and storage space.
units stretchers, supplies and monitors, equipment and
(PACU) gas storage area, suction outlets and ventilator.
Additionally 80 sq ft (7.43 sq m) for each patient
bed, clearance of 5 ft (1.5 m) between beds and 4
ft (1.22m) between patient bedsides and adjacent
wall should be planned.

One nursing station per recovery Here, this area is the same as the recovery
room with chatting facility. It should area adjacent to the minor OT’S and
contain a medication cabinet, hand steriliser connects to the main OT corridor.
per bed, storage space for stretchers, clinical
sink, bedpan cleaning space, supplies and
monitors, equipment and gas storage area, gas &
suction outlets and a ventilator.
Additionally 80 sq ft (7.43 sq m) for
each patient bed, clearance of 5 ft (1.5 m)
Recovery between beds and 4 ft (1.22m) between patient
room bed sides and adjacent wall should be planned.
Isolation room for infectious patients
should be planned.
● Entrance from outside ● Entrance from outside with a shoe
● Separate area for men and women dress CHANGE at first step and CLOTH
change from street cloth to OT attire change at the second step well before
● Lockers, shower and lavatory are essential entering OT complex.
amenities ● Separate change rooms for males
Staff room ● Rest room TV, etc. are desirable and
● One wash basin and
 one western closet (WC) should be provided Female doctors and staff members.
for 8-10 persons ● A Locker shower and lavatory were
● Showers and their number is a matter of provided.
local decision
● Inclusion of toilet facilities in changing
rooms is not
acceptable; they
should be located in an adjacent space.

Adequate space for changing and

resting too.

For staff nurse and anaesthesia staff - The office Storage rooms act as an office for the OT
should allow access to both unrestricted manager though the separate OT manager
and semi- restricted areas as frequent room was available.
Offices communication with the public is needed. The area allows communication with the
visitors and relatives without disturbing the
sterility of the complex.

Pleasant and quiet rest for staff should be Both male and female staff, as well as
arranged either as one large room for all grades doctor change rooms, have adequate space
of staff or as separate rooms; both have merits. given for sitting, resting and lockers.
Comfortable chairs and sofas, one writing table,
Rest rooms a book case etc., may be arranged.

Small laboratory with refrigerator for No laboratory but the frozen section is
Pathologist for Preparation and examination of provided in the OT complex. Samples for
Laboratory frozen the section should be frozen section have to be sent to laboratory
Arranged for Analysis by a transporter.

Since the staff cannot leave an OT complex No seminar room was available.
quickly, it is better to have a seminar room The hospital has separate seminar rooms
within the OT complex. Intra- departmental and conference halls
discussions, teaching and training sessions for
Seminar staff (with audio-visual aids) may be conducted
room here.
 This is designed to store large but less frequently A large storeroom was provided for
used equipment in the OT. There should be equipment storage and other purposes.
storage space for special equipment after
Store room
cleaning.

Within this area, the following are desirable Not available

● Temperatures 18o - 22o C,
● Humidity of 40%•- 50% is the aim.
● Air-conditioned with 10-12 air exchanges per
hour
● Storage of sterile drapes, sponges, gloves,
Theatre
gowns and other items ready to use.
Sterile
● Option to store from one side and
Supply Unit
removefrom the other side.
(TSSU)
● Safety inventory stock.

This is planned to be built within the restricted ● Here only the scrub bay was available
area. and was equipped with sensor and
● Elbow, knee operated or infrared sensor timing.
operated hot and cold water source with
minimum Water splashing is ideal.
● It is steel scrub essential to have non-slippery
flooring in this area.
Scrub room ● It should have minimum travel from scrub to
OT to eliminate contamination chances.
The main door to the OT complex has to be of Main door to the OT complex has
adequate width (1.2 to adequate width. The door of each OT is an
1.5 m). The doors of each OT should be electrically operated sliding door.
Doors spring-loaded flap type, but electrically operated
sliding doors are preferred as no air currents are
generated. All fittings in OT should be flush type
and made of steel.

