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THEATRE PRACTICE POLICY

Reference Number:416 2009

Author & Ti tle: Heather Cooper, Lynn Wallace, J ustineArchman, Pippa Humphries, Lynn Howes.

Responsible Directorate: Surgical

Review Date: September 2012

Ratif ied by (committee): Surgical Board

Date Ratified: September 2009

Version: 2

Related Policies


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Document Name: Theatre Practice Policy Ref 416/2009

Issue Date: September 2009 Status: Final

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Index:

POLICY _______________________________________________________________________ 7

INTRODUCTION _______________________________________________________________ 7

SECTION A ANAESTHETIC STANDARDS ______________________________________ 7

Anaesthet ic Theatre Standards Contents ________________________________________ 7

Anaesthet ic Theatre Standard No 1 _____________________________________________ 8

Anaesthet ic Theatre Standard No 2 ____________________________________________ 10

Materials & Equipment for both Adult & Paediatric ______________________________ 10

Anaesthet ic Theatre Standard No 3 ____________________________________________ 11Anaesthet ic Theatre Standard No 4 ____________________________________________ 12






Anaesthet ic Theatre Standard No 10 ___________________________________________ 16





Anaesthet ic Theatre Standard No 15 ___________________________________________20



Anaesthet ic Theatre Standard No 18 ___________________________________________22Anaesthet ic Theatre Standard No 19 ___________________________________________23




Anaesthet ic Theatre Standards No 23 __________________________________________27



Anaesthet ic Theatre Standards No 26 __________________________________________29


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Step One: ____________________________________________________________________30

Step Two: To prepare the collection system ____________________________________30

Step Three: Preparing the machine and disposables ____________________________31Step Four: Inspect & Finish ____________________________________________________32

Trouble Shooting _____________________________________________________________32


Prior to receiving a child into the anaesthetic room _____________________________34

Ensure the location and availability of the following _____________________________34

Please refer to the following Anaesthetic Theatre Standards _____________________36

Anaesthet ic Standard No 28 ___________________________________________________36




Anaesthet ic Standard No 32 ___________________________________________________42

Anaesthet ic Standards No 33 __________________________________________________44



Anaesthet ic Theatre Standard No 36 ___________________________________________47Anaesthet ic Theatre Standard No 37 ___________________________________________48

Operating Theatre Standard 38 ________________________________________________49

Anaesthet ic Standard 39 ______________________________________________________50

Operating Theatre Standard 40 ________________________________________________51



Operating Theatre Standard No 1 ______________________________________________57

Operating Theatre Standard No 2 ______________________________________________58

Operating Theatre Standards No 3 _____________________________________________59

Exceptions: None___________________________________________________________ 60

Operating Theatre Standard No 4 ______________________________________________ 60

Addenda to Collection of Specimens Standard__________________________________ 61

No 4a Localised Excision of Breast Lesion: _____________________________________ 62

No.4b Other Breast Specimens:________________________________________________ 62

No 4c) Frozen Sections: _______________________________________________________ 62


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No 4d) E.N.T. Specimens: _____________________________________________________ 63

No 4e Foetal Tissue and Remains ______________________________________________ 63

Operating Theatre Standard No 5 ______________________________________________ 64Operating Theatre Standard No 6 ______________________________________________ 64

Operating Theatre Standards No 7 _____________________________________________ 65



Operating Theatre Standard No 9A _____________________________________________ 68

Operating Theatre Standard No 10 _____________________________________________ 69




Operating Theatre Standard No 13A ____________________________________________ 74





Operating Theatre Standard No 17a ____________________________________________ 80Radiation Protection __________________________________________________________ 80

Standard Statement: __________________________________________________________ 80






Standard: ____________________________________________________________________ 86

Sharps use and safe disposal. _________________________________________________ 86

Method: ______________________________________________________________________ 86

Compliance: 100%_________________________________________________________ 86



Operating Theatre Standard No 25 _____________________________________________90

Addenda to Swab and Instrument Counts Standard No 25_______________________91


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No 25a: Swab and Instrument count for Obstetric Emergencies.__________________91


Sterile Services Unit Documentation ___________________________________________92Operating Theatre Standard No 27 _____________________________________________93




See also______________________________________________________________________99


Operating Theatre Standard No 33 ____________________________________________ 100




Wound, drain and catheter dressings. _________________________________________ 103

Method: _____________________________________________________________________ 103

Reference: NATN Principles of Safe Practice in the Perioperative Environment1998 104

Operating Theatre Standard Number 37 _______________________________________104

Operating Theatre Standard No. 38____________________________________________104

Operating Theatre Standard No. 39____________________________________________105

Operating Theatre Standard No 40 ____________________________________________106


Ordering:____________________________________________________________________108

Receipt:_____________________________________________________________________108

Use: ________________________________________________________________________109


SECTION C POST ANAESTHETIC CARE UNIT STANDARDS ___________________110

ORSOS Layout of PACU Standards Of Care____________________________________110

Maintenance of temperature 5 ________________________________________________110

High Dependency Care 16 + 17 _______________________________________________111

PACU Standard No 1 _________________________________________________________112

PACU Standard No 2 _________________________________________________________112

PACU Standard No 3 _________________________________________________________113

PACU Standard No 4 _________________________________________________________114


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PACU Standard No 5 _________________________________________________________115

PACU Standard No 6 _________________________________________________________116

PACU Standard No 7 _________________________________________________________117 PACU Standard No 8 _________________________________________________________118

PACU Standard No 10________________________________________________________119

PACU Standard No 10a_______________________________________________________120

PACU Standard No 10b_______________________________________________________121

PACU Standard No 11________________________________________________________122

PACU Standard No 12________________________________________________________123

PACU Standard No 13________________________________________________________124

PACU Standard No 14________________________________________________________124

PACU Standard No 15________________________________________________________125

PACU Standard No 15a_______________________________________________________126

PACU Standard No 15b_______________________________________________________127

PACU Standard No 16________________________________________________________127

PACU Standard No 17________________________________________________________128

PACU Standard No 18________________________________________________________129

CONSULTATION CHECKLIST_________________________________________________131


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POLICY

INTRODUCTION

All healthcare professionals have a duty to set a standard by which to practice. With afocus on clinical effectiveness and evidence based care theatre staff must be able todemonstrate the ability to audit nursing and theatre practice. The care that is deliveredand improvements in practice must be based on evidence and best practice.

The aim of this policy is to outline the standards of care that must be delivered to eachindividual patient to ensure a high quality of care is provided to patients entering theOperating Theatres.

The objectives of the policy are:

To ensure that a standard of care is delivered to each individual that isequitable and fair.

To identify the standards of care to be delivered to patients through all theareas within the operating theatres i.e. anaesthetic room, Operating

Theatres and the Post Anaesthetic Care Unit. To enable auditing of nursing practice throughout all areas. To ensure all staff are aware of standards of care to be delivered to

patients whilst in the Operating Theatre Department.

To provide information to all staff of the departments expectation of thestandards of care to be delivered to all patients.

Scope of the Policy

These standards of care will apply to all Operating Theatres across the Royal UnitedHospital site.

Day Surgery care standards will apply to all patients cared for in the Day Surgery Unit.

All new members of staff will receive an electronic copy of the standards applicable to the

area they will work in. All staff will be able to access the care standards via desktops inthe Department.

