Theatre Practice Standards
Theatre Practice Standards
Theatre Practice Standards
- SURGICAL
Table of Contents
1. Aim/Purpose of this Guideline ...................................................................................... 2
1.3. Objectives.............................................................................................................. 2
1.4. Scope .................................................................................................................... 2
2. The Guidance ............................................................................................................... 2
3. Monitoring compliance and effectiveness ..................................................................... 2
4. Equality and Diversity ................................................................................................... 3
4.2. Equality Impact Assessment ................................................................................. 3
Operating Theatre Standard No 1 - Aseptic Technique. ...................................................... 4
Operating Theatre Standard No 2 - Surgical Hand Antisepsis, Gowning and Gloving ......... 5
Operating Theatre Standard No 3 - Opening of sterile trays and packages....................... 12
Operating Theatre Standard No 4 - Trolley Preparation for Surgical Intervention. ............. 14
Operating Theatre Standard No 5 - Skin Preparation and Draping .................................... 18
Operating Theatre Standard No 6 - Use and Handling of Surgical Instruments ................. 25
Operating Theatre Standard No 7 - Handling of Instruments During Surgical Procedures 29
Operating Theatre Standard No 8 - Handling of Prostheses and Implants ........................ 31
Operating Theatre Standard No 8a - Checking of Prostheses and Implants ..................... 32
Operating Theatre Standard No 9 - Swab and Instrument Counts .................................... 34
Operating Theatre Standard No 10 - Use of Electro Surgical Equipment. ......................... 41
Operating Theatre Standard No 11 - Disposal of Used Instruments.................................. 43
Operating Theatre Standard No 12 - Disposal of Waste and Soiled Linen. ....................... 44
Operating Theatre Standard No 13 - Disposal of Human Tissue....................................... 46
Operating Theatre Standard No 14 - Wound, Drain and Catheter Dressings. ................... 47
Operating Theatre Standard No 15 - Handling Wound Drains........................................... 48
Operating Theatre Standard No 16 - Completion of Perioperative Documentation ........... 49
Operating Theatre Standard No 17 - Disposal of Surgically Explanted Items .................... 50
Appendix 1. Governance Information ................................................................................ 51
Appendix 2. Initial Equality Impact Assessment Form ....................................................... 53
1.2. The aim of this policy is to outline the standards of care that must be delivered to
each individual patient to ensure a high quality of care is provided to patients entering
all Trust Operating Theatres.
1.3. Objectives
To ensure that a standard of care is delivered to each individual that is equitable
and fair.
To identify the standards of care to be delivered to patients through all the areas
within the operating theatres i.e. anaesthetic room, Operating Theatres and the
Post Anaesthetic Care Unit.
To enable auditing of theatre practice and patient care throughout all areas.
1.6. 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 in operating departments.
2. The Guidance
The guidance is contained in the following sections as detailed in the table of
contents.
3.2. Overall performance against the standards will be included in the interdivisional
Performance Assurance Framework with overview and exceptions tabled at monthly
Divisional Governance Management Meeting.
Tool The revised theatre safety audit tool will be used to monitor
compliance monthly. Each senior auditor will assess practice
observed at each audit
Attach the tool to the policy or no one will know what you are
monitoring.
Frequency Each member of the theatre senior team will audit 10 observations of
practice each month
The observations will be submitted to the Divisional Nurse by the 2nd
Standard Statement: All staff involved in the preparation and performance of surgical
procedures will ensure a safe environment for the patient by maintaining asepsis and
limiting the risk of contamination.
Method:
• All staff will be aware of the principles of asepsis, have received appropriate training in
and have been assessed as competent in this skill, before undertaking any procedure
requiring an aseptic technique to be applied.
• Perioperative staff with infected skin lesions of the skin or bacterial infections of the
upper respiratory system should not participate in any aseptic technique.
• Staff participating in a surgical aseptic procedure should be scrubbed, gowned and
gloved.
• Personnel participating within sterile procedures must stay within the sterile
boundaries, and a wide margin of safety should be given between scrubbed and non-
scrubbed persons.
• All pre-sterilised articles must be checked for damage and expiry date prior to use. Any
packs found to be in an unsatisfactory condition must be discarded.
• All items used within the sterile field must be sterile.
• To maintain asepsis, it is essential that all staff are aware of the correct method of
opening sterile packages, to avoid contamination of their contents.