The surface / flooring must be smooth, slip The surface flooring is smooth,
resistant, strong, impervious & seamless slip-resistant, strong, impervious &
with minimum joints (e.g. mosaic with copper seamless with minimum joints or joint less
plates for antistatic effect) or joint with less conductive tiles.
conductive tiles/terrazzo, linoleum etc. The
recommended minimum resistance is 1m Ohm
and maximum of 10m Ohms. Presently the need
for antistatic flooring has diminished as
flammable anaesthetic agents are no longer in
use.
Floor Recommended floor area except storage and
cabinet in a normal OT 360 sq. ft. (18ft * 20ft),
major OT 480 sq. ft. (24ft
* 20ft) & specialty OT is 600 sq. ft (24ft *25ft).
 Laminated polyester or smooth paint provides a Walls are smoothly painted, seamless and
seamless wall as tiles can break and epoxy paint vinyled covering t. Vinyl of walls makes it
can chip out. Walls should be water and stain water and stain proof, easy to clean and
proof, easy to clean and fire resistant. Collusion fire resistant. Collusion corners are not
corners to be covered with steel or aluminium covered or covered. Light cream colour
plates, colour of paint should allow reflection of semi-matt washable paint is ideal in OT.
light and yet soothing to eyes. Light colour (light
Wall & blue or green) washable paint will be ideal. A
Ceilings semi-matt wall surface reflects less light than
a highly gloss finish and is less tiring to the eyes
of the OT team. The Walls and ceilings must be
covered to each other and to the floor to decrease
the infection.

There should be X-ray film illuminators There are X-ray film illuminators recessed
preferably recessed into the wall having space into the wall having space for at least 2
X-Ray for at least two films. films in each OT.
illumina
tor
should not be less than 2.85 m width for easy Corridors are an easy movement of men,
movement of men, stretchers & machines. stretchers & machines which has an access
Separate corridors for dirty utility other than area of 2.5m at the narrowest. No separate
Corridors going into OT. corridor is provided for dirty utility other
than going into OT.
There‟s a need for a separate corridor for
dirty utility, waste and other waste
material to be transported out of OT.
For all OTs & areas where patients are retained, For all OTs, pre-operative area & post
Oxygen gas and suction pipe to be connected operative care units where patients are
with central facility and standby local facility retained, Oxygen gas and suction pipe are
Gas & Suction should also be available. connected with the central facility and a
standby local facility is also available.

Water supply Provision for adequate & continuous water Provision for adequate & continuous water
supply Besides the normal supply of available supply is in place.
water at the rate of 400 L per bed per day, a
separate reserve emergency overhead tank
should be provided for operation theatre. Elbow
taps have to be 10 cm above the wash basin..

Proper drainage system should be planned. Well planned drainage system is in

Drainage pipes above the ceiling of OT should place.
Drainage be avoided.
 Safety in the workplace is essential. Fire Fire extinguishers are planned in the
extinguishers have to be planned in the appropriate zone. Fire fighting systems
appropriate zone. Fire fighting systems water water sprinklers with ionisation fire
sprinklers or steam sprinklers can be planned detectors are planned. Fire exit routes
with ionisation and optical fire detectors. Fire are well defined and checked
exit routes must be well defined and checked periodically. Emergency exit route plan
periodically. is well defined and communicated to all
Fire safety the employees, and the same is mounted
on the wall for use in case of
emergency.