SECTION A ANAESTHETIC STANDARDS

Anaesthet ic Theatre Standards Contents

Appropriately receive patients for clinical procedures Safely prepare and transfer patients for clinical procedures Safely position patients for clinical procedures Appropriately prepare the anaesthetic room and operating theatre ready for

adult/paediatric anaesthesia dependent on theatre operating list


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The anaesthetic assistant is competent in the location and use of all emergencyequipment required within their working environment

The patients temperature is maintained at the optimum level appropriate to surgery Safely and competently prepare materials and equipment for intravenous infusion

and transfusion Patients physiological parameters are adequately monitored during the induction of

anaesthesia The patient is safely transferred to the operating table from the bed or trolley All staff to attend mandatory training Faulty equipment is dealt with promptly and in the correct manner The anaesthetic care plan/ORSOS is accurately completed according to the

patients individual needs and received care The anaesthetic assistant appropriately assists the anaesthetist during the reversal

of anaesthesia Safely prepare and monitor anaesthetic materials and equipment Safely monitor and maintain medical gas supplies within the operating department Ensure the patient is adequately prepared for clinical procedures Safely assist in venous and arterial cannulation during clinical procedures for both

adult and paediatric patients Assist in the establishment and maintenance of the patients airway both adult and

paediatric Accurately monitor the physiological parameters and fluid balance of patients

undergoing clinical procedures Competently identify and respond to clinical emergencies Competently assist the clinician in treating patients during clinical emergencies Identify the need for and perform immediate life support

Anaesthet ic Theatre Standard No 1

Standard:Anaesthetic room and operating theatre preparation

Standard StatementThe anaesthetic room and operating theatre is appropriately prepared ready for

adult/paediatric anaesthesia dependent on theatre list and the anaesthetists requirementsMethod: All anaesthetic staff will have the required training, skills and knowledge, and will

have been assessed as competent The anaesthetic machine in the anaesthetic room and the anaesthetic machine in

the operating theatre should be checked following the manufacturers guidelines, i.e.cylinders and pipeline gases, vaporisers, breathing circuits, suction, ventilator,alarms, oxygen analyser, capnograph, airway manometer, spirometer andanaesthetic gas analyser (please refer to the royal college of anaesthetistsguidelines for checking all anaesthetic machines)

All patient breathing circuits should be changed at the start of each day, the

spirometer, CO2 line, pressure monitor tube and D-lites are now disposable items


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therefore should be replaced every Monday morning, please ensure that these linesare replaced when visibly soiled

Full monitoring should be available and ready for use, i.e. ECG, pulse oximeter,

capnograph, non invasive blood pressure, invasive blood pressure, spirometer,nerve stimulator and temperature monitor

The following equipment should be available at all times including during localanaesthetic procedures-

o Airway management trolleyo Laryngoscopes (McCoy, Polio, Standard Mcintosh & long blade)o A selection of cuffed endotracheal tubes for adults and uncuffed

endotracheal tubes for paediatrics appropriate to the type of surgical oranaesthetic procedure

o Appropriate oral & nasal airwayso Bougie introducer and styletso Suctiono Mcgill forceps

Anaesthetic Theatre Standard No 1 conto Selection of securing tapeso Invasive/spinal/epidural trolleyo Specialised needleso Basic packso Specialised dressingso Local anaesthetico Sodium chlorideo

Selection of needles and syringes

o Arterial and central venous equipment The anaesthetic room should be checked to ensure adequate stock levels of all

items that may be required appropriate to that speciality Specific paediatric equipment should be prepared appropriately for the patients

weight and size, please see paediatric standards The temperature in the anaesthetic room/operating theatre will be adjusted

accordingly dependent on the patients individual needs The anaesthetic room and all equipment should be clean after each patient and

kept tidy at all times Emergency equipment should be available, in good working order, within the

department in the designated areas at all times, and when in use documented onthe appropriate information boards

Equipment found to be faulty should be sent to the appropriate department forrepair and a replacement obtained if necessary

Any missing equipment should be traced and returned Play equipment should be readily available and used if appropriate (advice from the

play specialist in the childrens unit can be sought)

Compliance 100%

Exceptions None


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Reference Southampton University Hospital -ODP Level 3 Standards (Sept 2000)AODP/HPC Standards

Please refer to Paediatric Standards (PACU)Royal college of anaesthetists guidelinesAnaesthetic Standard No 20 (temperature)


Standard:Anaesthetic materials and equipment

Standard Statement:All anaesthetic materials and equipment are safely prepared and monitored in preparation

of the list and continuously throughout

Method: All staff must undertake the appropriate training and deemed competent in the use

of materials & equipment prior to use Ensure the correct materials and equipment are selected and prepared according to

the clinical speciality, the type of anaesthesia to be given, the requirements of theoperating list, and patients individual needs

Ensure all materials and equipment are prepared in the appropriate manner andtime, according to the patients clinical status

(i.e. elective or emergency) Ensure all equipment is checked and confirmed as safe, ready for use & functioning

correctly Ensure all equipment is set up & calibrated correctly in line with the manufacturers

instructions, and to meet the needs of the overall operating list and the patients planof care

Where equipment is found to be faulty or unsafe during preparation, the appropriateaction is taken to remedy or report the fault ( Refer to anaesthetic standards forfaulty equipment)

Ensure all materials and equipment are positioned in a way which facilitates theiraccess and use, according to the sequence of procedures on the operating list

Ensure all materials and equipment are handled and moved safely, correctly &hygienically, in accordance with manufacturers guidelines & infection control

Anaesthetic machine checks should be carried out using the royal college ofanaesthetists guidelines

Materials & Equipment for both Adult & Paediatric

Anaesthetic machines Ventilators Vaporisers

Breathing systems Vascular access/epidural/spinal procedure packs


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Specialised needles Suction apparatus Hotline fluid warmer and bear hugger Airway management trolley Invasive/spinal/epidural trolleys Laryngoscopes Intubation aids Endotracheal tubes (cuffed, uncuffed, preformed, endobronchial, laser, ILMA) Airways both oral & nasal HMEs Laryngeal mask airways Proseals ECG

Pulse oximeter NIBP/IBP Invasive blood pressure monitors and transducers Capnogragh Spirometer Disconnection alarms Nerve stimulator Temperature monitoring probes and equipment Intravenous fluids Syringes and Drugs

Compliance 100%Exceptions NoneReference Southampton University hospital - ODP level 3 Standards

AODP/HPC GudelinesPaediatric Standards (PACU)Royal college of anaesthetists guidelines


Standard:

Arterial cannulation

Standard Statement:Safely assist in arterial cannulation during clinical procedures for both adult and paediatricpatients

Method: Ensure the patient is offered appropriate information, support and reassurance in a

sensitive manner Ensure the care provided to the patient is consistent with their individual needs,

plan of care & expressed personal beliefs, & preferences, within the constraints ofthe setting and the clinical procedure


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Ensure that the required materials & equipment are made available & ready for usebefore the arterial cannulation procedure is started

Ensure the specified cannulation site is prepared & cleaned effectively, and in a

way which optimises the patients comfort, dignity & safety and that the site isprepared to provide optimal conditions to facilitate cannulation

Ensure the canula/line is secured adequately & safely, to facilitate access andminimise patient discomfort

Ensure the transducer line is clearly labelled and identifiable as an arterial line Ensure universal precautions for infection control are applied correctly and that

waste & sharps are disposed of safely in the correct manner.