• Dressings must be removed carefully from pre-existing wounds to prevent scattering of
microorganisms into the air. An assistant wearing gloves rather than a scrubbed
member of the surgical team should carry this out.
• Talking, moving, opening and closing of doors, exposure of wounds, disturbance of
clothing or linen and number of personnel in theatre should be kept to a minimum to
reduce the risk of airborne cross infection.
• Every sterile field must be constantly monitored and maintained, as sterility cannot be
assured without direct observation of the sterile field.
Compliance: 100%
Exceptions: None
References:
Method:
1. General Considerations
Regular education and training of staff, plus audit of practice should be undertaken.
Training and induction for all new personnel, both medical and perioperative staff should be
undertaken to ensure compliance.
Staff must be aware of differences between sterile items and non-sterile items and share the
responsibility for monitoring aseptic practice.
2. Facilities
Wet floors in the scrub up area are a potential hazard, with the risk of injury caused by
slipping. It is important that floor surfaces be kept as dry as possible. Storage facilities for all
necessary sterile equipment should be available and located away from the sterile field. Where
sterile equipment is stored in the scrub-up area, it should be situated away from the sink area,
in order to prevent water contamination.
The shelf or work surface used to open gowns should not be directly below any storage.
Disposal bins for waste paper must be provided, that do not require hands to open.
The scrub-up area must be kept adequately stocked with necessary equipment. Careful
consideration should be paid to the number of sterile gowns required to be stored in the scrub-
up area, ensuring adequate stock rotation.
Some individual perioperative staff may be allergic to some antiseptic preparations. A choice of
antiseptic solutions should be provided.
3. Surgical Hand antisepsis
All staff should be in the appropriate theatre attire before commencing surgical hand
antisepsis.
Fingernails must be short and free from polish or artificial (including acrylic and gel) nails.
Hands and forearms should be free from lesions or breaks in skin integrity. Minor lesions must
be covered by a waterproof occlusive dressing. An individual with a major wound or infected
wound must not scrub.
4. A systematic method
Using a systematic method of hand washing ensures an effective way of cleansing all areas of
the hands and arms (Gould, 2000). Surgical hand antisepsis must be performed before
donning sterile gloves for clinical invasive procedures.
8. Nails can be cleaned using a disposable nail pick under running water.
9. The use of a scrubbing brush is not necessary for reduction of bacterial counts and can
lead to skin damage and an increase in skin cell shedding
10. Subsequent washes should encompass 2/3 of the forearms to avoid compromising the
cleanliness of the hands.
11. Hands must be rinsed thoroughly from the fingertips to the elbows, allowing excess
water to drain from the elbows into the sink.
12. Splashing surgical attire should be avoided. If surgical attire becomes excessively wet
this can compromise the protection afforded by the gown. It may be necessary to
change attire before beginning the scrub-up procedure again.
13. Vigorous shaking of the hands to dispel water should be avoided.
14. Hands must be dried thoroughly – The skin should be blotted dry with sterile towels, as
rubbing the skin in order to dry it will disturb skin cells. Adhering to the principle of
working from the fingertips to the elbows and using one towel per hand is essential.
16. Hands should be held higher than elbows and away from surgical attire during the
process of surgical scrubbing and upon completion.
17. There is no evidence that more than 2 minute wash (decontamination) using an
aqueous disinfectant is required, before any sterile procedure can be undertaken (HIS,
2002).
18. Unless proceeding directly from one procedure to another, subsequent hand antisepsis
should be the same as for initial scrubs. Although evidence shows a reduction in
microorganisms on the skin over time with a cumulative effect, this depends on the
solution used and the technique applied.
19. Advocating the same procedure for all hand antisepsis reduces confusion and
increases compliance.
20. Alcohol hands rubs are an acceptable alternative to repeated washing. Alcohol hand
rubs are not appropriate for use when hands are visibly contaminated, as these hand
rubs do not remove soil or debris.
21. When proceeding directly from one procedure to another, cleaning and nails with a pick
can be omitted
Antiseptic hand washing solutions must be antiseptic or alcohol based, fast acting and
have a broad spectrum of action and residual effect.
Alcohol based solutions provide the most rapid and greatest reduction in microbial
count, but are not effective at removing debris and soiling.
Soap and water alone are not acceptable, as soap has no antiseptic properties.
