Current recommended areas within an operating theatre department are listed in Box 4.1.

Ideally the main inpatient theatre department in an acute hospital should be central and in one location (NHS Estates 2005). This helps to maximise the flexibility of facilities and provides efficiency of staffing, equipment and supplies. Many hospitals have a number of surgical facilities, but however many areas there are, they should all be covered by the same policies and procedures to ensure a high standard of care and good clinical governance.

Other considerations that need to be taken into account in designing surgical facilities include:

• infection prevention strategies – infection prevention teams should be involved from the start and a key principle of perioperative care is patient safety with a duty of care to minimise the risks of postoperative infection
  
• protecting patients’ privacy and dignity throughout their journey, including single sex accommodation (NHS Estates 2005)
  
• cultural considerations of patients and staff
  
• access for disabled people
  
• moving and handling of patients and equipment
  
• storage facilities
  
• wayfinding and signage.

Core Functions of Each Area

The reception area should be welcoming and staffed while the department is in use, acting as a point of entry and exit for patients and visitors.

The admission area is where formal identification of patients is made as they enter the department against the appropriate documentation to ensure the correct patient is received and their preparation for surgery is complete. In day surgery departments changing rooms are provided and patients then proceed to a sub-waiting area.

Anaesthetic rooms should provide a calm and undisturbed environment for the induction of anaesthesia (NHS Estates 2007). If used they need to be equipped with the same standard of monitoring as the operating theatre. Wall-mounted medical gas services – air, nitrous oxide, oxygen, vacuum and gas scavenging – are standard requirements. An adjustable ceiling-mounted examination lamp will be required for any clinical procedures (NHS Estates 2007). All anaesthetic rooms within a department should have the same layout for ease of use by staff and to decrease risks. Locked storage should be provided for drugs.

Operating theatres where the surgical procedures take place can be either conventionally ventilated or ultraclean ventilated.

Scrub rooms or areas designed for the scrubbing, gowning and gloving of surgical personnel should be large enough to accommodate several staff at any one time without the risk of contamination of sterile surfaces (NHS Estates 2007).

Preparation rooms are attached to the operating theatre and are used to lay up surgical instrumentation. They are good storage areas for essential supplies needed throughout surgical procedures, including a cabinet for warming fluids used in surgery. Ideally each theatre should have its own preparation room to avoid any potential risk of cross-infection (NHS Estates 2007). These rooms should also have a similar layout within departments for ease of use and minimising risk.

Patients are transferred post procedure to recovery rooms or post-anaesthetic care units (PACU) where they are cared for before discharge from the department. PACUs should be able to accommodate level 2 (and possibly level 3) patients for a period of time while they await transfer to a critical care bed. Each bay should have wall-mounted medical gases, vacuum and standard monitoring facilities. There should be an isolation bay for those patients with active infections. If children are cared for in adult areas, paediatric specific facilities and staffing must be considered to ensure the needs of both the children and their parents or guardians are met. The needs of the dying patient and their relatives should also be taken into consideration. PACU is often a central area in departments and is therefore used to store emergency and cardiac arrest trolleys and defibrillators (NHS Estates 2007).

Second-stage recovery in day surgery is used when patients have regained con­sciousness. They remain here until able to get dressed and transfer to the discharge lounge, where they continue to be monitored until allowed home (NHS Estates 2007). All patient care areas within the department should have an emergency call system that is linked to PACU and staff rest areas to be able to summon help (NHS Estates 2007).

Disposal areas are used for the immediate dismantling of used sterile trolleys, sorting equipment for reprocessing, disposal of sharps, body fluids and the processing of waste. Cleaning equipment for the theatre between patients and at the beginning and end of operating sessions is stored here. Central disposal areas can be used to store equipment for reprocessing or waste for collection from sources external to the department.

Storage facilities are important and need to be replenished on a regular basis. They include: areas for storing supplies such as sterile instrument trays, sutures, swabs implants, etc.; areas to store equipment such as operating tables, mechanical vacuum, diathermy and image intensifiers; a clean linen store; a pharmacy store supplied from the main hospital pharmacy that has a lockable door and used to supply the anaesthetic rooms, theatres and PACU with drugs, lotions and fluids, etc.

There should be a rest room so that personnel can take breaks in a relaxed area, with facilities to make drinks and food. Secure staff changing facilities with lockers should be provided so that staff can change into appropriate theatre attire, with facilities for storage and cleaning of theatre footwear.

The anaesthetic department should ideally be located in close proximity to the theatre department, providing office space and administration support. Admin areas within the theatre department are needed for management of the department and staff.

Education and training is important for competence and ongoing development, therefore a seminar room is a useful addition as it enables easy access to training.

Additional facilities might include a laboratory area for blood gas analysis and blood glucose monitoring, plus the provision of a blood refrigerator.

Building Notes – Areas to Consider

Within the operating theatre the ventilation system has four main functions:

• control of temperature and humidity
  
• to dilute airborne bacterial contamination
  
• to control air movement to minimise the transfer of airborne bacteria from less clean to cleaner areas
  
• to assist with the removal of and dilution of waste gases (NHS Estates 1994).