Compliance 100%

Exceptions None

Reference Southampton University Hospital - ODP level 3 StandardsPaediatric Standards (PACU)Manufacturers guidelines for setting up transducersAODP/HPC Guidelines


Standard:Airway maintenance and establishment

Standard Statement:Assist in the establishment and maintenance of the patients airway both adult andpaediatric

Method: All staff assisting in the establishment and maintenance of a patients airway will

have under gone the appropriate training and deemed competent Ensure liaison with the lead anaesthetic clinician and surgical clinician where

appropriate Ensure the required airway establishment & maintenance materials and equipment

are selected, according to the patient and the procedure, confirmed as fit for use,and prepared correctly at the appropriate time

Ensure the patient is offered the relevant information, reassurance & support in amanner which is sensitive to their needs & concerns

Appropriate action is taken to optimise the comfort & dignity of the patientthroughout & to minimise pain & trauma

Ensure the patient is appropriately positioned for the procedure (rapid sequenceinduction, oral/nasal intubation, tracheostomy, awake fibre optic intubation)

Ensure all materials & equipment are handled correctly & safely throughout, in linewith manufacturers instructions

Ensure patients physiological parameters are monitored throughout the procedure Ensure all devices used to maintain the patients airway are secured appropriately


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Apply universal precautions for infection control at all times Ensure that any signs of the patients airway being compromised is recognised

promptly and the appropriate action is taken immediately

Compliance 100%

Exception None

Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)AODP/HPC Guidelines


Standard:Clinical emergencies

Standard Statement:All staff to competently identify and respond to clinical emergencies

Method: Ensure observation and monitoring of the patients condition is sufficient to identify

clinical emergencies as soon as they occur Ensure any signs or symptoms of an actual, or potential, clinical emergency is

identified correctly and reported to the appropriate clinician Ensure the priorities for the patients care are identified promptly and accurately and

appropriate action is taken immediately Ensure the patients vital functions are maintained pending attendance of medical

staff and during interventions Ensure the relevant items of equipment are obtained promptly, prepared correctly

for use and made available to the appropriate clinician

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsAODP/HPC GuidelinesPaediatric Standards (PACU)RUH ILS Information pack


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Standard:Clinical emergencies

Standard Statement:All staff to competently assist the clinician in treating patients during clinical emergencies

Method: Ensure the patients condition, and the clinicians actions, are monitored closely to

determine what assistance is needed during the clinical emergency Ensure delegated activities are carried out promptly and correctly Ensure the required materials and equipment are made ready and available for use

by the appropriate clinician Ensure the required drugs and diluents are obtained promptly as requested by the

clinician Ensure the patient is given appropriate support and reassurance throughout Universal precautions for infection control are applied correctly Ensure all relevant information is clearly and accurately recorded in the appropriate

documentation

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)AODP/HPC GuidelinesRUH ILS information pack


Standard:Documentation is completed accurately and legibly for all patients

Standard StatementThe anaesthetic care plan/ORSOS is accurately completed according to the patientsindividual needs and received care

Method: All staff to complete ORSOS training All documentation to be legibly written, signed and dated Pre-operative care plan is checked for accuracy Al patient intervention is documented in full on ORSOS

Items are recorded on the care plan, Tray labels, LMA labels etc for traceabilitypurposes


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The care plan is evaluated for accuracy throughout the peri-operative period andchanges to care documented

Compliance 100%

Exceptions When the admitted patient is unconscious, directfrom A&E or ITU to theatre in a life threatening situation

Reference Southampton University Hospital ODP level 3 StandardsOrsos StandardsAODP/HPC Guidelines


Standard:Emergency equipment location and use of

Standard Statement:The anaesthetic assistant is competent in the location and use of all emergencyequipment required within their working environment

Method: All theatre practitioners working within anaesthetics will have undertaken the

necessary training to gain the knowledge and skills required, they will have been

assessed as competent

The anaesthetic assistant will know the whereabouts of all emergencyequipment/materials

All should undertake the mandatory ILS/BLS course and be deemed competent Competence in location and use of:-

o Airway management trolleyo Paediatric airway management trolleyo Difficult intubation trolley (including fibre-optic bronchoscope)o Cook exchange catheterso Tracheostomy (minitrach/manujet)

o Portable monitoring, ventilator and suctiono Emergency drugs/Cardiac arrest drugso Ambu-bago Defibrillator

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)

AODP/HPC Guidelines


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Standard:

Management of faulty equipment

Standard Statement:Faulty equipment is dealt with promptly and in the correct manner in conjunction with themanufacturers guidelines

Method: Equipment is made safe and withdrawn from use Staff to be aware of the appropriate repair requisition forms, the process in which to

liaise with the appropriate department and arrange for repair The appropriate member of senior staff are informed of any faults or breakages Records are kept of equipment sent for repair Equipment is decontaminated before sending for repair Manufacturers instructions are available and followed

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsAODP/HPC Guidelines


Standard:Preparation of and connection of intravenous infusions, delivery lines and transfusion

Standard Statement:Staff will safely and competently prepare materials and equipment for intravenous infusion,delivery lines and transfusion after liaison with the lead anaesthetic clinician

Method:

All staff have undertaken the appropriate training and assessed as competent withthe necessary knowledge regarding fluid/drug incompatibilities and route of delivery

The appropriate cannulae, administration sets and infusion equipment are preparedin the appropriate manner and time

All patient delivery lines and infusions to be labelled appropriately along the wholelength of the line intermittently paying particular attention to the distal ends witheither a label with IVI (Intra Venous Infusion) written on it or the appropriatecoloured DRUG label ( i.e. METERAMINOL/EPHEDRINE/EPIDURAL)

All delivery lines and infusions to be labeled correctly with the date and time ofpreparation and the name of the practitioner setting up the infusion

The fluid, rate and volume are to given as prescribed and recorded correctly on tothe fluid chart, anaesthetic chart or observation chart


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Two trained practitioners to confirm the solution required and the correct connectionsite prior to connection, and prior to the commencement of the solution

Asepsis and universal precautions are to be maintained throughout The cannulae site is secured and supported, observed regularly and any

irregularities reported and documented Appropriate connectors are used for multiple infusions, and filters used where

necessary Trust policy is adhered to regarding the checking and administration process by the

competent practitioners Pressure bags, hotlines and level 1 rapid infusers are used where required and

along with manufacturers guidelinesCompliance 100%

Exceptions None


AODP/HPC GuidelinesUniversal Precautions and Health and Safety Standards


Standard:Patients physiological parameters are adequately monitored during the induction of

anaesthesia

Standard Statement:All staff prepare for the safe induction of anaesthesia, taking into account the anaesthetistrequirements

Method: The patient is given appropriate information, support and reassurance throughout

the attachment of monitoring The physiological parameters of the patient are monitored accurately using the

correct non-invasive equipment Non invasive monitoring includes:- Pulse oximeter, ECG, NIBP, Capnograph and

nerve stimulator Monitoring is carried out in a way which optimises the patients comfort, dignity and

safety Any required measurements are interpreted accurately, and recorded correctly

using the required format Any deviation from acceptable limits is identified correctly and appropriate action

taken immediately, by informing the lead anaesthetist Universal precautions for infection control are applied correctly