should be on the principle that the direction of Direction of airflow is from the
airflow is from the operation theatre towards operation theatre towards the main
the main entrance. There should be no entrance. Efficient ventilation
Ventilation interchange of air movements between one OT controls temperature and humidity in
and another. Efficient ventilation will control OT, dilute the contamination by
temperature and humidity in OT, dilute the micro-organisms and anaesthetic agents
contamination by micro-organisms and which helps in controlling infection.
anaesthetic agents.
There are two types of air conditioning Non-recirculating systems cool the air
systems: re- circulating and non-re- circulating. as desired and convey it into the
Non-re-circulating systems heat/cool the air as operating room with ideally 20 air
desired and convey it into the operating room exchanges per hour. Air is then
with ideally 20 air exchange per hour. Air is exhausted outside. These are thus ideal
then exhausted outside. Anaesthetic agents in but expensive.
the OT air are also automatically removed. These include
These are thus ideal but expensive. ● 20-30 air exchanges/hour.
The circulating system takes some or all of the ● Ultraclean laminar air flow - the
air, adjusts the filtered air delivery is 99% efficient
temperature and circulates air back to in removing particles more than
the room which. 0.5mm.
The broad ● Positive air pressure system 5 cm
recommendations include: H2O from ceiling of OT
Downwards and outwards, to push
● 20-30 air
out air from OT.
exchanges/hour for re-circulated air.
● Relative humidity of 40-60% is
● Only up to 80% re- circulated air to prevent
maintained.
build up of anaesthetic and other gases.
● Temperature between 20o - 24oC.
● Ultraclean laminar air flow - the filtered
● Culture for every OT is taken on
air delivery must be 90% efficient in
Saturday every week after the
removing particles more than 0.5mm.
cleaning of OT. Reports are
● Positive air pressure system 5 cm H2O
collected before the opening of OT
from ceiling of OT downwards and on Monday. In case culture is
outwards, to push out air from OT. positive, OT is re-washed and
cultures are again taken by a
microbiologist. Until then OT is not
used.
 ● Relative humidity of 40-60% to be
maintained.
● Temperature between 20o - 24oC. The
temperature should not be adjusted for the
comfort of OT personnel but for the
requirement of patients, especially in
paediatric, geriatric, burns, & neonatal
cases etc.
● Air should not contain detectable
clostridium spores of coagulated+ve
staphylococcus.
● Aerobic culture should not indicate
˃35 bacteria carrying particles in 1m3 of
air. During surgical operations, the
Concentration of bacterially -
contaminated airborne particles in the
operating theatre averaged over any 5
minute period should not exceed 180 per m3
(5 per ft 3), and special types of
surgical operation, e.g.,
orthopaedic and transplantation procedures,
higher standards of air cleanliness must be
ensured.

There is a requirement to maintain a positive Protocol for positive pressure

pressure differential maintenance is followed.
between OT and adjoining areas to prevent We were able to observe it in
outside air entry into OT. The minimum working condition.
Positive positive pressure recommended is 15 Pascal
pressure (0.05 inches of water) as per ISO 14644 Clean
Room Standard.
 The AHU (Air Handling Unit) must be an air The AHU of each OT is a common
purification unit and air filtration unit. There link to the air conditioning main
must be two sets of washable flange type AHU.
pre-filters of a capacity of 10 microns and
5 microns with aluminium/SS 304 frame
within the AHU as per NABH 2010
amendments. The necessary service
panels are to be provided for servicing the
filters, motors & blowers. HEPA filters may
be provided in the AHU. The AHU of each
OT should be a dedicated one and should not
be linked to the air conditioning of any other
Air filtration area. During the non-functional hours, the
AHU blower will be operational round the
clock (maybe without temperature control).
VFD devices may be used to conserve energy.

Two ceiling pendants for pipeline services Two ceiling pendants for pipeline
Pendant service should be designed; one for the surgical team services are designed; one for the
and one for the anaesthetist. Anaesthetic surgical team and one for the
pendants should be retractable and have anaesthetist. Anaesthetic pendants
limited lateral movement and provide a shelf are retractable and have limited
for monitoring equipment. It should have lateral movement and provide a shelf
oxygen, nitrous oxide, four bar pressure for monitoring equipment. It has
medical compressed air, medical vacuum, oxygen, nitrous oxide, four-bar
scavenging terminal outlets and at least four pressure medical compressed air,
electric sockets. medical vacuum, scavenging
terminal outlet and four to eight
electric sockets per pendant.

