OT ATTIRE

Surgical attire is refers to the clean and sterile clothing worn in the OT, to provide effective barriers that prevent the dissemination of microorganisms to patients and protect personnel from blood and body substances of patients.

OT attire is a part of aseptic environmental control in OT. It ensures protective barrier for the patient's undergoing surgery as well as for the personnel during the surgical procedures.

PURPOSES

• The purpose of the OT attire is –
  • To provide protection from exposure of infection to the patient & surgical team member.
  • To prevent transmission of microorganism from hazardous material such as blood or body substances of the patient to the surgical team member.
  • To prevent from infection such as cold, cough, skin infection from the surgical team member may also be transmitted to the patient.

GENERAL CONSIDERATIONS FOR APPROPRIATE ATTIRE

• The OT Department should have a specific written policies and procedures for proper attire to be worn within the semi-restricted and restricted areas of the OT suite.
• Dressing rooms should be located in the unrestricted area adjacent to the semi-restricted area of the OT suite.
• The people in street clothes after arrival in the OT should not be allowed to move beyond unrestricted zone in the OT.
• Only approved, freshly laundered attire intended for use in the OT is worn within the semi-restricted and restricted areas.
• The OT attire policy should be enforced for all professionals, nonprofessional personnel and visitors entering the OR suite.
• A clean and fresh attire is donned each time on arrival in the OT suite and as necessary at other times if the attire becomes wet or grossly soiled.
• An adequate supply of clean scrub suits should always be available in the OT suite and laundered daily.
• The OT attire is to be worn with in the OT only. One should not go outside the OT in the attire.
• Before leaving the OT suit, everyone should change the OT attire and wear street clothes
• The OT attire is not to be carried done because there is risk of contamination to household articles & to the family members.
• On occasion, such as for lunch breaks, a single-use cover gown or other jacket may be worn over OT attire outside the suite. Then, it should be placed in a laundry hamper or if it is disposable it should be discarded.
• OT attire should not be hung or put in a locker for wearing a second time. It should be discarded in the trash or put in a laundry hamper after one use, as appropriate.
• Shoes should be stored on the bottom shelf or under the locker.
• Each person of surgical team should bathe daily with an antimicrobial and apply deodorant as appropriate.
• A person with an acute infection, such as a cold or sore throat, should not be permitted within the OT suite.
• Personnel with cuts, burns, or skin lesions should not scrub or handle sterile supplies because serum, a bacterial medium, may seep from the eroded area.
• Some sterile team members who are known carriers of pathogenic microorganisms should be treated with appropriate antibiotics until nasopharyngeal culture findings are negative.
• Fingernails should be kept short. Nail polish or artificial nails are prohibited in the OR.
• Jewellery, including rings, necklaces or chains and watches, should be removed before entering semi-restricted and restricted areas. Pierced-ear studs should be confined within the head cover. Dangling earrings are inappropriate in the OT.
• Facial makeup should be minimal.
• Eyewear or spectacles should be wiped with a cleaning solution before each surgical procedure and secured to the face with a head strap to prevent slippage.
• Comfortable, supportive shoes should be worn to minimize fatigue and for personal safety. Shoes should have enclosed toes and heels. Shoes are cleaned frequently, whether or not shoe covers are worn.

COMPONENTS OF OT ATTIRE

OT attire including scrub suit, head covering, mask, surgical gown, surgical gloves shoes covers and eyewear.

Each item of OT attire is a specific means for containment of or protection against the potential sources of environmental contamination, including skin, hair, and nasopharyngeal flora and microorganisms in air, blood, and body substances.

Scrub suits, masks and head covers are worn by all personnel in the semi restricted and restricted areas of the OT suite. Additional items, such as protective surgical gown, surgical gloves, shoes covers and eyewear, are worn during a surgical procedure and for protection during hazardous exposure.

SCRUB SUIT

• The suit is designed to prevent the shedding of skin particles and hair into the environment and to protect the wearer from contact with soiled and body fluids. It helps us prevent the release of these substances but is not considered personal protective equipment.
• For a female staff, the scrub suit consist a One-piece of half sleeve, collarless and ankle length cotton gown.
• For a male staff, the scrub suit consist a clean pair of cotton pyjama & half sleeve, collarless, bottonless shirt.
• It is made of lint-free cotton material. It should be lightweight & fit closely to the body.
• When personnel arrives or enters OT, he or she has to change his/hir dress from street clothes to scrub suit.
• Both sterile and nonsterile surgical personnel in the perioperative environment wear the scrub suit.
• The head cover or the cap is to be put on before the scrub suit or sterile gown is done. So as to prevent contamination of the sterile gown by hair or dandruff.
• The top should be secured at the waist, tucked into the pants, or fit close to the body to prevent contact with sterile surfaces.
• After changing, the street clothes to OT clean attire one can move in the semi restricted or restricted area in OT.
• When a scrub suit has been soiled by blood or body fluids, surgical personnel must remove it in such a way as to prevent skin contact with the soiled area.