Compliance 100%Exceptions None


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Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)Universal Precautions & Infection Control policy

AODP/HPC Guidelines


Standard:Immediate life support

Standard Statement:All staff able to identify the need for and perform Immediate Life Support

Method: Ensure all staff attend the ILS course Ensure the need for immediate life support is identified correctly Ensure medical assistance is summoned immediately Ensure the patients airway is established and maintained Ensure the patient is placed in a position which facilitates Immediate Life Support Ensure external cardiac compression and ventilation of the lungs are performed

correctly Ensure the patients physiological parameters are monitored appropriately and any

variations or abnormalities are reported immediately to the clinician Ensure a detailed log of events are recorded accurately in the patients medical and

nursing notes Universal precautions for infection control are applied correctly

Compliance 100%

Exceptions NonePlease see paediatric standards in PACU

Reference Southampton University Hospital ODP level 3 StandardsMonitoring physiological parameters standardAssist at establishing the patients airway standards

Paediatric Standards (PACU)AODP/HPC Guidelines


Standard:Mandatory training responsibilities

Standard StatementAll staff to attend and take responsibility for their individual mandatory training needs


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Method: Staff to take individual responsibility for keeping up to date with mandatory

requirements Staff and management produce evidence that all statutory training requirements

have been met in the following areas:- COSHH FIRE BLS/ILS/PBLS Manual handling Infection control Health and safety Risk management

Staff appraisal is done annually to assess individuals needs and to produce awritten action plan

Compliance 100%

Exceptions None

Reference RUH Mandatory Training Policy & Procedure


Standard:Position patients safely for clinical procedures

Standard Statement:Theatre staff will ensure that all patients are positioned safely in accordance with theproposed operation and the clinicians requirements

Method: The patient is offered the appropriate information, support and reassurance in

accordance with their individual needs and the proposed plan of care, relevant tothe specific operative procedure

The required positioning equipment is confirmed as safe and in good working order Any necessary assistance is sought from appropriate colleagues and clinicians

before starting the positioning procedure Safe and suitable moving and handling techniques are used throughout the

positioning of the patient taking into account their conscious level Positioning equipment is used safely and correctly to create the required position,

without causing harm to the patient or to staff, Positioning is carried out in a way which minimises the patients pain and discomfort,

and which maximises their dignity The patient is observed during positioning and any unexpected change is

recognised and the appropriate action taken without delay


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Appropriate padding support and covers are used to prevent patient injury andexcessive heat loss

The patient is positioned correctly to meet the requirements of the clinical

procedure, anaesthetist and surgeon

Compliance 100%

Exceptions None



Standard:Patient preparation prior to clinical procedures

Standard Statement:All staff to ensure the patient is adequately prepared for clinical procedures

Method: Ensure the patient is offered the appropriate information, support & reassurance in

a sensitive manner

Ensure operative site (draping, skin preparation & hair removal) is preparedcorrectly and safely, and in a manner which optimises the patients dignity, comfortand safety

Ensure that information is given to the patient (alert & orientated or disorientated) ina way which facilitates their understanding, and promotes the confidence in the careteam

Ensure that all questions & concerns from the patients are answered clearly &appropriately by the relevant member of the team

Ensure all care provided to the patient takes due account of their individual needs.Plan of care & expressed personal beliefs, preferences & views, within theconstraints of the setting & the procedure

Ensure the patients operative site is identified correctly, marked & any uncertaintiesare clarified with the appropriate member of the theatre team prior to thepreparation starting

Ensure all equipment and materials are selected & used correctly in a mannerwhich minimises risk to all

Ensure that the patient is prepared in accordance with the requirements of theprocedure and the clinician, & the assessed needs of the patient

Ensure that the appropriate site for attaching equipment is selected, attached &repositioned as necessary in accordance with the requirements of the clinicalprocedure

Ensure all waste is disposed of safely & correctly (refer to Waste policy)


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Compliance 100%

ExceptionsNone

Reference Southampton University hospital ODP level 3 StandardsPaediatric Standards (PACU)AODP/HPC Guidelines


Standard:Physiological parameters and fluid balance

Standard Statement:

All anaesthetic assistants to accurately monitor the physiological parameters and fluidbalance of patients undergoing clinical procedures

Method: Ensure the patient both adult & paediatric, is given the appropriate information,

support & reassurance throughout Ensure the patients physiological parameters and fluid balance of the patient are

monitored accurately using the correct technique & equipment Monitoring is carried out in a way which optimises the patients comfort, dignity &

safety

Any required measurements are interpreted accurately, & recorded correctly usingthe required format Any deviation from acceptable limits of the patients physiological parameters and

fluid balance is identified correctly, and appropriate action is taken immediately byinforming the lead anaesthetic clinicians

Universal precautions for infection control are applied correctly

Compliance - 100%

Exceptions - None

Reference Southampton University Hospital ODP level 3 StandardsRUH Universal Precautions PolicyInfection Control PolicyPaediatric Standards (PACU)AODP/HPC Guidelines


Standard:Receive patients for clinical procedures

Standard Statement:


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Appropriately receive patients for clinical procedures, ensuring the patient received is thecorrect patient as stated on operating list, and that the proposed operation correlates withthe op list, consent form and patients wishes

Method: The patient and any accompanying personnel are welcomed in an appropriate

manner, detailing name and role, offering support and reassurance throughout The patient identity is confirmed with the patient and against relevant records such

as checking patients notes, completed ward check sheet, operating list and consentform and patient identity band, questioning the patient, inspecting the operation siteand checking with accompanying person that all details are correct

The appropriate checks are made and recorded to confirm that all requiredpreparation has been completed such as, Hospital number, date of birth, allergies,removal or retained dentures, fasting, removal of jewellery, nail varnish and falsenails, the location of prosthesis and any relevant past medical history

Dentures and hearing aids and other sensitive prosthetics such as wigs, may beretained until the patient is in the anaesthetic room. These will then be removed andreturned to the ward by the accompanying ward escort

Details of the proposed procedure, operation site marking and date on the consentform are checked and confirmed with the patient

Any items or medication that the patient may need in the immediate post operativeperiod such as hearing aids or dentures and inhalers or sprays should be clearlylabeled with the patients details and kept with the patients records until safe arrivalinto PACU

Any problems identified are investigated and recorded, and where necessary thesurgeon and/or anaesthetist are informed and the appropriate remedial action taken

Compliance - 100%

Exceptions None



Standard:The reversal of anaesthesia

Standard Statement:The anaesthetic assistant appropriately assists the anaesthetist during the safe reversal ofanaesthesia

Method: Planning the patients extubation and reversal of anaesthesia must always be in

consultation with the lead anaesthetic clinician


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Staff must have the appropriate training and be competent to carry out thisprocedure

During the reversal of anaesthesia the theatre environment is kept as quite as

possible Suction apparatus is available and in good working order with a clean yankeur

sucker and suction catheters available The patient should be positioned correctly on the bed/trolley as required by type of

anaesthetic The airway management trolley is well stocked and available in close proximity to

the patient The anaesthetic assistant prepares any necessary equipment specifically required

by the anaesthetist for the patient concerned emergency re-intubation equipmentshould be readily available