A conventional ventilation system is designed to change the air within an operating theatre approximately 20 times per hour, forcing filtered air from the ceiling down and out through exhaust vents near the floor, thus creating a positive air pressure at all times (Hospital Infection Society 2005). To maintain the positive pressure and effectiveness of the ventilation doors should remain closed as much as possible, especially when surgery is taking place. Staff must consider their route through theatre to avoid having more than one door open at a time to ensure airflow is in one direction only (NHS Estates 1994, Williams 2008).

Ventilation systems are not normally turned off completely, to avoid the potential backflow of contaminated air, but can be turned to set back. There should be a visual indicator on the theatre control panel of the ventilation status plus an override facility if the system is on a timed cycle (Hospital Infection Society 2005).

Some clinical specialities, such as orthopaedics, where the risks and consequences of infection for patients are greater, need a higher specification of ventilation (Gilmour 2005). In ultraclean ventilation systems, filtered air descends in a unilateral flow over the patient thus creating a clean zone. The high flow of air is achieved by recirculating theatre air and passing it through HEPA (high-efficiency particulate air) filters. There are up to 300 air changes per hour in ultraclean systems (Hospital Infection Society 2004).

Piped medical gases supplied to the operating theatre, anaesthetic room and PACU include: oxygen, nitrous oxide, medical air, vacuum and anaesthetic gas scavenging. While these supplies are wall mounted in anaesthetic rooms and PACU, in theatre they should be ceiling mounted. For greater flexibility a pendant should be placed at each end of the operating table, allowing the configuration of the theatre to be changed dependent on patient needs (NHS Estates 2005). All systems must be checked before each operating session to ensure competent supply. Back-up cylinders of oxygen and nitrous oxide should be attached to anaesthetic machines in case of pipeline failure, and a mechanical vacuum facility should be available in case of line failure.

Within the general department a source of natural light has an important role on the sense of wellbeing of patients and staff (NHS Estates 2005, 2007) and where possible the operating theatre, PACU and staff areas should have natural light.

Within the operating theatre there must be an even distribution of light, which is individually and collectively controlled for brightness. Operating table lights must meet the needs of the clinical speciality being undertaken and are designed to be easily cleaned and maintained, and staff should be competent to operate and position them to maximise the view of the surgical team (Hughes and Mardell 2009, p. 272). During laparoscopic procedures the main theatre lighting is reduced to allow visualisation of display screens. Staff need to make arrangements to spot illuminate anaesthetic monitors and instrument trolleys to ensure monitoring is maintained and to reduce the risk of contamination of sterile fields. Staff should be aware of the potential for slips and trips in darkened theatres.

The finish on walls must be durable and robust enough to withstand the impact of moving equipment and trolleys. Vulnerable areas such as doorways, corners and storage should be reinforced to avoid damage. Walls should have a hygienic finish that is impervious and able to withstand repeated cleaning and be painted a light, attractive colour that does not interfere with monitoring changes in patients’ skin tone or colour (NHS Estates 2005). Damage should be repaired to avoid microbial contamination. Walls within operating theatres should be constructed to provide radiation protection (NHS Estates 2005). Ceilings within the operating theatre itself should be sealed to maintain microbiological standards (NHS Estates 2007) while other areas may have modular fittings to allow access for maintenance of estate.

Flooring must be able to withstand the movement of trolleys, operating tables and heavy equipment. It should be continuous and smooth between the floor and walls and have sealed or welded joints to avoid microbial contamination. Breaks or lifting of the surface should be repaired to avoid microbial contamination and the risk of slips, trips and falls (NHS Estates 2005). Floors need to be robust enough to withstand spillages and mopping, regular cleaning and be slip resistant (NHS Estates 2007). Floor markings are useful to denote the area covered by ultraclean ventilation hoods (NHS Estates 2005) and to denote the position of equipment for specific procedures for example robotic surgery.

Doors should close fully, usually with automatic closures, to aid the effectiveness of the ventilation system. Glass panels will reduce the risk of accidents, but should incorporate obscure glass for the privacy and dignity of patients. Doors should be lead-lined for radiation protection, and the glass should be laser proof (NHS Estates 2007).

While natural light is desirable if windows are present, they must be completely sealed and at least double-glazed (NHS Estates 2007), aiding noise reduction and energy conservation as well as ensuring positive air pressure (Weaving et al. 2008). To provide adequate blackout needed for certain procedures there should be electronically controlled blinds within the sealed units (NHS Estates 2007).

Storage facilities should avoid surfaces where dust can accumulate (i.e. horizontal) but be easy to reach, clean and use. Storage areas should be included on deep clean programmes and any damage to surfaces or fittings repaired promptly.

Each theatre should have a control panel that houses relevant controls for ventilation, lights, blinds, X-ray screening, clock and alarm systems. This should be accessible for maintenance from the theatre corridor.