HEAD COVERING

• While in the semi-restricted and restricted areas of the surgery department, a cap or hood is worn to cover all hair of the head and face.
• Hair has been shown to be a major source of contamination; therefore, no hair should be left exposed while one is in the surgical environment.
• Hair covers are donned prior to the scrub suit to decrease the possibility of hair or dandruff being shed onto the scrub suit, prevent contamination of the wound, and decrease microbial dispersal.
• Personnel with longer hair should wear bouffant-type caps or hoods.
• Bald heads should be covered to prevent the shed and dispersal of scalp dander.
• Hair covers should be changed if they become wet or soiled.
• Anyone with a scalp infection should be excluded from the OR and treated.
• The scalp and hair are a rich source of Staphylococcus aureus and other bacteria, which proliferate under surgical caps. All infection control agencies validate the donning of freshly laundered scrub attire at the start of the work shift and whenever scrub attire is soiled.

MASK

• The scrub personnel have to wear sterile facemask, which should cover both the nose & mouth.
• The facemask is worn to minimize the airborne infection.
• Facemask are usually designed with pleats or a conical cup for a close fit.
• The facemask is to be worn before entering the restricted area to filter droplets containing microorganism expelled from the nasopharynx &the mouth of the surgical team members while breathing, talking, sneezing & coughing.
• A reusable cotton facemask is commonly used but they filter effectively as soon as they become damp.
• Disposable facemask are soft, non-irritating & comfortable. They do not obstruct respiration & are equally effective.
• The sterile facemask should be handled just only by strings.
• The four corners strings of the face mask should be tied tightly at the back of the head. Two upper corners strings running over the ears & two lowers corners strings running below the ears, just at the hairlines.
• One should avoid frequently handling & touching of the mask.
• Once the use of the mask is over, it should not be lowered to hang loosely around the neck or should not be put into the pocket for reuse & should be discarded into specific container.
• The face mask should be changed B/W the operations when they become soiled or damp. Talking & laughing should be kept to minimize while wearing a face mask.

SHOE COVERS

• Protective shoe covers are worn in the semi-restricted and restricted areas of the surgery department.
• Primarily it provide a shield to the shoes and feet from gross fluid contamination.
• When a procedure will require large amounts of irrigation fluid or there is a possibility that large spills may occur, some individuals prefer to wear the larger impervious boot-style shoe covers.
• Some health care facility policies provide their own shoes to be worn exclusively in the surgery department without shoe covers, as long as the shoes meet surgery department policies. These shoes must not be worn outside the surgical suite; this is necessary to prevent cross-contamination to and from the outside areas of the facility.
• Even if shoe covers are not required at a certain facility, their use may still be indicated for personal protection according to the situation.
• If shoe covers are used, they must be removed whenever they become soiled or wet and must always be removed when one leaves the surgical suite.

SURGICAL GOWN

• A sterile gown is worn over the scrub suit to permit the wearer to enter the sterile field.
• It prevents contamination between the wearer and the field and differentiates sterile from nonsterile team members.
• Sterile gowns may be disposable or reusable and must be constructed of a lint-free woven or nonwoven fabric that offers a protective barrier.
• After scrubbing the hands & drying the hands with a sterile towel, the surgical team member have to wear the sterile scrub gown.
• It is a full sleeve, full length collarless, button-less gown having a round neck, front closed & a back opened with strings at the back which are to be tied by an assistant after the gown has been worn.
• The front of the gown from the mid-chest level to the waist and the sleeves circumferentially to 2 inches proximal to the elbows is considered sterile.
• Although the entire gown is sterilized, the back is not considered sterile nor is any area below the level of the sterile field, once the gown is donned. The back is never in view of the team so it cannot be guaranteed to be sterile.

SURGICAL GLOVES

• Sterile gloves are worn by all sterile team members.
• The sterile gloves are applied immediately after donning the sterile gown.
• They are worn to permit the wearer to handle sterile supplies and tissues of the surgical site.
• After wearing the sterile gown & gloves the surgical team members should restrict their stay in the restricted sterile zone of the OT & also should restrict their movement in OT.
• Surgical gloves are made of natural rubber latex, synthetic rubber, thermoplastic elastomers, neoprene, vinyl, or polyethylene.
• Disposable latex gloves are worn most frequently.
• Sterile team members should not wear latex gloves if the patient has a known latex sensitivity or allergy.
• Sterile gloves are available in a variety of styles and sizes and have been developed for specific surgical specialties (such as ophthalmology and orthopedics).
• Selection of surgical gloves worn during specific procedures depends on the following:
  • Length of the surgical procedure
  • Type of surgical procedure
  • The need to double-glove
  • Stresses to which the glove is exposed
  • Chemical exposure to the gloves during the surgical procedure
  • Caregiver and patient sensitivity
  • Individual preference
• Latex gloves of varying thickness, with a minimum of 0.1 mm, can be chosen to meet the needs of the surgeon for tactile sensation.
• Additionally, double gloving is recommended for the following reasons:
  • Fat is known to degrade latex.
  • The barrier efficiency of latex decreases over time.
  • The structure of latex is lattice-like, containing many spaces that fill with fluid during the surgical procedure.
• Double gloving significantly reduces the amount of blood contamination of the hands.
• Sterile gloves may be used without a sterile gown to allow a nonsterile team member to perform a sterile activity, such as urinary catheterization. However, in that situation they are not considered scrub attire.