The anaesthetic assistance should provide any assistance required by theanaesthetist and should continue to care for the patients safety and dignity Once the anaesthetic is reversed and the patient is breathing spontaneously and

adequately, oxygen should be provided for the transfer to recovery

Compliance 100%

Exceptions None


Universal Precautions & Infection Control PolicyAODP/HPC Guidelines


Standard:Transfer patients for clinical procedures

Standard Statement:Theatre staff will ensure that theatre is prepared ready for the safe transfer of patients forclinical procedures

Method: The appropriate method and route of transfer is selected e.g. pat slide and

equipment checked for its integrity The patient is informed of the nature and purpose of the transfer in a manner which

encourages their cooperation To ensure the immediate surroundings are prepared appropriately for the transfer

from the patients bed to the operating table All potential hazards are recognised and removed Safe and suitable moving and handling techniques are used throughout the transfer


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Patients level of consciousness is taken into account prior to the transfer and theappropriate support equipment is secured during the transfer, and care is taken notto damage or displace it

The conscious patient is offered reassurance and support throughout the transfer The patient monitored during the transfer, and any unexpected changes are

recognised, and dealt with appropriately without delay The transfer is carried out in a way which minimises the patients pain and

discomfort and maximises their dignity The transfer must be directed by the person at the head of the patient, taking

responsibility for the transfer in accordance with manual handling guidelines

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)Patient Transfer Standard No 21AODP/HPC Guidelines


Standard:Temperature maintenance

Standard Statement:The patients temperature is maintained at the optimum level appropriate to the surgicaland anaesthetic requirements

Method: Room temperature and humidity are within an acceptable range:- humidity 45% -

55% and temperature 19 21 degrees Warming devices should be available for use if required Temperature monitoring equipment and devices should be used if warming or

cooling aids are used during any procedures Main theatre doors should not be used intra-operatively and traffic flow through

theatre should be according to operational policy

Compliance 100%

Exceptions The theatre temperature may vary according to the age, and weight of the patient, e.g. Paediatrics



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Standard:

Patient transfer from bed to operating tableStandard Statement

The patient is safely transferred to the operating table from bed or trolley under theinstruction of the person at the head of the patient

Method: All members of staff had undertaken the mandatory manual handling training The operating table is correctly positioned with the brakes on, brakes also engaged

on the bed/trolley Table attachments for positioning are available Appropriate moving aids are available and correctly used An appropriate number of staff are readily available for moving of patient, maximum

load per person 25kg,I.e. 75kg patient 3 people, 80kg 4 people

The member of staff at the head of the patients must co-ordinate the movement The patient is supported in all areas during transfer Patients limbs are secured and protected from injury All monitoring equipment, iv infusion, catheters etc, are safeguarded A qualified member of staff must be present at all times Pressure care is given as appropriate The patients dignity is maintained throughout manoeuvre

Compliance 100%

Exceptions Patients size and injuries may dictate safe alternativemovement and procedure

Reference Southampton University Hospital ODP level 3 StandardsAnaesthetic Standards for Safe TransferPaediatric Standards (PACU)AODP/HPC Guidelines


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Standard:Transfer of patients from the operating theatre to the post anaesthetic care unit (PACU)

Standard Statement:Staff will ensure the safety and dignity of the patient during the transfer from theatre toPACU post operatively, and ensure full handover takes place

Method: A qualified theatre practitioner will accompany the patient and the anaesthetist

during the transfer Ensure the bed is appropriate for the patient type Ensure all drains, catheters, infusion etc are protected and are not pulled or

dislodged accidentally during the transfer Care should be taken to ensure that limbs remain in an appropriate anatomical

position Ensure the patient is moved only at the command or permission of the anaesthetist

(if no anaesthetist present, the member of staff at the head of the patient will co-ordinate the transfer)

Ensure the patient is moved carefully and placed in a position appropriate for thesurgery undertaken and to ensure an adequate airway is maintained

Monitoring should be removed on the instruction of the anaesthetist

All patients should have an adequate supply of oxygen during the transferavailable, and an appropriate oxygen delivery system e.g. Hudson mask or T-bag

Ambu-bags should be available at all times Cot sides should be raised during movement of the bed and for transfer of patient to

PACU The patient must remain covered to protect dignity at all times during the transfer

process Theatre staff will ensure the exit route is clear to facilitate rapid transfer Cot side guards should be used as necessary On arrival to PACU an appropriate bay will be located. The bed or trolley will be

positioned to allow access to the head of the bed, and the brakes applied Theatre staff will assist in the application of the oxygen delivery system and full

monitoring as required The anaesthetic assistant will handover any relevant information concerning the

patient to the Designated PACU staff member The scrub practitioner should handover any relevant information regarding the

surgical procedure etc to the PACU practitioner, any property to the patient shouldalso be transferred to PACU

All relevant documentation should accompany the patient and should be completed Using the ORSOS printout, theatre staff will handover to PACU all relevant details

i.e. operation performed, skin closure, dressings, drains, catheters, any local

anaesthetics given, any items left in situ requiring later removal


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Other relevant patient care details such as pressure are problems, known skinbreaches or adverse reactions must be recorded in the peri-operative printout andhanded over to PACU for communication to the ward staff

The theatre staff will sign the printout on completion of handover

Compliance 100%

Exceptions None


Transferring patients from table to bed Standard No 21Patients safety and dignity StandardAODP/HPC Guidelines

Anaesthet ic Theatre Standards No 23

Standard:Transfer of patients from theatre to ITU/HDU

Standard Statement:All patients requiring ITU/HDU postoperatively will be transferred safely and rapidly

Method: Once it is identified that the patient will require an ITU/HDU bed, the anaesthetist

will ascertain its availability, and inform the ITU anaesthetist and staff of patientsrequirements

The transfer will be discussed with the anaesthetist to allow accurate preparation The anaesthetic practitioner will liaise with ITU on the collection of the ITU bed,

Oxylog ventilator, full monitoring unit and Oxygen cylinder, and organise thecollection with a theatre orderly

The anaesthetic practitioner will ensure the orderly returns the ward bed back to thecorrect ward, and that the ward is notified of the patients projected destination

The anaesthetic Practitioner will ensure that the following accompany the patient to

ITUo Ambu-bago Emergency drugso Additional intravenous fluido Oxygen cylinder applicable to ambu-bag connectiono Patient notes, x-rays and theatre ORSOS form The anaesthetic practitioner and scrub practitioner will accompany the lead

anaesthetist and the patient during the transfer to ITU A member of the theatre team will phone ITU/HDU to advise that transfer and

arrival of the patient is imminent An orderly will be directed to call for and hold a lift to facilitate as rapid a transfer as

possible


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The patients physiological parameters will be monitored closely during the transferand any deviation remedied immediately

On arrival to ITU the theatre staff will ascertain which entrance is the most

appropriate for the available bed space and direct the transfer team accordingly Once the anaesthetic handover has been completed and the patient is settled, the

accompanying theatre members will ensure all relevant patient care details arehanded over, and the theatre database printout is signed

Confirmation from the ITU practitioner is essential prior to leaving The anaesthetic practitioner and theatre tem member will ensure that all theatre

equipment used during the transfer is returned to the operating department

Compliance 100%

Exceptions None

References Southampton University Hospital ODP level 3 StandardsTransfer patients to PACU Standard No 22Patient dignity and safety Standard

