Organization and Management of Operation Theatre - Dr Sheetal Yadav

1. Management and Organization
of OPERATION THEATRE
Dr. Sheetal Yadav

2.  OT is that specialized facility of the hospital
where life saving or life improving procedures
are carried out on human body by invasive
methods under strict aseptic conditions in a
controlled environment by specially trained
personnel to promote healing and cure with
maximum safety, comfort and economy.
 It is a room in a hospital equipped for the
performance of surgical operations under
complete aseptic conditions.

3. 1. Emergency Surgeries
2. Elective Surgeries
3. Major Surgeries
4. Minor Surgeries
5. Intermediate Surgeries
6. Ambulatory / Daycare Surgeries
Types of Operations / Surgeries

4. Emergency operation: It must be carried out as
soon as possible after the diagnosis has been made
and the patient is prepared for operation in proper
way.
Elective operation: It is carried out some time
after the diagnosis has been made and when they
suit best for the patient and the hospital

5. Some Advances
 Microsurgery: surgery performed under magnification.
Used most commonly for anastomosis.
 Cryosurgery: surgery which is based on use of liquid
nitrogen at a very low temperature (based on cryoablation)
 Laproscopic Surgery: its use requires minimal incision
and minimal post operative care and stay in the hospital.
 Advantages: faster recovery, lesser pain and less scarring.
 Bio-medical Laser : in this, there is absence of physical
contact and the cutting is without mechanical pressure
(scalpel) which makes the operation non-traumatic. (Light
amplification by simulated emission of radiation)

6. Objectives
 Promote high standard of asepsis.
 Ensure maximum standard of safety for
patient and staff from environmental,
anaesthetic, radiological equipment and post
operative hazards
 Ensure optimum utilization of operation
theatre and its staff.
 Ensure optimum conditions of work for
surgical and supporting team
 Ensure comfortable treatment of patients.

7. OT COMPLEX
 Operation Theatre: where surgical operations and
certain diagnostic procedures are carried out.
 Operating suite and Theatre suite- O.T with
ancillary areas, anaesthesia room, room for
instrument trolleys, a disposal room, a scrubbing &
gowning area.
 Operation Theatre Complex. : An unit consisting of
one or more operating suites with ancillary
accommodation for the common use such as
changing room, rest room, receptions, transfer, pre-
operative area, post-operative area and circulating
space.

8. LOCATION OF OT
 Accessibility to ICU, Post surgical wards, CSSD,
Emergency and Blood Bank
 Access to lifts
 Away from internal & external traffic flow
 Future expansion
 Ideally located on Top Floor, dust free environment &
reduced bacterial load in area
 Quiet environment: No Noise, Dust, Wind, Heat and
Direct Sun light Problem
 Least scope of cross infection

9. Number of OTs
Depends upon -
 No. of Surgical beds
 No. of surgeons
 Scheduling of operations
 Quantum of emergency cases
 Out patient surgery
 Type of hospital
 Type of specialities
 Number and nature of elective and emergency surgery
anticipated
 Number of operations per day
 Expected ALOS of surgical patients
 Expected turn over interval in OT
 Estimated time for cleaning between operations
 Time allowed for staff breaks
 Amount of time reserved for emergency use

10. Number of OT ROOMS
 Putsep recommends - Thumb role of 0.1 operations
per bed/day is recommended - (Putsep).
 No. of ORs should be 5% of total No. of surgical
beds.
No. of opn rooms needed: No.of opns
/day
Average capacity of
operating room
Total number of Surgeries /day = N x BOR x
365
ALOS x WD x
100

11. The Planning Commission Expert Committee
Recommendations:
a) 50 Beds: 1 Major and no Minor operating room
b) 50 to 100 Beds: 1 Major and 1 Minor operating rooms.
c) 300 Beds: 3 Major and 1 Minor operating rooms.
d) 500 Beds: 5 Major and 2 Minor operating rooms
e) 750 Beds: 8 Major and 2 Minor operating rooms.
f) 1000 Beds: 10 Major and 2 Minor operating rooms.
Americans: 1 OT for 25 beds.
Europeans: 1 OT for 50 beds.