IT facilities are needed within the operating theatres with enough stations provided for effective working. Touch screen monitors, flat wipeable keyboards or plastic covers for conventional keyboards should be utilised.

Telephones within patient care areas should be volume controllable or silent with a light indicator so that they do not disturb the surgical or anaesthetic teams during patient care (NHS Estates 2007).

For security, entry and exit points should have electronically controlled access to reduce the risk of unauthorised access, with CCTV monitoring in use at all times.

If laser is to be used within theatres, doors should lock from inside, and there must be warning lights at all entrances and exits to warn staff that laser is in use.

Electrical supply to departments should be continuous and monitored. If there is electrical failure it is important critical equipment is supplied by an uninterrupted power source (UPS) for example, anaesthetic monitoring and operating lights. Staff should be aware of the location of UPS sockets and use them for critical equipment only.

Handwashing facilities should be available throughout departments in easily accessible prominent positions to reinforce the importance of hand hygiene to staff (NHS Estates 2005). Hand basins should be wall mounted with curved sides, no plugs or overflows and with non-touch mixer taps, with ample space for soap and towel dispensers (NHS Estates 2007).

Patient Flow

Perioperative practice aims to achieve an absence of infection by controlling the movement within and entry to the environment to reduce airborne contamination (Hospital Infection Society 2004, Gilmour 2005). Sources of postoperative infection are either endogenous to the patient or exogenous – which includes airborne contaminants such as skin cells shed by staff movement and which may contain bacterial colonies (Gilmour 2005). Staff working in surgical care facilities must be educated and trained regarding the rules of movement and divisions within the department, to minimise traffic and keep air turbulence to a minimum (Hospital Infection Society 2005). Departments can be divided into areas where access is unrestricted, semi-restricted and restricted dependent on the function and the need to consider the cleanliness of the air (Hospital Infection Society 2005).

Unrestricted areas include the reception area for visitors, admission areas for patients and changing rooms. Some administration areas and training facilities are unrestricted dependent on layout of the department.

Semi-restricted areas include sterile storage areas, anaesthetic rooms, PACU and discharge areas. Movement of staff, patient and equipment is controlled to minimise flow and allow only that which is necessary.

Restricted areas include the theatres, preparation rooms and scrub rooms, and numbers of staff are kept to a minimum for patient safety while reducing the risk of contamination by air turbulence.

The flow of patients, staff and equipment throughout the departments should be agreed and adhered to. Traffic flows, deliveries, waste disposal and storage are separated from patient care areas so that there are clean and dirty zones designed to reduce cross-contamination (Williams 2008).

Movement of staff and equipment during procedures should be kept to a minimum, discouraging entry or exit directly from the theatre to avoid air turbulence, loss of positive air pressure and potential breach of patient dignity.

Within semi-restricted and restricted areas staff are required to wear theatre attire, appropriate footwear and hair covering. While there is little evidence that wearing hats reduces infection (Hospital Infection Society 2005), Weaving et al. (2008) argue it can act as a reminder of the vulnerability of patients.

In restricted areas staff must be aware of which areas and items are considered sterile and keep movement around these to a minimum, and a distance of 30 cm from a sterile field to avoid the risk of contamination. Constant vigilance of the sterile field is needed to ensure they remain so.

Waste

The management of waste is regulated by legislation and surgical care facilities need robust policies and procedures to ensure waste is disposed of correctly and in a timely manner (AfPP 2008). Such policies should comply with regulations governing health and safety, environment and waste and transport and reflect the most up-to-date recommendations, which lead to a unified approach across practice (Department of Health 2011).

Current European and UK legislation recommends adopting:

• a methodology for identifying and classifying infectious and medicinal waste
  
• a revised colour-coded best practice waste segregation and packaging system
  
• use of the European Waste Catalogue codes
  
• an offensive/hygiene waste stream to describe waste that is non-infectious (Department of Health 2011).

All staff involved in waste management have a duty of care to ensure it is dealt with correctly from the point of production to the point of disposal (Department of Health 2011).

Types of waste within theatres include:

• domestic – general household waste that is suitable for disposal by landfill
  
• clinical waste – produced from healthcare activities such as human tissue, blood or body fluids, excretions, swabs and dressings, syringes, needles or other sharp instruments that if not rendered safe may prove hazardous and could cause infection to anyone coming into contact with it (Department of Health 2011)
  
• medicinal waste that includes any expired, unused or contaminated pharmaceutical products, drugs and vaccines (Cytotoxic and cytostatic waste is treated separately as not all waste facilities are able to process these.)
  
• sharps – items that can cause cuts or puncture wounds and include suture needles, syringes with needles attached, scalpels and blades, glass ampoules and the sharps from infusion sets (Department of Health 2011).

It is important staff have training and education to deal with waste appropriately to avoid injury or contamination. Training should include:

• risks associated with waste
  
• segregation and handling of waste
  
• use of personal protective equipment (PPE) and personal hygiene
  
• storage and collection protocols
  
• day-to-day procedures
  
• procedures for spillages, accidents and emergencies

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