Transfer from operating table to bed Standard No 21AODP/HPC Guidelines


Standard:

Venous & central venous cannulation

Standard Statement:Safely assist in venous and central venous cannulation during clinical procedures for bothadult and paediatric patients

Method: Ensure the patient is offered appropriate information, support and reassurance in a

sensitive manner Ensure the care provided to the patient is consistent with their individual needs,

plan of care & expressed personal beliefs, & preferences, within the constraints of

the setting and the clinical procedure Ensure that the required materials & equipment are made available & ready for use

before the venous and CVP cannulation procedure is started Ensure the specified cannulation site is prepared & cleaned effectively, and in a

way which optimises the patients comfort, dignity & safety and that the site isprepared to provide optimal conditions to facilitate cannulation

Ensure the canula/line is secured adequately & safely, to facilitate access andminimise patient discomfort

Ensure the transducer line is clearly labeled and identifiable as an venous andcentral venous line

Ensure universal precautions for infection control are applied correctly and thatwaste & sharps are disposed of safely in the correct manner


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Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsPaediatric Standards (PACU)Manufacturers guidelines for setting up transducersAODP/HPC Guidelines


Standard:Maintenance of medical gas supplies within theatres

Standards Statement:All staff will safely monitor & maintain medical gas supplies within the operating theatredepartment

Method: All staff dealing with medical gases must have undergone the appropriate training

and be competent in there use Ensure cylinders both on anaesthetic machines and for transporting patients to

recovery are correctly identified & confirmed as being at the correct temperaturebefore use

Ensure cylinders are handled correctly & safely with minimum risk to self, others &cylinders Ensure gas supply connectors are attached safely and correctly to anaesthetic

machines Ensure that cylinders are stored safely in the designated racks and ensure that full

& empty cylinders are stored separately from each other & are clearly identifiable Ensure the pipeline, valves and connectors are checked to be in good condition Ensure that the integrity and pressures of the pipeline system and cylinders are

monitored effectively and the appropriate action taken if faults occur (refer to policy)

Compliance 100%

Exceptions None

Reference Southampton University Hospital ODP level 3 StandardsAODP/HPC Guidelines

Anaesthet ic Theatre Standards No 26

Standard:Cell Saver Preparation and use


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Standard Statement:All staff to be trained in the preparation and use of the Haemonetics Cell Saver Machine,be competent in its use and be able to identify when its use is appropriate

Method: All anaesthetic staff will have the required training on the preparation and use of the

Cell Saver Machine, and be deemed competent by the trainer The use of the Cell Saver will be in consultation with the lead anaesthetic clinician Staff must ensure that the patients rights, choices and wishes are maintained

throughout the use of the Cell Saver Machine Use of the Cell Saver must be in conjunction with the written standards The required equipment and materials will be collected from theatre 6s anaesthetic

room, ensuring that its location detailed on the communication board

Universal precautions will be applied throughout Ensure that the following steps are followed

Step One:

This anaesthetic theatre standard for the preparation and use of the HaemoneticsCell Saver is intended to aid in its use and is not in place of appropriate individualtraining sessions that you must have with SODP Pippa Humphries

The supplies you will need can be found in theatre 6s anaesthetic room please alsorefer to the guide on the wall of what disposables are required

1. Cell saver machine2. High speed cell saver bowl set

3. Hard shell reservoir4. Aspiration Set5. ACDA (Anticoagulant Fluid) 750ml6. 1000ml sodium chloride x 2

Anaesthetic Theatre Standards No 26 cont

7. Standard suction tubing to connect to the suction unit and reservoir8. Suction apparatus

Step Two: To prepare the collection system

The use of the disposables with this machine is expensive, so to help keep ourcosts down, during elective cases please follow steps one and two, when the hardshell reservoir contains 500ml or more then the remaining steps can be followed,this is because during an elective case the patient may not have excessive bloodloss in order for the machine to be cost effective.

Gloves must be worn during the set up of the disposable kit to avoid finger markson the tubing as sensors shine through, and will pick up finger prints which willcause the machine to alarm during its use

Place the hard shell reservoir suction unit onto the shelf on cell saver machine

Close the red clamp Hang the ACDA anticoagulant fluid on the top pig tail on IV pole


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Attach the standard suction tubing to the yellow port on the hard shell, and attachthe other end to the suction apparatus

Set the suction level at 80 120 mmHg Using an aseptic technique pass the aspiration set to the scrub nurse Ask the scrub practitioner to pass out the double end, from the sterile field, attach

the aspiration set to the hard shell, which consists of a suction line and infusion line,connect the blue end to the blue port on the hard shell, turn the roller clamp off onthe infusion end and aseptically spike the ACDA anticoagulant bag

Turn the suction on Open the roller clamp to prime the line and fill reservoir with 100ml of the ACDA

anticoagulant fluid, to ensure the sponge in the reservoir is soaked through Adjust the roller clamp to set the delivery rate at 1 drip per second Please continue only if there is an excess of 500mls of blood in the hard shell

reservoir, or if the patient is an emergency with expected high volume loss e.g.Abdominal Aortic Aneurysm or Bleeding DU

Step Three: Preparing the machine and disposables

Plug in the cell saver machine, turn the power on & wait for the self test to becompleted

Open the High Speed Cell Saver Bowl set Install the centrifuge bowl by pushing it into the centrifuge chuck, there are two

tubes they should be facing left & right as you look at it, the right facing tubing hasthe waste bag attached, the left had three coloured lines attached

To secure the bowl, move the bowl arm forward & turn locking knob to 12 oclock Thread the right facing tubing through the lower line sensor, try to avoid leaving

finger marks on sensor area Hang waste bag onto the front of the machine and ensure the drain port is closed Hang the saline x 2 on the lower two pig tails ensuring they are at different heights Thread the left facing tube through the air detector on the left ensuring it is over

upper hook, continue to thread tubing around the pump and install manifold, in thesequence from left to right red, yellow & then blue

Close pump lever (pale blue handle) and close & lock manifold door(Bring grey door above pump over and lock with pale blue clamp)

Hang the reinfusion bag (marked with a blue stripe) from the top pig tail on IV pole,close the two small white clamps, keep the large clamp on the blue stripped lineopen at all times

Ensure the blood bag for re-infusion is labeled correctly, legibly and accuratelydetailing the patients name, hospital number, date of collection time of collectionand expiry time (labels supplied with disposable kit)

Attach the red line to the red clamp on the bottom of the reservoir hard shell,ensure the red clamp is open

Spike the two sodium chloride bags with the double ended yellow infusion line andunclamp lines


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Step Four: Inspect & Finish

Inspect all parts of the disposable for twists, kinks or flat spots and check that allappropriate clamps and covers are closed

The machine will ask you to press start to confirm that the disposable has beenloaded

Press start once the system is properly loaded & checked The system will then enter standby mode and be ready to start processing The following screen will be displayed

STANDBY

Need 800ml in reservoir to FILLautomatically

AUTOMATIC Volumes mlPROC 0REINF 0Wash volume 0Bowls processed 0

Press START to fill bowlPress MODIFY to change parametersPress YES to reset modifyparameters

Press start to fill bowl or alternatively you can press nothing and allow the reservoirlevel sensor to initiate automatic filling

Trouble Shooting

Blood for reinfusion should be reinfused within 6 hours from the time of initialcollection