OT electrical networks need to be connected to Separate power backup facility are

the emergency generators with an automatic provided for OT which are of very
two way changeover facility. Power advanced technology.
back up for life-saving equipment and OT light
is necessary. UPS of adequate capacity should
be installed after considering OT light,
Emergen anaesthesia machine, monitors, cautery etc.
cy power until the backup generator takes over.
 Colour corrected fluorescent lamps to Some natural daylight is preferred by
produce even the windows in OT. At least one
illumination of at least high-level window is installed in the 5
Lighting MOT and in 3 minor OT for a visual
500 Lux at working height, with minimal glare
are preferred. appreciation of the outside world'.
Adequate illumination with shadow less lamps
of 70,000-120,000 To minimise eye fatigue, the ratio of
Lumen intensity (2000 Lux) is required for intensity of general room lighting to
assessing patient colour and tissue visibility. that at the surgical site is 1:5. This
White and contrast is maintained in corridors and
glistening/shiny body tissues need less light scrub areas, as well as in the room
than dark and dull tissues. itself, to make the surgeon become
Overhead light should be shadowless and accustomed to the light before
glare- less with 27,000 – 1, 27,000 Lux of light entering the sterile field. Adequate
(50000 to100000 Lux at the centre and at least illumination with shadow less lamps
15,000 Lux at the periphery). Lights of 70,000- 160,000 Lumens intensity
should be freely movable both in horizontal (2000 Lux) is provided for assessing
and vertical ranges. OT light should produce patient colour and tissue visibility.
blue-white colour of daylight at spectral energy
range of 50000 K (35000-67000
Kelvin acceptable). Halogen lights
produce less heat and hence are preferred. OT
light should not produce more than 25000
mw/cm2 of radiant energy.
Elimination of heat by diachronic reflectors
(cold mirrors) with heat absorbing reflectors or
filters should be available along with the
luminaries.

Telephones, intercom and code warning signals are There is a phone

desirable inside the OT. One hands-free phone per set in the OT complex for
OT and one exclusively for use of anaesthesia communication. Intercom
Communication personnel is desirable. to connect to the control desk,
Intercom to connect to control desk, pathology and pathology and other parts
other OTs as well as the use of paging receivers of the hospital are given by
(bleeps) is also ideal. A code signal, when activated, a landline at the manager
signals an emergency state such as cardiac arrest or the control desk.
need for immediate assistance.
 A hatch is provided in each OT to remove No hatch was available.
waste materials from the operation theatre to
the dirty linen area just adjacent to OT. Each
hatch is equipped with two doors and the doors
is electronically interlocked
i.e. the hatch is designed in such a way that
only one door is opened at one time. The UV
light is installed so that it is kept on while both
the doors are closed. This UV light
automatically turns off in case of opening of
Hatch box either of the doors. There are indicators on
both sides of the OT so that the door
open/close status can be monitored from both
ends.

Every OT must be equipped with a control Control panel is there in all OT, all the
panel. It indicates the following: parameters are recorded in the control
a. Time Day Clock panel installed in OT. Such as
b. Time Elapsed Clock temperature, humidity, and air pressure.
c. General Lighting System
d. Medical Gas Alarm Panel
e. Hands-Free Telephony set with
Control panel memory
f. Temperature and humidity indicator
with controller
g. HEPA filter status module
h. Room Pressure indicator

Basic services such as preparation of No facility is available from the

beverages and some snacks, and use of hospital side but staff can have their
vending machines may be planned, personal eateries in the staff lounge.
augmented by the provision of hot and cold
meals from the main hospital kitchen.
Catering

Customised network connections should be HMIS is used for all the required
Data put in place or a conduit facilities such as registration, patient
management should be planned. A well-designed system record, online scheduling pharmacy
can provide automated indent etc.
records, materials
management, quality
improvement and assessment, laboratory
tracking, etc. The software for OT
management is costly and hospitals are
generally slow to adapt to changes.
Customised OT software can be designed for
individual needs.
 Access to the OT areas and outside should be No facility is available but a
possible. It should have a refrigerator for blood temporary stock of essential
storage and a warmer space for drug storage, medication is there in the case for
locked containers for controlled substances, a emergency.
computer, a desk area for paperwork and
pharmaceutical literature. Special kits for
specific surgeries may also be arranged. The
Pharmacy pharmacy may open for 1 to 24 hours based on
need but it is desirable that an after hour system
is planned.