12. DESIGN CONSIDERATIONS

13.  Basic activities involved in the Act of Surgery
 Supporting Procedures
 Administrative Procedure
 Clerical Procedures
 Housekeeping Procedures

14. Basic activities involved in surgery
 Reception and identification
of patient
 Patient / Attendant’s Consent
 Pre-operating supervision of
patient
 Depilation of patient
 Transfer of patient to OT
table
 Administration of
Anaesthesia
 Intubation
 Positioning
area
 Draping of patient
 Wound sewn up and
dressed
 Drapes removed and
bagged
 Extubation
 Transfer of patients from
operation table to trolley or
bed to recovery room
 Post operative supervision of
patient

15. Supportive procedures
 Staff changing to operating room garments
and shoes
 Putting on cap, gloves and apron
 Aseptic washing of hands
 Gowning
 Laying out, checking and re-checking the no.
of instruments

16. Administrative procedures
 Preparation of operation lists, duty schedules
 Requisition of patient
 Notification to wards of time for patient transport to
and fro the surgical department
 Distribution of messages
 Requisition of records, equipment and material
 Contacts with other departments, lab, workshops and
supplies
 Ascertain availability of doctors and supporting staff

17. Clerical procedures
 Preparation of operation records
 Preparation of operation room records
 Filing
 Statistical interpretation of operation room
records
Housekeeping procedures
 Collection of used instruments
 Collection of used materials and soiled surgical
instruments, dressings and underlays
 Cleaning of operation rooms and other areas in
the surgical department
 Disposal or incineration of refuse

18. ZONING in OTs
 Minimises risk of hospital infection in the operating
room
 Minimises unproductive movement of staff, supplies
and patients
 Ensures smooth work flow
 Reduces hazards in the operation suites
 Ensures proper positioning of the equipment
 Ensures optimum utilization of the operation suites
 There should be movement from one clean area to
another without having to pass through dirty areas.
 Soiled linen & wastes should be removed without
passing through highly clean areas.

19. Types of ZONES
 Protective Zone
 Clean Zone
 Sterile Zone
 Disposal Zone

20. Protective Zone
This includes entrance for patients, staff & supplies where
normal hospital standards of cleanliness applies & where
normal everyday clothes are worn.
 Reception
 Waiting room
 Changing room
 Store room
 Autoclave/TSSU
 Trolley Bay
 Control area of electricity

21. Clean Zone
This is the main area of the OT where all patients, staff
should undergo complete changing of clothes before
entering.
 Pre-operating room
 Recovery room
 Theatre work room
 Plaster room
 X-ray unit with dark room
 Sisters work room
 Staff work room
 Anaesthesia Store

22. Sterile / Aseptic Zone
This is the inner zone, where conditions are as near
sterile as possible. It applies to 2 rooms in a suite, the
theatre & theatre supply room. All staffs who might
handle the exposed instruments, must be scrubbed &
gowned.
 Operating Room
 Scrub Room
 Anaesthesia Room
 Instant instrument sterilization
 Instrument trolley area

23. Disposal Zone
This is where all exposed instruments (used or unused),
pathological specimens, lotions, suction jars, soiled linen
are passed from the theatre to disposal corridor &
returned for changing, sterilizing or any other necessary
procedure.
 Dirty wash up room
 Disposal Corridor
 Janitor’s Closet

24. Maintenance of OT and Aseptic
Standards

25. Maintenance of OT and Aseptic Standard
 One day in a week should be given for maintenance
of OT
 Swabs should be taken away from areas of OT
 Air-conditioning of OT should be checked regularly
 Filters should be properly maintained
 Spare bulbs should be kept in stock in OT department
 Adequate pressure should be maintained all the time
 Operating staff having infection should not be
permitted in OT
 Sterilisation of mobile equipment and operation table
should be ensured

26. POLICY ON CLEANING TECHNIQUE
 Preparatory Cleaning
 Operative Cleaning
 Intermediate Cleaning
 Terminal Cleaning

27. Preparatory Cleaning
 An hour before the beginning of the first
operation, a damp dusting with detergent or
disinfectant.
• Every morning OT is to be cleaned and
carbolized before starting of first case.
• All equipment OT tables, walls and floors have to
be cleaned and carbolized using 1% hypochlorite
solution. Check the concentration of available
hypochlorite, dilute accordingly.
 Example: Hypochlorite solution (available 4%
solution of sodium hypochlorite: dilute 1 in 4, to
250ml of 4% sodium hypochlorite add 750ml of

28. Operative Cleaning
 Areas contaminated by organic debris such as
blood & sputum, during the operation should
receive immediate cleaning. An in use dilution
of phenolic detergent germicide or other broad
operation germicide.