Attach the blood for reinfusion to a hotline as blood is cooled during the washingprocess

The slide clamp on the blue line between the reinfusion bag and the cell savermachine must not be clamped off

Do not use a pressure bag or level one pressure device with the cell saver, as thisincreases the risk of air infusion & the clamp being closed confuses the machine

Anaesthetic Theatre Standards No 26 cont

Due to washed & packed cells being depleted of clotting factors during the cellsaving process, FFP & platelets may be required,

Therefore consultation with the lead anaesthetic clinician is essential The on screen display PROC = the total volume of fluid which has been processed

from the reservoir The on screen display REINF = the total so far of RBCs which have been sent to

the reinfusion bag


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The on screen display Wash Volume = the total mls of sodium chloride used duringthe wash cycles, this does not include the ACDA (750 ml bags)

The on screen display Bowls processed = the total amount of bowls emptied A high blood loss situation can be managed by following the steps below1. Press the Mode key twice2. Confirm the selection by pressing the Yes key within 10 seconds3. An option will appear on the screen during the emergency mode to allow you to go

back to automatic mode4. This emergency mode allows the cell saving process to speed up during emergency

procedures The use of blood from the cell saver may be contraindicated in the cases listed

below1. Sepsis, Malignancy & Tumour cells (unless the leukocyte depletion filter set is used

during re-infusion, liaise with lead clinician)2. Amniotic fluid (unless the leukocyte depletion filter set is used during re-infusion,

liaise with lead clinician)3. Antibiotics not licensed for parenteral use4. Betadine, hydrogen peroxide, sterile water & alcohol5. Clotting adjuncts (microfibrillar collagen agent, topical thrombin)6. faecal contamination & Gastric fluids7. fibrin glue8. Methylmethacrylate

Please make sure you keep yourself up to date with training on the Haemonetics cell

saver machine, it is your responsibility. If you experience any problems please do nothesitate to contact SODP Pippa Humphries, theatre 6.


Standard:All children requiring an anaesthetic will be cared for by appropriately trained competentanaesthetic support staff

Standard Statement:The anaesthetic room and operating theatre is appropriately prepared with all required

equipment and materials, necessary to carry out the proposed anaesthetic techniques,there will be close liaison with the lead anaesthetic clinician, on the proposed plan of care

Method: All anaesthetic staff will have the required training, skills and knowledge, and will

have been deemed competent in paediatric anaesthetic care All staff to be aware of the child protection policy and procedure Ensure that children where possible are scheduled early onto and adult operating

list thus decreasing the amount of anxiety, hunger and fasting time and any risks ofdelay or cancellation


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Prior to receiving a child into the anaesthetic room

All routine anaesthetic equipment will be checked following written anaesthetic

standards Ensure the correct materials and equipment are selected and prepared according to

the clinical speciality, the type of anaesthesia given, the requirements of theoperating list, and the childs weight (a weight can be obtained by contacting thechildrens ward prior to sending)

Ensure that the ward staff have applied a local anaesthetic cream to the childsdorsum of hands and ante-cubital fossa at least half an hour before coming totheatre

Ensure that the necessary volatile agents and anaesthetic drugs, to perform eitherdrug or gas inductions, are easily accessible

Ensure that the operating theatre temperature is adjusted accordingly, ensure that abear hugger & hotline is available for the child during surgery, always cover thechilds head where possible

Ensure all materials and equipment are prepared in the appropriate manner andtime, according to the patients clinical status (elective and emergency)

Ensure all equipment is checked and confirmed as safe, ready for use & isfunctioning correctly

Ensure the location and availability of the fol lowing

Emergency Paediatric Airway Management Trolley

Defibrillator and paediatric paddles Paediatric drugs and doses handbook Paediatric emergency drug box Intravenous fluids and paediatric giving sets (burette) Penlon ventilator Paediatric circuits, reservoirs and spirometers, including an paediatric ambu-bag Paediatric oropharyngeal airways Paediatric HMEs Paediatric Endotracheal uncuffed tubes & laryngoscope blades Paediatric Magill forceps

Paediatric LMAs Paediatric venous, arterial & intra-osseous canulas Paediatric Epidurals Paediatric rigid bronchoscopes (outside theatre 8) Fibre optic bronchoscope (fits smallest tube size 4.5)

Ensure that the environment is as child friendly as possible prior to the childsarrival, including the availability of distraction therapy books and toys, andthat all excessive equipment has been removed

One carer accompanied by the ward nurse may remain in the anaestheticroom until such a time when the childs anaesthetic begins, as soon as thechild becomes unconscious the ward nurse and accompanying carer must


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leave the anaesthetic room without delay, and exit the theatre departmentimmediately via the quickest route

The anaesthetic room and surrounding areas must remain quiet and calming,

all staff in the immediate surrounding must be informed that a child & carerare present in the department

Ensure a full introduction of the anaesthetic team to both child and carer arecompleted

Ensure identification of any language or learning difficulties that the childmay have

Ensure the developmental age of the child is taken into consideration,ensuring as far as possible that the child fully understands what will happento them during their stay

The childs details must be checked, following the written standards ensuringthat the correct consent form is signed by the appropriate legal guardian

The induction of anaesthesia will take place in the anaesthetic room if thelead anaesthetic clinician requests it, but only if the appropriate monitoring isavailable (Co2, SpO2, BP & ECG)

Entry through the anaesthetic room during the induction of anaesthesia mustbe kept to a minimum

Ensure that a chair is available for the carer in the anaesthetic room, to makethe childs hand more accessible for the insertion a cannula

One carer accompanied by the ward nurse may remain in the anaestheticroom until such a time when the childs anaesthetic begins, as soon as thechild becomes unconscious the ward nurse and accompanying carer must

leave the anaesthetic room without delay, and exit the theatre departmentimmediately via the quickest route

Ensure that both child and carer are offered the appropriate information,support and reassurance in a sensitive manner throughout

Ensure that the care provided to the child is consistent with their individualneeds, plan of care, expressed personal beliefs & preferences within theconstraints of the setting and the clinical procedure

Ensure that the child is never left alone whether awake or anaesthetised atany one time

Ensure that any electrosurgical return plates are of the appropriate size

Compliance 100%

Exceptions None

Reference AODP/HPC StandardsNational Association of Theatre NursesChild Protection Policy & Procedure


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Please refer to the fol lowing Anaesthetic Theatre Standards

No 1 Anaesthetic room & operating theatre preparation No 2 Anaesthetic materials & equipment preparation No 4 Airway establishment and maintenance No 5 Clinical emergencies (identify & respond) No 6 Clinical emergencies (assist in treatment) No 7 Documentation No 10 Intravenous infusion and transfusion No 11 Induction of anaesthesia & patient monitoring No 14 Positioning patients in theatre No 15 Patient preparation prior to clinical procedures

No 16 Patients physiological parameters & fluid balance No 17 Receive patients for clinical procedures No 18 Reversal of anaesthesia No 20 Temperature maintenance No 21 Transfer of patients to operating table from bed/trolley No 22 Transfer of patient from operating theatre to PACU No 24 Venous and central venous cannulation No 28 Tourniquet application No 29 Use of electro surgical equipment

Anaesthet ic Standard No 28

Standard:Tourniquet application.

Standard Statement:All staff will ensure that tourniquets are applied safely and securely without risk of injury ordamage to the patient or staff.