EYE WEARS

• Eye wears or eye goggles may be worn whenever a risk exist of blood fluids of the patient splashing into the eyes of the sterile members.
• Sometimes during orthopaedic operations, bone-cutting machines can splatter bone chips to the eyes. Therefore, it offers protection.
• Laser eye wear should be worn for eye protection form laser beams during laser surgery.

OTHER SPECIFIC ATTIRES

• They are used for specific purposes are as follows:
  • A decontamination water or liquid proof apron - it is needed to be worn over the clean OT gown or pyjamas suit. When there is risk of blood fluids of a patient splashing onto the gown of sterile team members.
  • Lead apron - Lead apron may be worn below the sterile gown to protect against the radiation exposure when surgical team members are doing procedures such as implanting radioactive implants or removing such items.
  • Fire resistant gowns - may be worn for laser surgery.

 

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PRINCIPLES OF ASEPTIC TECHNIQUE

STERILITY

• Sterile or sterility means, an object or surface completely free of all living microorganisms including microbial spores.
• All nonsterile surfaces are considered potentially contaminated with pathogenic microorganisms.
• Sterility is absolute. Something is either sterile or not sterile—there is no "partial sterility."

CONTAMINATION

• Contamination is the contact between a sterile surface or object and a nonsterile item, substance, or entity. Contaminated + sterile = contaminated.
• It is an event in which a sterile item or surface has come in contact with a nonsterile item or surface
• It defines an item or surface that was previously sterile but comes in contact with a contaminant.

  For Example –

  • A sterile instrument that falls to the floor. The instrument is contaminated.
  • The surgeon's gloved hand accidentally touches the nonsterile edge of the surgical drape. His glove is contaminated.
  • The scrubbed surgical technologist accidentally punctures her glove with a suture needle. The needle is contaminated (remember that skin is not sterile).
• Gross contamination is the contamination of the surgical wound or sterile field by a highly infective source such as in the example just given.

  For Example –

  • An infected appendix has ruptured, spilling pus into the abdominal cavity. Gross contamination of the peritoneal cavity has occurred.

BARRIERS

• One of the foundation principles of aseptic technique is based on the concept of creating a barrier between the sources of contamination and a sterile surface.
• A physical barrier prevents a non-sterile surface from touching a sterile surface. In other words, it contains (encloses) or separates a source of contamination.

  For Example –

  • Hair caps and masks are barriers that contain sources of contamination (hair, dander, exhaled air).
  • A sterile table cover provides a barrier between the nonsterile surface of the table and sterile equipment placed on the cover.
  • A chemical barrier is produced by the residual effect of antiseptics used during patient skin preparation and the surgical scrub or hand rub.

SURGICAL CONSCIENCE

• Admitting and reporting any break in aseptic technique demonstrates a high level of professional maturity and surgical conscience.
• All members of the surgical team are jointly responsible for reporting and responding to breaks in aseptic technique so that steps can be taken to mitigate the risk of infection.

  For Example –

  • If a sterile team member contaminates the field without knowing, others may quickly report the break—"Dr. X, your glove touched the anaesthesia screen."
  • If the gloved hand is contaminated, the glove is changed as soon as possible.
  • If irrigation fluids are contaminated, they are discarded and new sterile basins and fluids are obtained.
  • In the case of gross contamination, this may mean starting the patient on intravenous antibiotics.
• One of the most important roles of the scrubbed surgical personnel is to protect the field; this includes watching for breaks in technique and reporting them quickly.

THE PRINCIPLES OF ASEPTIC TECHNIQUE

• Aseptic technique encompasses the practices used to create, protect, and maintain the surgical field.
• The objectives of the technique are containment, confinement, reduction, and elimination of microorganisms to prevent contamination of the sterile field.
• Techniques are based on the central principle that microorganisms transmit disease from objects, surfaces, air, and dust to patients and personnel.
• The sterile field is the physical area starting with the surgical incision at the centre and extending to include the patient drapes, sterile instrument tables, and any draped equipment such as the operating microscope. It also includes scrubbed team members.
• The sterile field is created using specific rules and standards. The following practices pertain to any situation in which a sterile field exists:

1. Sterile surfaces contact only sterile surfaces; nonsterile surfaces contact only nonsterile surfaces.
2. A sterile item is considered sterile only after it has been processed using methods that have been proven effective and that yield measurable results.
3. Sterile drapes, gowns, gloves, and table covers are barriers between a nonsterile surface and a sterile surface.
4. The edge of any sterile drape, wrapper, or covering is considered nonsterile.
5. Sterile liquids in bottles with an edge (lip) that is protected with a sealed sterile cap may be delivered directly from the bottle into a sterile container on the field.
6. If any doubt exists about the sterility of an item, consider it contaminated.
7. The draped patient is the centre of the sterile field during surgery.
8. Sterile gowns are considered sterile only in front from midchest to table level.
9. Sterile personnel must pass other sterile personnel back to back or front to front.
10. Sterile tables are considered sterile only at table height.
11. Sterile personnel remain within the immediate area of the sterile field.
12. Nonsterile team members never lean over or reach over a sterile surface to distribute sterile goods to the field. They do not pass between two sterile surfaces.
13. Movement is kept to a minimum during surgery.
14. Drapes and linens should be handled as little as possible and with a minimum of movement.
15. Talking is kept to a minimum during surgery.
16. Moisture carries bacteria from a nonsterile surface to a sterile surface.
17. The sterile field is created as close as possible to the time of surgery and is monitored throughout the procedure.