29. Intermediate Cleaning
 General clean up OT room for the next patient’s
instruments should be placed directly into perforated
trays for processing in a washer sterilizer, or may be
covered for transportation to the CSSD for terminal
sterilization.
 Furniture - cleaned with germicide
 Floor - wet vacuuming is the method of choice. If wet
mop is used, then a fresh one must be used each time
& no buckets at all.
• Collect waste materials, sharps, sponges and soiled
linen separately in colour coded bags according to
hospital waste disposal protocol.
• After removing the blood from the floor and other
spillage areas (as per hospital protocol) disinfect and

30. Terminal Cleaning
 At the end of day’s schedule a vigorous cleaning of the OT
table etc.
• Clean the O.T. area, after removing all the used material &
other items to be discarded.
• Mop with 1% sodium hypochloride solution , dilute as
mentioned earlier.
• After mopping the floor carbolize the OT walls, floor,
tabletops and equipments except where contraindicated
(marked “X”: in red).
• Bacilocid spray
 Fumigation: Fumigation in gas proof enclosure with 40%
formula for 8 hours and then neutralized with a gauge

31. FUMIGATION
Area that requires fumigation:
•Operation Theatre complex and Intensive Care areas
•Cardiac Cath Lab, Endoscopy Lab, Bronchoscopy Lab
•Special cases as advised by Infection Control Committee
Method Of Fumigation
By OT care machine using formaldehyde solution
Solution used:
Formalin 40% - 500ml clean water (for Thousand cubic
/feet)Before Fumigation
1) Remove all articles likely to be damaged by fumigation
2) Remove any containers with Hypo-chlorite solutions
3) Wash OT properly
4) Fumigate

32. METHOD
•Send note to maintenance to TURN A/c off (Very important)
•Check OT care machine
•Put the solution in OT care machine (Formalin 40% 500 ml,
water 100 ml)
•Put the machine inside the OT (wire and switch outside the
OT)
•Seal the OT properly
•Put on the machine for ½ hour.
•Keep the OT sealed for 10-12 hours
•Turn the A/c on and exhaust the fumes
•Remaining fumes if any may be neutralized with ammonia
•Cleaning, carbolization & bacilloacid spray should be carried

33. Cleaning of entire OT on weekends
(Saturday Evening)
•Remove all equipment, OT tables, anesthesia machine,
and heart lung machine, Ventilator etc.
•Wash each OT thoroughly with detergent and water
paying special attention to the corner of OTs.
•Dry the OT and walls with dry duster and carbolize
properly with 1% hypochloride
•Carbolize all the equipment and place them properly in
the OT.
•Close the OT and to not allow anybody to enter unless
there is a surgical case.

34. Planning of OTs

35. General Considerations
 OT unit needs specialised services, such as piped
suction and medical gases, electric supply, heating,
air-conditioning, ventilation and efficient lift services.
OT requires more height (above 4.2 meters)
Dedicated (AHU) Air Handling Unit for 100% fresh
air for each OT.
 Minimum area for general operating room is 40 sq
m
 Cardio-vascular, Neuro-surgery, Orthopeadic and
other procedures which require additional
equipment needs minimum area of 60 sq m.

36. Grouping of Operation Theatres.
1. Maximum flexibility in use
2. Easy expansion
3. Simplifies theatre staffing
4. Easy & economical maintenance
5. Improved cleaning and better sterilization
6. Minimises infection & cross-infection
7. Minimizes cancellation of operating schedule
8. Improves utilisation of operating suites
9. Flexibility in allocation of operating suites

37. OT CONSTRUCTION
 Floor
Flooring - Vinyl floors, Antistatic to minimize danger of
static electricity
Earthing for electrical installation - laying flat copper strips 6ft
deep in the floor.
Minimum conductivity-1ohm, maximum-10 ohm.
Floor corners and edges rounded to facilitate cleaning .
 Walls - plain, free of glare, easily cleaned & impervious
 Doors: sliding doors, wide for passage of pt trolleys &
equipments .
 Ceiling: False roofing not preferred.
 Paint colour: Light & non reflecting

38. Light
 Most important component of OT
 Central field of operation should be 2000-3000 candela
per sqm.
 The floor around surgical table should be 200-300
candela per sqm and walls 300-500 candela per m sq.
 The colour composition should be such that
anaesthestist will be able to see the colour changes of
the patient skin.
 General light luminance may vary from 500 lux to 2000
lux
 Operating Light:
• Easy maintainability repair and maintenance
• Fitting be directly flexible
• Control accurate and quick
• Shadowless
• Heat radiation small

39. Power Outlet
 OT require electro-medical equipment for life support
and for performing surgery. For using these
equipments power outlets at convenient location are
needed.
 Sparkless electrical outlets at least 5 ft. from the floor,
.
 4 power outlet should be provided on every wall of OT
 Near Anaesthetist, 6 power outlets should be provided
 All these outlets should be on UPS
 Power outlet should also be located at one meter
above the floor level.