Method: All staff who need to apply and monitor tourniquets will be trained appropriately and

assessed as competent before carrying out this task unsupported. All staff applying tourniquets must be conversant with the equipment and the

manufacturers guidelines regarding maintenance and checking of the equipment.o All pipes, tourniquets and connectors must be in good working order.o There should be 2 x 12 cuffs, 2 x 24 cuffs and 2 x 34 cuffs.o The connection of the machine to the compressed air outlet should be

checked.o The controls should be set to 150mmHg, and each cuff connected and

inflated to check for leaks. Ensure the cuff is tightly wrapped prior to inflating.o The Rhys-Davies exsanguinator should measure 18 in diameter, if not

inflate or deflate appropriately.


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o Any damaged or leaking equipment must be removed from service, reportedto the Theatre Coordinator and sent for repair.

It remains a surgical decision whether to use a tourniquet, always ask, never

assume. All tourniquets must be applied as far up the limb as possible, checking for pre-

existing skin damage in the area. The upper part of the limb must be wrapped with sufficient padding to prevent skin

damage. The appropriate sized tourniquet should be selected allowing sufficient overlap

when wrapped around the limb. The tourniquet must be wrapped firmly over the padding ensuring no skin folds or

genitalia are trapped. The pressure on the control box should be set to 100mmHg above the patients

systolic blood pressure for arm tourniquets and 150mmHg above for leg tourniquets. Always check the inflation pressure with the

surgeon prior to inflation, and confirm the pressure achieved once inflation hastaken place.

Please ask the surgeon regarding pressures if tourniquets are to be used onchildren.

Check that the surgeon is ready to start before inflating the tourniquet in order tominimise the time the tourniquet remains inflated.

A clean plastic bag should be placed over the limb to be exsanguinated.Exsanguination may be by use of the Rhys Davies exsanguinator, elevation orEsmarch bandage.

o To use the Rhys Davies exsanguinator, roll the exanguinator up your ownarm first and grasp the patients foot or hand, ensuring all the patients digitsare lying flat in your palm. Then roll the exsanguinator down your arm andover the patients limb in one movement. Holding the Rhys Daviesexsanguinator as far up the limb as possible, turn on the tourniquet machine,wait until the required pressure is achieved before releasing theexsanguinator.

o When elevating a limb to exsanguinate, the limb should be held upwards asvertically as possible to aid blood return. Gentle massage may also be usedto assist exsanguinations, in the direction of the heart, depending on the skincondition. Elevation should continue for a minimum of 5 minutes before the

cuff is elevated.o When using an Esmarch bandage, ensure that the bandage is stretched

before you wrap it around the limb. Starting at the distal end of the limb wrapthe bandage tighly around the limb, moving towards the tourniquet cuff,ensuring an overlap as you go. Inflate the cuff to the required pressure,remove the Esmarch bandage and check the patients skin condition.

Once the tourniquet has been inflated, the time must be noted and recorded in thetheatre register and on the theatre database. The stop clock in theatre may be usedas a secondary reminder, if there is no counter on the tourniquet machine, and theinflation time should also be clearly recorded on the dry-wipe board in theatre.


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The surgeon must be informed of the duration of the tourniquet at regular intervals,the first reminder at 60 minutes, then at 90 minutes, then every 15 minutesthereafter.

It is the surgeons decision how long the cuff may remain inflated. If required a cuffmay be re-inflated providing at least 10mins has elapsed to allow sufficientperfusion of the limb.

The anaesthetist must always be informed prior to the tourniquet being deflated asthere may be a drop in blood pressure as perfusion of the limb occurs. Also wasteproducts such as CO2 and lactic acid build up in the tourniqued limb, which arethen released into the circulatory system.

If bi-lateral cuffs are used, each cuff must be deflated separately allowing sufficienttime for the blood pressure to stabilise before deflating the second.

After deflation the tourniquet and padding must be removed immediately to preventvenous congestion and arterial stasis.

The skin condition must be assessed following removal and the limb assessed forfull perfusion prior to the patient being transferred to PACU. Any doubt about thequality of capillary return in the digits must be reported immediately to the surgeon.

The method of exsanguination, inflation, deflation and total tourniquet times mustbe recorded on the perioperative theatre database, and in the theatre register.

Caution must be exercised in the use of tourniquets in patients with the followingconditions;

o Blood diseases e.g. sickle cell anaemiao Localised infection of the limbo Regional infections e.g. cellulitis

o Peripheral vascular diseaseo Severe bone trauma

Soiled tourniquets must be washed with warm water and detergent and driedthoroughly.

Compliance: 100%

Exceptions: None

References: Southampton University ODP Level 3 StandardsNATN Principles of Safe Practice in the Perioperative Environment

1998

See also Theatre Standards:Theatre Documentation


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Standard:Use of Electro surgical Equipment.

Standard:Staff will ensure that all patients whose surgery requires the use of diathermy, will beprotected from the risk of burns.

Method:

All personnel using diathermy equipment will receive the appropriate trainingand have been assessed as competent. They must be fully conversant with

the safe use of the equipment and understand the principles of electrosurgery.

Diathermy machines will be checked prior to the start of every list, inaccordance with the manufacturers guidelines.

Yearly maintenance and testing of equipment must take place by MEMS toensure its safety, any faulty or damaged items must be removed from useimmediately and reported for repair.

Application of diathermy grounding plates is only done by competentpractitioners in accordance with the manufacturers instructions, ie. Applied toa clean, dry, hair free, muscular area, as close to the operation site as

possible, away from any pre-existing metal work in the patient. Diathermy grounding plates must be kept clean and dry, and preventative

measurers taken to ensure the plate does not become soiled with prep.Solutions or body fluids.

The scrub person must check diathermy forceps and leads prior to use, toconfirm intact insulation and good connections between components.

The scrub person must keep the diathermy forceps/ blade etc. within asuitable insulated receptacle during surgery, to prevent accidental burns tothe patient or members of the surgical team.

All staff must be aware of any patient contraindication to the use ofmonopolar diathermy e.g. pacemaker, prior to commencement of surgery.

Staff will be educated regarding the use of visor masks to prevent inhalationand eye contamination with diathermy plume.

The diathermy machine must be switched off or set to standby beforeconnecting or disconnecting live electrodes, and the surgeon informed of thepower

settings before commencing use. Single use return electrodes (grounding plates) must never be reused. The return electrode must be in direct and complete contact with the patient

throughout their surgery. If the patient position is changed after application ofthe plate, the site must be rechecked.


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Patient skin condition must always be checked after removal of thegrounding plate, and the site and skin condition recorded on theperioperative documentation.

The patient must be shielded from metal objects to prevent a short circuitbypass of the grounding plate.

Compliance: 100%

Exceptions: None

Reference: Principles of Safe Practice in the Perioperative Environment.Southampton University ODP Level 3 Standards


Standard:Theatre handover of post-op patients to ITU

Standard Statement:All anaesthetic support staff to appropriately hand over the care of patients requiring ITUto the designated ITU nurse, in the most appropriate manner according to the individualsituationMethod:

All anaesthetic support and scrub staff to ensure that the Theatre to ITU/HDU

patient transfer communication sheet is accurately and legibly completed with allrelevant information In cases where the handover time is

416 theatre practice policy

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