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DUTIES AND RESPONSIBILITIES OF NURSES IN OT

Nursing personnel or nursing section in OT is headed by the Nursing Director or Chief Nursing Officer (CNO). The other members of the nursing team working under the nursing director are as the following:

• Deputy Nursing Director or Deputy Nursing Officer (DNO)
• Nursing supervisors
• Scrub nurses
• Circulatory nurses
• Nurse – in – charge store
• Nurse – in –charge reception, admission, transfer etc.

The nurse patient ratio in OT is –

• Major OT - 1: 2 per table
• Minor OT - 1: l per table

HIERARCHY OF NURSING PERSONNEL IN OT

Duties and responsibilities

NURSING DIRECTOR AND DEPUTY NURSING DIRECTOR

• The unit of nursing services in OT is headed by the Nursing Director.
• Nursing director should have a qualification of post-graduation in nursing with the experience in OT Nursing.
• He/she is the administrative or managing authority of nursing services in OT.
• She has three areas of responsibilities: Administration, Management, and Education & research.
• The Nursing Director is responsible for: -
  • Maintaining high standards of patient care in the department.
  • The welfare, employment and professional development of staff.
  • Forward planning and ordering.
  • Liaising with other hospital departments, e.g., the Department of Surgery, the Department of Anaesthesia, the School of Nursing, senior nursing administrators, Personnel Department, Pharmacy, Works Department and laundry.

NURSING SUPERVISOR

• Nursing supervisor needs to have a postgraduate qualification in nursing with experience in OT nursing.
• Responsibilities are-
  • The day-to-day running of theatre suite.
  • Planning OT activities as per the surgical schedule.
  • Delegating responsibilities to the scrub & circulatory nurse for smooth conducting of the surgical schedule.
  • Assessing the requirements of equipment's & articles & other supplies along with arranging for obtaining them.
  • Communicating effectively to the nursing personnel under her to ensure that all information is received.
  • Weekly/monthly ordering of stock.
  • Liaising with surgeons and anaesthetists working in the suite regarding operating lists and equipment orders.
  • Evaluating the effectiveness of the performance of the nursing personnel in OT.
  • Informing the nursing director of any changes or problems in the suite.
  • The continuing education of staff and student nurses.
  • Conducting research in OT Nursing and participating in the team researches conducted in OT.

SCRUB NURSE

• The scrub nurse is on works directly with the surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure.
• She is the members of the surgical team who prepares and preserves a sterile field in which the operation can take place.
• Duties of scrub nurse-
  • Before an operation
    • Ensures that the circulating nurse has checked the all the equipment needed during procedure.
    • Ensures that the theatre has been cleaned before the trolley is set.
    • Prepares the instruments and equipment needed in the operation.
    • Prepare own self by using sterile technique like scrubbing, gowning and gloving.
    • Receives sterile equipment via circulating nurse using sterile technique.
    • Performs initial sponges, instruments and needle count, checks with circulating nurse.
  • When surgeon arrives after scrubbing
    • Provide assistance for gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite
    • Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet.
    • Assist the surgeon in draping the patient aseptically according to routine procedure.
    • Place blade on the knife handle using needle holder, assemble suction tip and suction tube.
    • Bring mayo stand and back table near the draped patient after draping is completed.
    • Secure suction tube and cautery cord with towel clips or Allis.
    • Prepares sutures and needles according to use.
  • During An Operation
    • Maintain sterility throughout the procedure.
    • Awareness of the patient's safety.
    • Adhere to the policy regarding sponge/ instruments count/ surgical needles.
    • Arrange the instrument on the mayo table and on the back table
    • Before the incision begins, provide two sponges on the operative site prior to incision.
    • Passes the first knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon.
    • Passes the retractor to the assistant surgeon.
    • Watch the field/ procedure and anticipate the surgeon's needs.
    • Pass the instrument in a decisive and positive manner as needed in the procedure.
    • Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge
    • Always remove charred/burned tissue from the cautery tip
    • Notify circulating nurse if you need additional instruments as clear as possible.
    • Always keep 2 sponges on the field throughout the procedure.
    • Save and care for tissue specimen according to the hospital policy
    • Remove excess instrument from the sterile field.
    • Adhere and maintain sterile technique and watch for any breaks. If any breaks found then inform immediately to the surgeon.
  • End of operation
    • Undertake count of sponges and instruments with circulating nurse and correlate with the pre-surgery findings.
    • Informs the surgeon regarding count result.
    • Assist the surgeon for suturing the surgical incision.
    • Apply the dressing over the surgical site.
    • Clears away instrument and equipment.

