Understanding ot protocols devyesh shah

1. Understanding OT Protocols &
Guidelines
Dr. Divyesh P. Shah
SightFirst Technical Advisor, MD-322

2. Metamorphosis
of hospitals

3. Patient centric strategies

4. Layout: OT with 10 Beded Ward

5. Operating Room (O.R.)
The operating theatre is a room specifically for
use by the anaesthetist and surgical teams and
must not be used for other purposes.
• Good lighting and ventilation
• Dedicated equipment for procedures
• Equipment to monitor patients, as required for the
procedure
• Drugs and other consumables for routine and
emergency use.

6. General Considerations
1. OT Layout : 2 way entry, Barrier System, Top Floor.
2. Big enough for free circulation : 180 v/s 400 sq ft.
3. Two openings : Towards scrub area.
Towards sterile area
4. Openings fitted with hermetically sealed Doors.
5. Granite or Tiled floor. Porous marble not preferred.
6. Steel or Glazed tile walls, Curved, no angles
7. Operation table to be kept away from the entrance
and head end should be close to the sterile area.
8. Restricted entry of personnel : reduces air pathogens.

7. OT Wall

8. • Between cases, clean and disinfect the table and
instrument surfaces
• At the end of each day, clean the O.R.: start at the top
and continue to the floor, including all furniture,
overhead equipment and lights, use a liquid
disinfectant at a dilution recommended by the
manufacturer
• Sterilize all surgical instruments and supplies after use
and store them protected and ready for the next use
Leave the O.R. ready for use in case of emergency.

9. safe air in OT
1. Air Exchange Rate.
2. Air Flow Pattern.
3. Filtration.
ASHRAE = American Soc. Heating, Refrigerating and Air-conditioning Engineers.
HTM = Health Technical Memorandum, UK
Parameter ASHRAE HTM India
Air Exchange 15 / hour 20 / hour 30
Temperature 17 ~ 27 °C 15 ~ 25 °C 21 ± 3°C
Humidity 45 ~ 55 % RH 40 ~ 60 % RH 40 ~ 60 % RH
Pressure +25 Pa +25 Pa + 15 Pa

10. OT Air
• Split AC in the OT as window AC has direct connection with outside
• Maintenance record
• Maintenance protocol

11. Air Flow Pattern :
LAF with Positive Pressure
Perforated Laminar
Diffuser
Supply Air Duct
Operation Table
Return air
outlet

12. To avoid un-necessary storage of medicine & instruments
Medicines should be kept in proper place
Temperature monitoring & humidity control
OT cleaning protocol & record
Crash Cart for efficient management of instrument & medicine handling
Separate entry & exit point

13. • Air : Fumigation Weekly.
• Walls : Cleaning Daily [including clock, lights,
switches].
• Floor : Daily Cleaning by “Three bucket technique.”
– A simple detergent reduces flora by 80 %
– Addition of a disinfectant reduces it by 95 %
– In busy hospitals, count rise in 2 hours.
• Cleaning of Microscope, Table with disinfectant :
Daily.
• Instrument Cleaning : daily.
General Upkeep

14. Formaldehyde Fumigation
Commonly used to sterilize the OR.
Requirement for an area of 1000 cubic feet :
• 500 ml of 40% formaldehyde in 1.00 L of water.
• Stove or hot plate for heating formalin.
• 300 ml of 10% Ammonia.

15. Autoclaving
• Display of autoclaving instruction
• Autoclave should have vacuum output/air removal point.
• Autoclaving record – details of materials, instruments sets with numbering (eg. Set no. 1, set
no. 2 etc) should be mentioned properly
• Person autoclaving, his signature with date & time should mentioned in the register
• Class-B Sterilizer (Horizontal)
• Indicator strips should be class V
• Indicator strip should be used inside the autoclave & inside of instrument tray to ensure the
authenticity of autoclaving
• Chemical indicator strip outside the drum

16. Autoclaving is suitable for sterilization of most
metallic ophthalmic instruments, except sharp
knives and fine scissors.
 Autoclaving at 121°C for 20 minutes at 15 lbs psi
pressure effectively kills most microorganisms &
spore.
 Types of autoclaves
• Gravity displacement type
• Pre-vacuum type.
• Vertical or horizontal type
High Pressure Steam Autoclaves

17. Class IV and Class V Indicator strips

18. Who is Responsible for Asepsis ?
• Make someone incharge of maintaining Asepsis.
• Infection Control Nurse.
Staph.Aureus 50,000 X
Pseudomonas

19. Microbiological Monitoring :
“Surface Sampling”
• Swabbing and culture for bacteria in OR.
Frequency - Once a month.
• Areas swabbed – In all OR’s
1. Operation table at the head end.
2. Over head lamp.
3. Four Walls.
4. Floor below the head end of the table.
5. Instrument trolley.
6. AC duct. Media for culture
7. Microscope handles - Aerobic : Chocolate Agar.
- Anaerobic : Robertson’s
Cooked Meat Medium.
- Fungi : Malt Agar Media
with antibiotics .