40. Air-conditioning and Ventilation
 Construction of OT should be made in a way that it could be
fitted with modern air-conditioning system.
 Height of 4.2 m is needed in OT, coz air-conditioning duct,
laminar flow and high efficiency filter takes 1 m space above
false ceiling.
 Grill for return air-duct should be located 30 cm above floor
level. Minimum of 2 return ducts should be provided in the OT
 Vertical laminar flow is preferred in OT, which is the most
advanced A/c technology today, which is a unidirectional air
flow through high efficiency particulate filters.
• The laminar flow system maintains an air change of 10-
20/hour in the OT & supplies 100% fresh filtered air through
HEPA filers which flows in 2 directions in high velocity,
vertically down wards or horizontally.
 Positive pressure in the OT room should be maintained to
eliminate risk of infection.
0

41. Scrub Station
 It is provided near the entry room of the OT
 One scrub room per Operation room should be
provided.
 The working height of scrub station is 96 cm with
water source 10 cm higher
 If possible gowning area should also be provided
 It is better to have photo electric cell operated wash
basin, so that there is no body contact

42. PERSONNEL MANAGEMENT IN OTs
 By convention, OTs all over the world are under the overall
charge of the anaesthesiologist.
 OT is a area which needs certain qualities from its personnel
such as, stamina for long standing hours, emotional stability
to cope with the stressful environment, good team spirit,
stable health and respect the patient’s right for privacy.
 Surgeon
 Anaesthetist
 Assistant
 Scrub nurse
 Circulating nurse
 Anaesthetist nurse
Further there are assistants to help: Radiographer, Technicians,
Disposal staff

43. Equipments
Mobile Equipments Fixed Equipments
 Anaesthetic apparatus
 Anaesthetic table
 X-ray equipment
 Diathermy equipment
 Electrical suction
apparatus
 Pulse monitor
 Ventilator
 Monitor-cum-
defribrilator
 Heart lung machine
 Operating Table
 Wall intercom station, nurse
call system, wall clock
 Tele. at circulation nurse work
area
 Film illuminator at foot end of
operating table
 Sx light, ceiling mounted over
the centre of the operating
table.
 Video cameras for observation
on ceiling tracks.

44. INSTRUMENT STERILIZING POLICY
 CSSD - can be located anywhere in the hospital to
facilitate utilization by other areas , preferably close to
OT as they are the main user.
 TSSU -This system is seldom used.
Located within the operating deptt. to facilitate
maximum utilization, flow of instruments, supervision
of sterilization by nursing staff. However, on economic
& efficiency grounds 2 sterilizing units in one hosp is
difficult.
 Sterilization unit between 2 OTs -This is practiced in
small setup, where the autoclave is kept between 2
OT suites.

45. Computerization in OT
 Modern OT is incomplete without complete
computerization.
 HIS – OT Module
 Computerization has become a necessity for the
following :
- Maintaining pts records so as to avoid stacks of
record keeping.
- For telecommunication with the various wards &
support areas so as to fasten the supporting works in
OT
- For teaching purposes the functions in the OT can be
directly telecasted in to the students room or doctors
room so that doctor can visualize the procedure sitting
outside the OT room.

46. UTILISATION OF
OPERATION THEATRE

48. Operating list management
• Close communication and coordination between pre-op area
and theatre using agreed procedures is essential
• A nominated person should liaise with wards and transport
staff from theatres
• A suitable holding area staffed and equipped will assist with
smooth flow
• Agreement should be made for preparation and transport of
patients to and from theatres
• Policies on fasting, anticoagulation, shaving, dentures,
jewellery, appropriate underwear and removal of make-up
should be developed
• Units should agree the level of training needed to escort
patients to and from theatres
• A documented system of handover and identification of
patient should be in place

49. Effective use of theatre time
 It is important that all theatre lists start and finish at
the agreed time.
 Realistic scheduling of theatres will prevent
cancellations
 All day theatre lists have proven efficient, within the
synchronising of surgical and anaesthetic time and
staffing
 Good time keeping principles should be adopted
and monitored by the theatre management team
 Pro-active re-allocation of cancelled theatre lists.