CIRCULATOR NURSE

• The circulator is responsible for managing the nursing care of the patient within the operating room and coordinating the needs of the surgical team with other care providers necessary for completion of surgery.
• The circulator nurse observes the surgery and the surgical team and assists the team to create and maintain a safe and comfortable environment for the patient.
• The circulator nurse assesses the patient's condition before, during, and after the operation to ensure an optimal outcome for the patient.
• The circulator nurse must be able to anticipate the scrub nurse's needs and be able to open sterile packs, operate machinery and keep accurate records.
• Duties/Responsibilities of Circulating Nurse
  • Before an operation
    • Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table.
    • Make sure that theater is clean.
    • Arrange furniture according to the need of the procedure.
    • Place a clean sheet, arm board (arm strap) and a pillow on the OR table.
    • Provide a clean kick bucket or pail.
    • Collect necessary stock and equipment.
    • Turn on the aircon (AC) unit and adjust the temperature of the OT room as per the patient need.
    • Help scrub nurse with setting up the theater Assist with counts and records.
  • During the induction of anaesthesia
    • Turn on OR light.
    • Assist the anaesthesiologist in positioning the patient.
    • Assist the patient in assuming the position for anaesthesia.
    • Anticipate the anaesthesiologist's needs.
  • After the patient is anesthetized
    • Reposition the patient per anaesthesiologist's instruction.
    • Attached anaesthesia screen and place the patient's arm on the arm boards.
    • Apply restraints on the patient.
    • Expose the area for skin preparation.
    • Catheterize the patient as indicated by the anaesthesiologist
    • Perform skin preparation.
  • During operation
    • Remain in theater throughout the operation.
    • Focus the OR light every now and then.
    • Position kick buckets on the operating side.
    • Replenishes and records sponge, instruments and needles or sutures.
    • Ensure the theater door remain closed and patient's dignity is upheld throughout the procedure.
    • Watch out for any break in aseptic technique. If any breaks found then inform immediately to the surgeon.
  • End of operation
    • Assist with final sponge and instruments count and documented.
    • Signs the theater register.
    • Ensures that all the specimen are properly labelled and signed.
  • After an operation
    • Assist the scrub nurse for patient dressing.
    • Helps in removing and disposing the drapes.
    • Helps to prepare the patient for transporting to the recovery room.
    • Assist the scrub nurse, taking the instrumentations to the service (washroom).
    • Make arrangement for preparation of theater for the next case.

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STAFFING IN OT AND MEMBERS OF SURGICAL TEAM

Staffing is a selection, training, motivating and retaining of a personnel in the organization. The norms are providing staffing requirement information in a number of ways, to facilitate various uses.

The staffing requirements in can be measured by –

• Staffing needs,
• Population ratios,
• Fixed staff requirements per level of care,
• Number of hours worked,
• Hours associated with direct patient care
• Workload calculation

The staffing requirements in OT staffing is based on the –

• Number of cases operated per day,
• Total number of hours of cases,
• Type of cases,
• Nature of cases,
• Prescribed norms, policies and procedures

BENEFITS OF GOOD STAFFING

• Improves patient outcome
• Lowers mortality rate
• Increase OT efficiency
• Reduce patient waiting time for surgery
• Balance workload

STAFFING PATTERN OF OT

 