Effective Utilisation of Theatre Time for Elective Surgery

1. It is important that all lists begin and end at times agreed and adhered to by all theatre users.
The advantages of this include:-
● Anaesthetists will have time to visit patients preoperatively before the agreed start of the
operating list.
● Timely preparation of patients for theatre.
● Increased ability to match staff to workload in theatres and recovery units.
● Staff can take meal breaks, reducing fatigue
● A reducing the need for overtime
● A prompt start in the afternoon with less chance of overrunning into the evening.
● Realistic scheduling of meetings, professional and other commitments.
2. The start of a theatre session is defined as,when the anaesthetist takes charge of the (first)
patient in preparation for anaesthesia and the end as,when the anaesthetist has finished
handing the (last) patient over to recovery staff and is free to start another task.
3. It is important that lists are scheduled in such a way that surgical and anaesthetic time is
synchronised. For example, infectious patients should be put on the end of the list to avoid
delays caused by contamination of the theatre; patients requiring only local anaesthesia
administered by the surgeon and no monitoring by an anaesthetist, at the beginning or the end
of the list. Pooling of such patients onto one list may enable the anaesthetist to be reallocated.
4. Realistic scheduling of procedures will avoid the cancellation of operations. Potentially long
operations should be identified and planned in such a way that it is possible to complete them
within the time available.
5. Computerised collection of data on operating times of individual surgeons and anaesthetists
for different procedures makes it relatively easy to predict probable overruns and
automatically flag this up to the medical secretary or scheduling clerk who can alert the
surgeon to rearrange the list.
6. Operating lists may be overrun due to unforeseen circumstances; dealing with this should not
involve the use of the emergency team.
7. All-day lists using the same theatre team, including surgeon and anaesthetist can be
particularly efficient and should be encouraged. There should be provision for meal and
 comfort breaks, however, and overall operating time should not be in excess of the number of
planned sessions.

8. Day surgery lists increase overall efficiency and usually have a high utilisation time.
Effective utilisation is increased by the provision of purpose-built self-contained and
autonomous premises.
9. It is both unreasonable and unfair to rely on the anaesthetist to instigate the curtailment of
overrunning lists by the cancellation of scheduled cases. A culture of good timekeeping
within the operating theatre encouraged and enforced by the theatre manager will facilitate
such decisions.

Cancellation/Postponement of Surgery
It is deeply trouble to a patient and hospital management to have an operation postponed on the
day of surgery and economically wasteful both for the patient and the hospital. Many
cancellations could be avoided with good pre- operative assessment, effective bed management
and better communication between patient and hospital, and between staff groups within the
hospital. The management team should undertake a regular review of all cancellations.
Dealing with the patient whose operation has to be postponed for non-clinical reasons:
1. Local procedures should be developed for dealing with the cancellation of surgery at short
notice. A senior member of the team should visit the patient as soon as possible after the
decision is made and offer an appropriate apology and an explanation. 'The patient must be
offered another binding date within a maximum of the next 28 days.
2. There should be full documentation of the reasons for cancellation, the explanation given and
any action taken in the patient‟s record.

Dealing with the patient whose operation is cancelled for clinical reasons:
1. It may be necessary to cancel an operation because of a new or inadequately treated medical
condition, or exacerbation of chronic illness.
2. Most pre-existing medical conditions should be detected and treated following screening
and/or in the pre-operative assessment visit, providing pre-assessment is carried out within
two weeks of admission.
3. In the event of the system failing, the patient deserves an appropriate apology and an explanation.
4. It is unacceptable to cancel surgery without arranging suitable referral or treatment. It is the
responsibility of the clinician to document exactly what investigations and/or treatment are
required and the responsibility of the pre-operative assessment team to ensure that this is
carried out.

Unplanned returns to the OT:-

Unplanned returns to the OT occur across a broad spectrum of general surgical procedures and
carry significant implications. Because they most often reflect problems related to the procedure
itself, reoperation rates may be useful for monitoring quality across hospitals and for identifying
opportunities for quality improvement locally. A very low rate of unplanned return (approx. 1%)
is a very good indicator of the efficient team of surgeons in the hospital and the quality of care
given pre- operative, intraoperative and postoperative too.
Final Conclusion and Recommendations after brief discussion with AMS