Personnel who are allergic to antiseptic solutions should be allowed to use soap but
must combine this with an alcohol solution/gel following consultation with the infection
prevention and control team and occupational health department.
Each antiseptic solution varies in the time needed for optimum effect and the
manufacturer’s instructions should be adhered to. Antiseptic solutions must be in
adequate volume and contact with the skin to achieve their optimal effect.
Although surgical face masks were originally developed to protect the patient from
micro-organisms expelled from the mouth and nasopharynx of surgical staff during
procedures, they also provide a protective barrier for the surgical team.
Given the anticipated risk of splash injuries from blood and body fluids, face and eye
protection (that also covers the side of the face) must be used by scrub-up personnel.
Face masks should be positioned and secured prior to hand antisepsis to cover the
nose and mouth. Masks must be handled only by the ties. Spectacles or microscopic
glasses must also protect the sides of the face/eyes.
o Specific face masks and/or eye protection are required when dealing with specific
risks, for example surgical smoke plume or lasers.
o Specific equipment must be donned for use within laminar flow enclosures, for
example aspirators.
o Additional protective clothing may be indicated, for example lead gowns, plastic
aprons.
8. Gowning Procedures
On completion of surgical hand antisepsis, the folded gown should be lifted from the
gown pack, and then allowed to unfold without contamination against any other
surface, whilst retaining a grip on the shoulder and neck of the gown. The arms should
then be inserted into the gown but should not protrude through the cuff of the gown at
this stage. The back of the gown should be fastened by another person. The
wraparound tie should be handed off to the circulator once gloves have been donned
and not before.
9. Gloving procedures
Failure of surgical gloves from sutures, sharp instruments, bone fragments and natural
wear and tear is a common source of contamination of the hands of surgical personnel
with blood and body fluids.
Double gloving provides an extra layer of protection and significantly reduces the
number of perforations to inner gloves in low risk surgery.
The decision to double glove should be based on the risk posed by the surgical
procedure e.g. the exposure to sharps and not the risk posed by the patient, or
personal preference.
Evidence supports the use of double gloving for all surgery including low risk surgery.
Aqueous fluids can affect the integrity of the glove. This indicates that the outer glove
should be changed after preparation of the patient’s skin for surgery.
Latex free gloves are available for individuals who are sensitized.
The ‘closed’ method of gloving is the preferred option for donning sterile gloves.
When staff have performed hand antisepsis and are gowned and gloved, it is
considered that the area of sterility includes:
o their gloved hands and forearms
o below nipple line to waist level. Hands must be kept at or above waist level and
below shoulder level, and should be visible at all times in order to avoid
inadvertent contamination
Scrubbed personnel must only touch items or areas which are sterile. When not
involved in a sterile procedure, scrubbed personnel should stand with their hands
within the area of the sterile field.
At the completion of the sterile procedure, gowns and gloves are treated as clinically
contaminated or clinical waste. When removing the gown, contaminated hands should
not undo the gown. Once released the gown should be pulled forward over the gloved
hands, folding it onto itself. It should then be discarded appropriately.
To avoid contamination of the hand, gloves should be removed by ensuring that the
glove surface comes into contact with the glove, and skin with skin.
Face masks and single used eye protection must be discarded after each procedure.
Reusable eye protection must be cleaned between procedures in accordance with the
manufacturer’s instructions.
Hands must be washed thoroughly once gown, gloves and face protection are
removed.
Theatre Practice Standards - Surgical
Page 10 of 54
11. Skin Care
Personnel should care for their hands in order to ensure adequate hand
decontamination and good practice.
When skin is damaged the micro-organism count rises, leading to an increased risk of
cross infection.
Antiseptic solutions and soap must only be applied to wet hands. Hands must be
rinsed thoroughly to remove any soap residue and then dried properly.
Hand creams can be used but they must be non-ionic in order to avoid their inhibiting
actions on some antiseptic solutions and latex gloves. Hydrocarbon products are not
compatible with latex, water based hand creams are best. Products containing mineral
oil, petroleum or lanolin should be avoided. The user should always check with the
manufacturer of the skin care product to verify that it is compatible with the chosen
hand antisepsis agent. Containers must not be communal as they can be
contaminated.
Compliance: 100%
Exceptions: None
References:
Aseptic Technique
Preparation of Personnel
• All members of staff will be given training regarding the safe opening and of
equipment, and will have been assessed as competent before undertaking this
unsupervised.