MEMBERS OF THE OT TEAM

• The management of intra-operative nursing care is the coordinated efforts of well-organized surgical team. Whose function include safe, efficient & effective care to the surgical patient in OT.
• OT surgical team has the following personnel:
  • Medical personnel
  • Anaesthesiologist
  • Nursing personnel
  • OT technician
  • OT Attendants
  • Lab technician
  • OT Sweepers or Cleaners
• MEDICAL PERSONNEL OR SURGEON
  • A surgeon can be defined as a doctor, who operates a body either to cure or prevent a disease, fix an injury, or to solve a health problem. Thus, it is said that a surgeon is a medical practitioner, who is an expert at performing operations on the body.
  • The surgeon job description depends upon the type of the surgeon he/she is. There are different types of surgeons and their set of duties:
    • General Surgeon - A general surgeon usually operates on the abdominal parts and performs operations related to hernia and appendicitis.
    • Neurosurgeon - operates on brain and spinal cord
    • Orthopaedic surgeon - An orthopaedic surgeon is an expert at performing operations related to bones, joints, spine, etc.
    • Plastic surgeon - They perform various types of cosmetic surgeries which include, liposuction, treating skin burns, etc.
  • Each of these specialized surgeon is an expert in operating the respective parts of the body.
  • Duties of surgeon -
    • Before surgery learn the medical history of the patient, make sure if the patient has certain allergies, expected outcome after the operation.
    • Before starting with the surgery, a surgeon should make sure that the operation theatre is well equipped with surgical instruments required for the surgery.
    • The surgeon should provide all the information and risks associated with the surgery to the patient.
    • The surgeon should manage, plan and schedule the surgery, after studying the physical condition of the patient.
    • After completion of the surgery, the surgeon should prepare the case history and provide all the necessary after surgery care to the patient.
• ANAESTHESIOLOGIST
  • Anaesthesiologist is a physician trained in anaesthesia and perioperative medicine.
  • Duties of Anaesthesiologist -
    • Administer anaesthetics to prevent patients from feeling pain and sensations;
    • closely monitor patients' vital signs during surgery and adjust anaesthetics accordingly;
    • Monitor patients through the first recovery stages after an operation;
    • Anaesthesiologists may also help treat patients with conditions causing chronic pain.
    • More than ninety percent of the anaesthetics used in health care are administered by or under the direct supervision of an anaesthesiologist.
• NURSING PERSONNEL
  • Nursing personnel or nursing section in OT is headed by the Nursing Director or Chief Nursing Officer (CNO). The other members of the nursing team working under the nursing director are as the following:
    • Deputy Nursing Director or Deputy Nursing Officer (DNO)
    • Nursing supervisors
    • Scrub nurses - works directly with the surgeon within the sterile field
    • Circulatory nurses - responsible for managing the nursing care of the patient within the operating room and coordinating the needs of the surgical team with other care providers necessary for completion of surgery.
    • Nurse – in – charge store
    • Nurse – in –charge reception, admission, transfer etc.
• OT TECHNICIAN
  • O.T. Technician is a qualified person, is the member of the surgical team.
  • Operating room technicians are also called surgical technicians.
  • They assist in preparing operating rooms for surgery.  They are responsible for having surgical instruments, sterile bandages and linens, needed fluids, and other equipment ready for the operation.
  • They may also assist doctors by handing them needed instruments during surgery and for counting sponges and needles before and after the operation.  They deliver specimens to hospital laboratories for analysis, and after operations they take patients to the recovery room.
  • Duties of OT technician
    • Operation Theatre Technician has to carry out the routine work pre-operatively such as – Carbonization, Fumigation, Sterilization and Autoclaving.
    • Ultra Violet (U.V.) lighting has been used for germicidal sterilization to prevent Mould / Bacteria Growth etc.
    • So the environment is free from the disease causing microorganisms & the required instruments, linen, dressing materials etc. are free from the pathogenic microorganisms & ready for the use in operation / surgical procedure
• OT ATTENDANTS
  • Also known as OT nurse assistant or OT ward boy.
  • OT Attendants is assisting medical and nursing staff with various nursing and medical interventions.
  • These duties are classified as routine tasks involving no risk for the patient like –
    • Lift patients on and off trolley to OT table with the assistance of nurses.
    • Transfer patients' files between departments, specimens to laboratories.
    • Make sure that an adequate supply of clean clothing and linen is available for the patient and that soiled items are removed and send for cleaning.
    • Assist in the maintenance of stocks of linen and non-medical supplies.
• LAB TECHNICIAN
  • Collect samples of body fluids and tissues.
  • Perform clinical tests usually of a simpler nature.
• OT CLEANERS
  • OT cleaners are the personnel who are engaged themselves in cleaning the OT pre-operative & post operatively.
  • Cleaners clean the OT with the antiseptic lotion with wearing of gloves, mask & cap.
  • They are responsible for maintaining the cleanliness of OT.

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PHYSICAL LAYOUT THE OPERATING ROOM

An operation theatre is the "heart" of any major 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.

OT are designed and built to carry out investigative, diagnostic, therapeutic and palliative procedures of varying degrees of invasiveness. Many such setups are customized to the requirements based on size of hospital, patient turnover and may be speciality specific.

The aim is to provide the maximum benefit for maximum number of patients arriving to the operation theatre. Both the present as well as future needs should be kept in mind while planning OT.

OT design

Several basic design types are used in surgical services departments, depending on the age of the facility and the physical design of the areas outside the department. All surgery departments are designed with the idea of controlling traffic patterns and quickly providing each operating room (OR) with the necessary supplies during and after each case, while keeping clean and contaminated traffic patterns separate.

Most surgical suites are constructed according to a variation of one or more basic designs. The basic designs are:

• Central corridor plan – these plans are two types
  • Racetrack plan - In this design, the front entrance to each OR is from the outer corridor, and supplies are retrieved through a rear entrance to the room leading to the central-core storage and work areas.

    

  • Hotel plan - In this design, the ORs are situated along a central corridor, with separate clean core and soiled work areas. The primary difference in this plan is that all traffic enters and exits the surgery department through a single entrance or a primary entrance and holding area entrance situated along the same corridor.

    

• Peripheral corridor - In this design, the front entrance to each OR is from the peripheral corridor, and supplies are retrieved through a rear entrance from the OR leading to the central-core storage and work areas.

  

• Specialty grouping plan - The "specialty grouping" plan is simply a variation on the hotel or race track plan, in which ORs are grouped by specialty (e.g., neurosurgery, general surgery), each with its own closely associated clean storage areas and, in some cases, each with its own soiled instrument work area.

The design of any surgery department revolves around environmental control, traffic control, and the desire to prevent surgical site infection (SSI). Such factors as the separation of clean and soiled work areas and areas of the department specified as restricted and unrestricted assist in the promotion of this idea. Efficiency is increased with strategic placement of computers, preparation areas, and staff areas.

