Operation Theatre Management

OPERATION THEATRE MANAGEMENT

PAPER-402 Ms. SUSMITA BHAUMIK

An OT is that specialised 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

Function Operating theaters had a raised table or chair of some sort at the center for performing operations, and were surrounded by several rows of seats (operating theaters could be cramped or spacious) so students and other spectators could observe the case in progress. The surgeon wore his street clothes with an apron to protect them from blood stains, and he operated bare-handed with unsterile instruments and supplies. (Gut and silk sutures were sold as open strands with reusable, hand-threaded needles; packing gauze was made of sweepings from the floors of cotton mills.) In contrast to today's concept of surgery as a profession that emphasizes cleanliness and conscientiousness, at the beginning of the 20th century the mark of a busy and successful surgeon was the profusion of blood and fluids on his clothes.

OPERATION THEATRE

The operating theatre is based on whole system thinking and includes a whole of hospital perspective on effective and efficient theatre utilisation.

Goals Key elements to efficient use of operating theatres are: • Effective management • Good communication • Well trained staff • Appropriate facilities and equipment • Operational layout that allows flow of patients. Support services play a large part in maximising efficiency by providing: • Pre-operative preparation and assessment • Available beds • Sterile theatre equipment • Portering, cleaning and maintenance staff. •Effective planning and scheduling systems will enable smooth patient flow thus increasing capacity, improving patient and carer experience, improved employee satisfaction and morale

The operation theatre complex consists of four main systems, •Surgical support system (the environment) •Traffic and commerce (the activities) •Communication and information (the records) •Administration ( the management)

ADMINISTRATION

Overview and strategy

Key elements

Theatre Management structure

Planning patient pathways

Staffing Postponements Operating list management Trauma and emergencies

Theatre design

Effective use of theatre time

Theatre management structure Theatre management structure should be clearly defined with accountability for: •Full budgetary authority •Adequate sessional allowance •Information systems •Utilisation •Administrative, medical and nursing staff. Day to day management should be provided by an experienced trained and skilled theatre manager, who is responsible for clear communication, ensuring competent staffing and suitable equipping of all theatres.   Suitable systems for planning activity should be available to allow allocation of staff, and to respond safely and flexibly when changes take place to routines.   Policies should be developed to deal effectively with changes to operating lists. Operating lists should be clearly posted well in advance and in suitable locations.   Theatre management team should regularly review utilisation, cancellations, list overruns, late starts and waiting lists.

Planning patients pathways Patients pathways should take into account ways to maximise use of theatres and bed availability. Patients admitted to pre-operative units can be transferred to wards following surgery allowing time for discharge of previous patients.

Integration of pre-operative assessment and day case recovery area located adjacent to theatres provides an efficient use of space, skilled staff and may aid patient transport to and from theatres. This scheme also reduces time on ward rounds for surgeons and anaesthetist as patients are in one place.

Staffing Department should provide a system of staffing that works locally and is acceptable to staff •Department staffing should match clinical activity, with sufficient cover for elective and emergencies A lead anaesthetic consultant should be identified to support the theatre management team and trainees •Adequate orientation of new or locum staff should be made a priority •Adequate staffing should be available to cover governance tasks of note recording and data entry.

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 • A system to book critical care beds for elective admissions should be in place and booking confirmed before anaesthesia for surgery.

Theatre design and operational layout Design of operating theatres is essential for maximising patient flow, consideration needs to be made for: • Large multi-purpose accommodation to enable increase in complexity and equipment • Transport routes that flow through stages of theatre care • Internal communication IT systems communication and supervision.

that

facilitate

appropriate

Trauma and emergency surgery Effective planning for emergency and trauma surgery is needed to prevent cancellation of elective surgery. Provision of exclusive emergency list will assist in preventing cancelled elective surgery. Good communication enables clinical decisions to be made rapidly, increasing the number of surgical procedures carried out in a safe time and environment. Time should be allowed for the Anaesthetist to assess emergency patients to their satisfaction. Experienced surgical staff should prepare patients who have multiple and complex medical problems, this can prevent cancellation at anaesthetic assessment. Pre-operative assessment for patients who are elderly, have multiple and complex medical problems can benefit from a team approach between anaesthetist, surgeon and physician.

Cancellations of surgery It is extremely distressing and stressful to patients who are postponed surgery, many cancellations can be prevented by assisting patient flow with good planning in: • •

Pre-operative assessment Increased communication

Regular review of cancellation can assist with target areas for redesign and innovation. Cancellation data should be collected and reviewed weekly with agreed action plans.

It is essential for operating theatre innovation to have a skilled, trained and committed innovation team.The team should consist of representatives of all theatre staff groups. Management – clinical/non clinical Nursing – Pre op and theatres, including operating department practitioners Clinical – Anaesthetist/Surgeons Administration – Admin and Portering

Processes Initial recording of overall patient processes should be made covering: Admission

Receive patient to ward following operation

Administration Processes will also need to map demonstrating process from: Allocation to theatre list

Theatre reception on day of operation

Processes Process map groups

Theatre

Theatre

Bed

ICU

Theatre

Recovery

Recovery

Theatre

Theatre

ICU

Home

Bed

HDU/ITU

ICU

Bed

Home

Bed

Bed

Home

Home

Home

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. 9.00 am Case 1

Case 2

Case 3

1 2.30pm

Processes Process steps examples

Step Patient transported from ward Patient checked in to theatre Patient taken to anaesthetic room Anaesthetic given Patient positioned onto theatre table Surgery completed Patient taken to recovery area Patient in post op Patient taken to ward Theatre hands over patient to ward

Time per step (min) 5 5 2 10 5 40 5 20 5 5

Processes Process steps examples

Step

Time per step

Patient transported from ward

5

Patient checked in to theatre

5

Patient taken to anaesthetic room

2

Anaesthetic given

10

Patient positioned onto theatre table

5

Surgery completed

40

Patient taken to recovery area

5

Patient in post op

20

Patient taken to ward

5

Theatre hands over patient to ward

5

COLOUR

Processes Build your schedule Use graph paper with one square per minute to sequence time scales per procedure.

1 MINUTE

102 MINUTES

DATA Core data set Suggested Measures Late Starts (e.g. >15mins) / Early Finishes (e.g. >60mins) / Overruns (e.g. >30mins) • Example – For ten Orthopaedic sessions with a scheduled start time of 8:30am the sample showed four (or 40%) started >15mins late. • Number of Major Procedures (>1hr) v Minor Procedures (