• Staff must check that the pack to be opened is intact i.e. no visible tearing of either
paper or drape.
• Any packaging that feels damp or contains moisture is not fit for use, and must be
discarded.
• Staff must be aware that all packaging has a shelf life and must therefore examine
each item before opening to check the expiry date has not been exceeded.
• Any tray or package that has auto-clave tape must be checked to ensure that the tape
has turned brown indicating the item has been through a correct autoclaving process.
• A lot of items are now purchased pre-sterilised and will have been sterilised by
irradiation. These items have a longer shelf life, but still carry an expiry date, which
must be checked.
• Auto-clave tape must be peeled upwards, care being taken not to tear the outer
packaging in the process.
• When an item is packaged in a bag staff must run their fingers along the gulleys on
either side in an upward motion so the inner package emerges from the top.
• Trays must be opened in a manner whereby the unscrubbed circulating person does
not lean over any part of the sterile inner drapes.
• Items must not be dropped onto the scrub trolley without the scrub persons consent
and knowledge as to what the item actually is.
• Sutures must be peeled open and presented for the scrub person to take. Items must
be presented to the scrub person from the edge of the sterile field.
• Staplers and disposable pre-packaged items should have the paper peeled off the top
of their packaging, from the semi-peeled point, so as the scrub person can take the
item from within the sterile plastic packaging.
Compliance: 100%
Exceptions: None
References:
Aseptic Technique
Theatre Documentation
All practitioners, staff and clinicians working, or who come to work in the operating theatre
environment are expected to act as role models, demonstrating positive behaviours that
actively promote best practice for infection prevention and control procedures in the operating
theatre environment.
A ‘zero’ tolerance for breaches to practice for infection prevention and control procedures in
the operating theatre environment must be fostered.
All staff involved in the preparation of trolleys for surgical intervention will have received
training appropriate to their level of participation and have been assessed as competent.
Staff will ensure that sufficient trolleys, mayo stands and bowl stands are available for the
planned surgical procedure and that they are in a good state of repair and have been cleaned
thoroughly prior to use.
Staff will collect together all items expected to be required for each procedure in advance of
surgery. Any items not available must be detailed to the surgeon in charge of the case prior to
start of anaesthesia, to allow the surgeon to make an informed decision regarding whether to
continue.
All items to be used must be inspected for sterility and damage.
5.5.2. Equipment and medical devices safeguards
All pre-sterilised articles must be checked for evidence of sterilisation, damage, the integrity of
packaging, and an expiry date, prior to use. Any packs found to be in an unsatisfactory
condition must be discarded.
Items used within a sterile field must be sterile. Any items that fall into an area of questionable
cleanliness must be considered non-sterile.
Compliance: 100%
Exception: None
References:
See also
Aseptic Technique
Disposal of Equipment
Hair should only be removed if it will directly interfere with access to the incision site,
or if there is a risk it will contaminate the wound site.
Where hair removal is necessary:
o Patient consent must be obtained prior to hair removal, with a full explanation of
the method to be used and why it is necessary.
o The person who performed the hair removal, the area from where the hair was
removed and the method should be documented.
o Hair removal should take place as close to the time of surgery as possible to
minimize the risk of bacterial contamination to the skin surface.
o Hair removal should be carried out by an experienced practitioner in a clean area of
the surgical suite, with good lighting, affording patient privacy at all times.
Clippers used for hair removal, must be stored and decontaminated between patient
use according to manufacturer’s instructions and Trust decontamination guidelines.
Single use shaving heads must be used and discarded after every patient use.
Shaving including wet shaving is not an appropriate method, due to the skin trauma it
can cause and associated increased risk of surgical site infection.
When surgery is to be performed on an already contaminated wound, shaving prior to
surgery is not recommended as this holds a high risk of postoperative wound infection.
10.4. Types of solutions used in skin preparation
There are several types of antiseptic skin preparations available at RCHT. The type of
solution selected should be influenced by the area that requires preparation, the
condition of the skin and patient allergies.
o Povidone-iodine alcoholic solution
Compliance: 100%
Exceptions: None
References:
Compliance: 100%
Exceptions: None
References:
Compliance: 100%
Exceptions: None
References:
AfPP Principles of Safe Practice in the Perioperative Environment (2011)
An introduction to the local count policy must be included in the induction to the
operating theatre for all new staff.