Different Zones/ Areas

Regardless of the design chosen by the facility, certain principles apply universally. Traffic control follows predetermined traffic patterns that all persons entering the department are expected to follow. The OR department is divided into four zones 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. Unrestricted zone or clean area.
2. Semi restricted zone or sub sterile area
3. Restricted zone or sterile area
4. Disposal zone or area

1. Unrestricted/ Clean zone or clean area

• This is the area where hospital personnel, OT personnel, patient's & their attendants can move about in street clothes.
• Connects protective zone to aseptic zone and has other areas also like
  • Stores & cleaner room
  • Equipment store room
  • Maintenance workshop
  • Kitchenette (pantry)
  • Firefighting device room
  • Emergency exits
  • Service room for staff
  • Close circuit TV control area

1. Semi restricted/ Protective zone or sub-sterile area

• After changing from street clothes, with clean gown, cap & OT slipper, the OT team or personnel are, enter in this area. (Operating room attire is required)
• It includes -
  • Change rooms for all medical and paramedical staff with conveniences
  • Transfer bay for patient, material & equipment's
  • Rooms for administrative staff
  • Stores & records
  • Pre & post-operative rooms
  • I.C.U. and P.A.C.U.
  • Sterile stores

1. Restricted/Aseptic zone or sterile area:

• This zone has operation theatres & operation room where operations are done.
• This is a place where staff & patients in street clothes & shoes are not allowed to enter. Scrubbed personnel wear sterile gowns & gloves & get ready for operation procedure. (Operating room attire is required)

1. Disposal zone or area

• Dirty utility area
• Disposal corridor
• OT attire mandatory in this area

Advantages of zoning

• Minimizes risk of hospital infection.
• Minimizes unproductive movement of staff, supplies & patient.
• Increases efficacy of operative team members.
• Ensures smooth workflow.
• Deceases hazards in operating room.
• Ensures proper positioning of equipment's.

Sub areas

• Nurses station or counter - Nurses station is an area where nurses and other health care staff sit behind when not working directly with patients and can perform some of their duties. The station has a counter that can be approached by visitors and patients who wish to receive attention from the nurses. It should be spacious enough to allow two or more personnel to work together.
• Pre-operative check area (reception) - It is the area where OT nursing personnel receive patients. Here patients and his records are checked.
• Holding area - This area is planned for 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.
• Induction/Anaesthetic room - It should have all facilities as in OT, but there is controversy as to its need. It should provide space for anaesthetic trolleys and equipment and 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 have sufficient power outlets and medical gas panels for testing of equipment.
• Post anaesthetic care units (PACU)/Post–operative or recovery room – Room where patients are kept & cared until they are out of anaesthesia & until their vital signs become stable. These should contain a medication station, hand washing station, nurse station, storage space for stretchers, supplies and monitors / equipment and gas, suction outlets and ventilator.
• Staff room – Men and women change dress from street cloth to OT attire; lockers and lavatory are essential; rest room etc. are desirable.
• Sanitary facility for staff- One washbasin and one western closet (WC) should be provided for 8-10 persons. Showers and their number is a matter of local decision. Inclusion of toilet facilities in changing rooms is not acceptable; they should be located in an adjacent space.
• Offices – for staff nurse and anaesthesia staff- The office should allow access to both unrestricted and semi-restricted areas as frequent communication with public is needed.
• Rest rooms- 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, one writing table, a book case etc., may be arranged.
• Laboratory – Small laboratory with refrigerator for pathologist to be arranged.
• Seminar room- Since staff cannot leave an OT easily, it is better to have a seminar room within the OT. Intra-departmental discussions, teaching and training sessions for staff (with audio-visual aids) may be conducted here.
• Store room-
  • These rooms should have steel cabinets & separate for specific items.
  • These cabinets should be spacious enough to accommodate various items such as sterile linens, sterile trays, sterile drums with sponges, dressings, cotton swabs, bandages, sterile rubber sheets, catheters, sutures, syringes, infusion & transfusion sets.
  • A separate store room is needed for unsterile, clean articles such as linen, OT dress items, stainless steel equipment's
  • The cabinets of store rooms should be made up of such materials which can be cleaned & washed without being damaged.
  • There should be bigger store room for equipment's such as monitoring devices, suction apparatus, O₂ cylinder, trolleys, wheel chairs, stretchers, defibrillator, pace makers, bed urinals, OT slippers etc.
• Scrub room- This is planned to be built within the restricted area. This should be spacious. Sometime s two or three operation theatres can share one scrub facility. Scrub area should have deep & wide shink to avoid splash of water on the surrounding area. There should be facilities for running water. The taps should be such that they could be opened or closed by foot pedals or they have long handles that can be operate by elbows.
• Waiting room – Patient's attendants or family member's waiting room with attached toilet & drinking water facility.
• Visitor's gallery - Gallery from where the visitors can see the operative procedures being performed.
• Utility Room - This is also called clean up room where instruments, articles, gloves are received following surgical procedures. Here all these are cleaned, washed & wiped dry & then wrapped, stored & sent for sterilization.
• Disposal or sluice room - This room receives all soiled linen & dressing. Here all disposable items are separated according to biochemical waste management code & then packed in leak proof containers. The soiled linens are sent to the laundry. The OT set up should be such that it should be possible to dispose off soiled items without taking them through sub-sterile or sterile areas.

OPRETING ROOM

NUMBER & SIZE

• The number & size can be as per the requirement.
• The standard OT should be rectangular or square in shape and similar in design.
• It should be 20×20×10 feet in size so it provides a floor space of 400 Sq. feet approx.
• It should be spacious enough to allow free movement of personnel, trolleys, stretchers, wheel chairs, monitoring devices, portable x-ray machines etc.
• Cardiac or neurosurgery OT should be bigger in size of 20x30x10 feet with 600 sq. feet floor space.
• OT for endoscopy or minor surgery can be of small size of 18x18x10 feet with a floor space of 324 sq. feet.