20. Checklist
• To check the temperature, humidity inside OT.
• The differential pressure inside & outside OT.
• Maintenance record of AHU & filter cleaning
frequency.
• Last HEPA filtration report & HEPA validation report.
• Is Air-conditioning done through split AC or AHU?

21. Check list
• Documented procedures to be performed
• Adherence to standard procedural protocols
• Informed consent in proper consent form
• Policies and procedures to prevent wrong patient/
wrong eye/ wrong procedure
• Documented policies of consumables
• Monitoring, management, documentation and
protocols for adverse drug reactions

22. • Qualified medical person to induce General anaesthesia
• Pre-anaesthetic assessment protocols and record
• Immediate pre-op condition
• Informed consent for anaesthesia
• Vitals monitored and recorded
• Post anaesthesia parameters recorded
• Availability of appropriate equipments and medicines to deal
with complications of sedation/ Anaesthesia
• Patient transfer and management protocols and MOU/s with
appropriate facility/s
Checklist

23. Equipment policies & Maintenance

24. Equipment registry
• Tag for each equipment – Identification No, last maintenance date and next
maintenance due date
• Preventative maintenance record for every equipments (calendar schedule of
maintenance)
• Maintenance record and calibration report as per operating manual
• Internal / self calibration report
• Provider name, contact person, contact number for breakdown
• Separate files with above information’s for OPD, Ward & OT
• Checking of medicines & expired medicine (purchased or physician samples)
dispose regularly

25. Medical Records

26. Data maintenance
• MRD -- a separate entity.
• Every files, papers, office stationary in proper place
• Registers for files with identification no
• Labeling for every almirahs & drawers
• EMR facility

27. Record Keeping
• Admission note/preoperative note
• Operating room records usually includes:
• - Patient identity
• - Procedure performed
• - Persons involved
• - Complications.
• Delivery book
• The operative note
• Postoperative notes
• Discharge note

28. Issuing & receiving register
• An issue & receiving register to be develop to
maintain the record for issuing & receiving of
Instruments sets & medicine as per OT schedule
• Documentation of instrument set used per patient

29. Safety Control
• Electricity safety and Power Loss
• Fire Safety
• Biological Hazard
• Reporting of Mishaps/ Just missed events.

30. Biomedical waste policy
• Display of Biomedical guideline in OPD & IPD
• Display Instruction for storage of biomedical
waste at outside OT complex
• Alternative space for waste storage
• Hospital Infection Control Committee
• Documentation of working procedure, action plan
and implementation record
• Treatment of biomedical waste

31. Infection prevention
The facility must be designed in a manner to prevent cross infection between
patients. Things that should be taken care of for this are:
** Inter-bed distance in patient’s wards should be about 6ft
** Accessibility of hand washing basins in each patient areas. Alternatively, hand rub can be
made available near each patient’s bed.
** CSSD should have zoning to separate clean, sterile and general areas
** Operation Theatre should have zoning and engineering controls. The infrastructure
requirements related to OT are important and has been described in detail by NABH.

32. Display on all wash basins

33. Hand Wash
Technique
First – Soap Wash
Use Rotatory movements from
fingertips to elbows with special
attention to the nails and the
webs of fingers.
Rinse thoroughly under running
water in the same manner as
above.
Scrub with soap and water for 7-8
minutes.

34. Human Resource
• Staff knowledge about the facilities available in the hospital – IMPORTANT
• Periodical training program for staff – In-house/Outsourcing – details documented
• Yearly training schedule calendar for staff
• HR back-up policy

35. Human resources
1. Trained staff
2. Technical Skills
3. Task to skill matching for individual
“you can have the best strategy and best
building in the world, but if you don’t have
the hearts and minds of the people who
work with you, none of it comes to life”