Healthcare assistants/support workers should not be involved with the count until they
have been assessed as competent to do so by a registered practitioner.
The integrity of the X-ray detectable markers in swabs, packs, peanuts etc. must be
checked during the count. This includes the integrity of tapes on abdominal
swabs/packs with a gentle tug.
At the initial count, and when added during the procedure, swabs and packs should be
counted into groups of five. These should not be added to those already counted until
verification of the number in the packet. The additions should be in multiples of five.
Opening all packages during the initial needle count is not recommended. Used
needles on the sterile field should be retained in a disposable, puncture resistant
needle container.
Wire snares should be measured to ensure the full 100mm length is present.
Swabs should be in full view of the operating surgeon and anaesthetist where
applicable throughout a clinically invasive procedure.
Used swabs and packs should be counted off the sterile field. The technique used
should be safe and should incorporate infection control measures in conjunction with
standard precautions.
All items should be fully opened by the circulating practitioner and placed into an
appropriate contained disposal system. Currently at RCHT we use clear plastic bags.
Used swabs and packs must be counted off the sterile field in batches of five and
disposed of into clear polythene bags. Each bag should be sealed and the number of
swabs inside i.e. 5, and the type recorded on the outside in permanent marker.
If there is a discrepancy in the closure counts, all bags or containers must be opened
and their contents recounted.
When batches of 5 swabs are counted down the white board record must be crossed
through but not erased.
If a counted item is inadvertently dropped off the sterile field, the circulating staff
member must retrieve it, show it to the scrub practitioner and isolate it from the field to
be included in the final count.
Items must not be cut or altered unless specifically intended for the purpose.
If alteration of any item is requested by the person performing the procedure this must
be documented in the patient’s records, highlighted on the dry wipe board and
included in the count.
The perioperative document must be fully completed and signed, indicating the scrub
and circulating practitioners. This will be retained in the patients’ medical record.
When an item is intentionally retained, with plans for later removal, this should be
documented appropriately in the patient record.
Compliance: 100%
Exceptions: None
References:
Exceptions: None
References:
Exceptions: None
References:
RCH Trust Infection Control Policies; Disposal of Waste, and Linen Policy.
Staff must confirm with the surgeon that the tissue in question is for disposal only and
not required for specimens.
Any human tissue that is required for laboratory analysis must be dealt with according
to Generic Theatre Standard No 11 Management of Specimens.
Any tissue for disposal that includes any foetal remains must be dealt with according to
Generic Theatre Standard No 12 Management of Sensitive waste.
Any tissue for disposal should be kept separate until the operative procedure is
complete and all counts have been carried out.
The tissue may then be placed securely in a rigid yellow clinical waste bin for
incineration. Care must be taken with any tissue containing sharp penetrative items
such as bone fragments. Staff must wear appropriate personal protective equipment
when dealing with tissue for disposal.
Larger items, such as amputated limbs, should be placed directly into a rigid yellow
bin. The bin should be sealed and labelled clearly with the Theatre of origin, date and
case number.
The general porters should then be contacted via theatre reception to arrange for
removal of the bin to a secure area awaiting collection for incineration.
Compliance: 100%
Exceptions: None
References:
Compliance: 100%
Staff must be aware of the content of and have access to the Trusts Infection Control
Policy.
Staff must have a good understanding of the mechanics of the different types of wound
drains.
They must have been taught how to correctly assemble the drains, ensuring that the
relevant clamps are closed to prevent spillages.
The Surgeon can insert the drain trochar and ensure that the sharp end is effectively
protected.
The drain receptacles must be kept in the bag and put to the side to prevent
contamination.
At the end of the case, at an appropriate time, the top gloves (when two pairs are
worn) must be removed. An extra pair (when only one pair is worn) must be added.
Clean gloves MUST be donned prior to handling.
The drainage receptacle can then be attached maintaining an aseptic technique.
Compliance: 100%
Exceptions: None
References:
Compliance: 100%
Exceptions: None
o Bone fragments
o Foreign bodies
o Teeth
All or part of this document can be released under the Freedom of Information Act
2000
This document is to be retained for 10 years from the date of expiry. This
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the express
permission of the author or their Line Manager.
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age
Race / Ethnic
communities /groups
Sexual Orientation,
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No
9. If you are not recommending a Full Impact assessment please explain why.
Signature of policy developer / lead manager / director Date of completion and submission
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
Signed _______________
Date ________________