DOORS

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

SURFACE / FLOORING

• The surface / flooring must be slip resistant, strong with minimum joints.
• It should be easily washable, free as possible joints, seams so that they do not permits adherence of bacteria or dust particles containing microorganism.
• It should be able to withstand repeated washing with germicidal agents.
• It should be able to absorb sound.
• The colour of the flooring should be such that if a needle is dropped on the floor it is visible.

WALLS

• The walls, ceiling & floor surfaces should be made of hard fire resistant, smooth, non-porous material.
• It should be light in colour (light blue or green) and washable paint should be ideal.
• Colour of paint should allow reflection of light and yet soothing to eyes.
• Adequate electric points should be available on the wall at < 1.5 m height from the floor.

SCRUB STATION

• For sterile hand wash
• Types: Stainless/ Granite/Marble/ Cement
• Gradient of basin forward and downwards
• Gradient towards outlet
• Hot water mixing: automatic or manual
• Non splashing taps; possible to change direction
• Elbow/ Foot or Infra-Red operated taps
• Soap dispenser: Manual/automatic
• to be planned for at least for 2-3 persons in each OT.

VENTILATION, TEMPERATURE & HUMIDITY

• The OT Require Efficient ventilation that will control temperature and humidity in OT and dilute the contamination by microorganisms and anaesthetic agents.
• The ventilation in OT should follow the principles that the direction of airflow should take place from the sterile to the clean zone & form the clean zone to the less clean areas.
• There should be no open window in the OT and sliding doors of the OT should be open from the OT towards the sub sterile zone.
• There should be no interchange air movement between one OT and another.
• There should be no circulating fan or cross ventilation to prevent airborne contamination of the surgical wound.
• An effective ventilation system is necessary to exchange the air. This air is filtered with an efficient air filtering system.
• There are two types of air conditioning systems : recirculating and non recirculating.
• The circulating system takes some or all of the air, adjusts the temperature and circulates air back to the room.
• Non-recirculating systems heat / cool the air as desired and convey it into the operating room with ideally 20-air exchange per hour. Air is then exhausted to outside. Anaesthetic agents in the OT air are also automatically removed. These are thus ideal but are expensive.
• The broad recommendations include:
  • 20-30 air exchanges / hour for recirculated air
  • Only up to 80% recirculation of air to prevent build-up of anaesthetic and other gases
  • Ultraclean laminar airflow – the filtered air delivery must be 90% efficient in removing particles more than 0.5m m.
  • Positive air pressure system in OT: It should ensure a positive pressure of 5 cm H2O from ceiling of OT downwards and outwards, to push out air from OT.
  • Relative humidity of 50-60% to be maintained
  • Temperature between 18o-24oC. Temperature should not be adjusted for the comfort of OT personnel but for the requirement of patient, especially in paediatric, geriatric, burns, neonatal cases etc.

LIGHTING

• The general room illumination the OT is provided by fluorescent lamps (surface ceiling mounted) to produce even illumination of at least 500 Lux at working height, with minimal glare are preferred.
• 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.
• To minimize eye fatigue, the ratio of intensity of general room lighting to that at the surgical site should not exceed 1:5, preferably 1:3.
• Colour and hue of the lights also should be consistent.
• The surgical or operation light should be an overhead ceiling mounted unit.
• The overhead operating light must:
  • Overhead light should be near daylight in colour and shadow less and give25000-125000 Lux of light (50000 to 100000 Lux at the centre and at least 15000 Lux at the periphery).
  • Give contrast to the depth and relationship of all anatomic structures. The light may be equipped with an intensity control mechanism. The surgeon may ask for more light when needed therefore a reserve light should be available (e.g. a mobile operation light).
  • Provide the diameter light pattern of a focus appropriate for the size of the incision. These are adjusted with controls mounted on the light fixture.
  • Be freely adjustable to any position or angle. Most overhead operating lights are ceiling mounted on mobile fixtures. It can be positioned so that light is directed into a single incision or two concurrent operative sites.
  • Be spark-proof where anaesthetic gases are used.
  • Produce minimum heat to prevent injury to exposed tissues, to ensure the comfort of the sterile team, and to minimize airborne microorganisms.
  • Be easily cleaned. Tracks recessed within the ceiling virtually eliminate dust accumulation. The radiant heat produced by the light should raise the tissue temperature not more than 2^oC.

EMERGENCY SIGNAL

• The OT management committee should consider installing an alarm system in case of a life-threatening emergency.
• The activation of this alarm will save valuable time to mobilize the emergency designate staff and direct them to the site of the emergency.

OTHER FACILITIES OF OR

• Electric generator - OT department should have electric generator to ensure uninterrupted electricity supply in case of electricity failure.
• O₂ supply & suction system - OT should have piped in O₂ supply through central O₂ supply system from a central source. There should also be central suctioning through piped in suction arrangement.
• Music system - Operation theatre can also have a soft music system. Music creates a pleasant environment for patients & staff. Music also provide diversion of the patient's mind. Music can provide relaxation to pts who undergo surgery under local, regional or spinal anaesthesia. It also provide a soothing atmosphere & decreases tension & fatigue of the OT staff.
• Computer terminal - The modern OT construction also provide a surface area for the computer terminal in each OT. These computers are being used to record & maintain patient information.