50. SCHEDULING
 The realistic building of theatre lists start in
processes outside of theatre environment, essential
validation of how ‘lists’ are made needs to be
undertaken to maintain effective and efficient
operating theatres.
 Agreement can be made on average time per
procedure to enable effective booking of theatre
lists.
 Average time per operation can be agreed and
used to assist building theatre templates.

54. During the theatre allocated time, a theatre may be in
one of the following states:
 A patient undergoing an operating procedure
 A patient may be administered anaesthesia
 The theatre being cleaned or set up
 The theatre may be unused
The theatre could be unused due to one of the
following reasons:
 Delay in starting the first case
 Delay between cases

55. Operation Theatre Utilisation
 The efficiency of an operating theatre is commonly
expressed in terms of theatre utilisation, and is a
frequently quoted performance indicator.
 There is no universally accepted or consistent descriptor
of theatre utilisation. Therefore benchmarking and
improving theatre utilisation and resource allocation
within the health system is extremely difficult.
 Theatre utilisation = Theatre used time
Theatre allocated time
The theatre allocated time is a period for which the
theatre is adequately staffed and scheduled for given
service or clinician.

56. Improving theatre utilization is a key performance
target for hospital in terms of ensuring :
 Timely surgical intervention for patients.
 Reduce length of stay.
 Increase activity and income.
 Improved productivity and value for money from
the services provided.

57. FACTS…..
 OTs generate 42% of a hospital’s revenue.
 The average OR runs at only 68% capacity.
 The average OR starts on time only 27% of time.
 The average patient out to patient in time is 31.5
minutes (standard- 15 minutes)
 O.Ts are choked by paperwork.
(nurses fill in average of 15 pieces of paper per
patient.)

58. KEY PERFORMANE INDICATORS
 O.T. Utilization: depends upon
 No. of cases canceled or delayed
 Doctor or Anesthetist availability
 Patient canceling the process
 Lab /radiology reports not available on time
 Bills /advances not paid
 Consent not taken
 CSSD not functioning or not making instruments available on
time
 O.T. equipments non functioning
 First procedure prolonged
 Attendants not properly communicated about the procedure
 Clean-up & set-up time
 Performance data of surgeon
 Number of Minor and Major cases

59. Studies on
OT
Utilization
Preoperative phase
 Delay in assembling of OT team
in the OT complex (sequencing)
- Due to different OPD hours
- Due to heavy OPD.
- Tight scheduling of doctors.
 Delay in supplies.
Operative phase
 Sequencing of equipment
 Standardization of procedures.
 Specific surgeons for specific
procedures.
 Trained staff.
Post operative phase
 OT preparation
 Availability of beds in ICU and
 Time motion
study low /on-
time starts
 Process flow
charts
 Root cause
analysis

60. Studies on Equipment Management
USE COEEFICIENT=M/N*100
M= Maximun No of Hours the Equipment is used in a day
N =Maximum No of Hours The Equipment can be used in a
day
Down time analysis to reduce down time.
CHECKLIST FOR DOWNTIME MANAGEMENT
 S.No.
 Name of equipment
 Warranty period
 Date of breakdown
 Date of repair
 Cost incurred

61. HISTORY SHEET
1. Name of equipment
2: Date of purchase
3: Cost of equipment
4: Name and address of supplier
5: Date of purchase
6: Date of installation
7: Department where installed
8: Environmental control*
9: Spare parts inventory
10: Technical manual/circuit diagrams/literature
11: After sales service arrangement
12: Guarantee period
13: Warranty period
14: Life of equipment
15: Depreciation per year
16: Charges of tests**
17: Use coefficient***
18: Down time up time
19: Cost of maintenance
20: Date of condemnation
21: Date of replacement
(*) Proper environment control in terms of temperature, lighting and ventilation should be
ensured and recorded, whenever applicable.
(**)whenever applicable.
(***) should be applied to assess the utilization of equipment.
RESOURCE
UTILIZATION
(MACHINE)

62. Stores Audit and Analysis
STORES AND SUPPLY CHAIN MANAGEMENT
 Standard products selection /usage
 Proper forecasting and need assessment (bulk
purchases )
 Limited no of vendors ( purchases discounts, Quality
assured)
 Reorder levels estimation
 Proper usage analysis
 Just in time