THEATRE DESIGN & TECHNIQUE
The main objectives are to emphasize the importance of preparing a good design brief which
clearly identifies user requirement and to describe current trends in operating theatre design.
To demonstrate the principles of good design, it is important and appropriate to identify those
features which are considered to be ideal. However, despite the construction of many new
operating departments many hospitals still have these facilities which are not ideal, despite
extensive upgrading scheme. But even new department cannot be expected to fulfill all
theoretical requirement as new ideas are constantly being developed and by the time they are
incorporated into buildings, fresh ones take their place on the drawing board.
The following terms are used in this topic:
1. OPERATING DEPARTMENT-This comprises a unit of two or more suites and supporting
accommodations.
2. OPERATING SUITES- Comprises operating room together with its immediate ancillary
accommodation.
3. OPERATING THEATRE- This is the room in which surgical operations and some
diagnostic procedures are carried out.
The importance of identification of user requirement in brief cannot be over emphasized .Unless
this is achieved, there is likelihood of experiencing the frustrations which may result from
apparent misinterpretation of user requirements into bricks and mortar .Those commissioning a
new department or working in it for the first time who have not been involved at the planning
stage may be unaware of the operational policy assumptions which the design was based. Often
inadequate information of the real user requirements given to the designer has created
misunderstandings.
The design brief is prepared by a project team (planning team) acting on behalf of the
client/potential user. The multi-professional project team which includes users representative,
health administrator, architect, engineer, quantity surveyor, has to ensure that the design of new
building or upgrading of existing building is functional and yet remains within the financial
limits imposed.
To achieve this, it is vital that the designer understands fully the intentions of the project team.
This is not in respect of accommodation required but how the accommodation is to be put to use;
in other words the operational policies. For these reasons it is quite wrong to start with a
preconceived sketch plan and then attempt to fit in the operational intentions. This can result in
under or over provision of activity spaces /rooms, poor space relationships in the department are
unacceptable circulation patterns. The content of a design brief should proceed from the general
to the particular.
The following list, though not exhaustive give examples of aspects which should be included in
the brief for an operating department:-
- Scope of service to be provided and estimated workload
- Specialties to be excluded
- Functional content e.g. Number of theatres
- Preferred vocational relationships with other hospital departments.
- Operational policies e.g.
1. Access zones
2. Staff facilities including changing rooms e.t.c
3. Patient transportation, reception, documentation, transfer and post-anaesthesia recovery area.
4. Preparation, recycling and sterilization of instrument set, Gowns e.t.c.
5. Supplies system and storage
6. Disposal of used dressing and other waste materials
7. Administration, a secretarial support
8. Teaching (Seminar room)
9. Cleaning
10. Catering
11. Communication e.g. Telephone & intercom
12. General design requirements and statutory regulations.
In view of bacteriological considerations, there is a great need for situating the operating theatre
in some kind of cul-de-sac away from the through fares. It should be regarded functionally by
the architect as a sterile zone in which traffic other than that specific to the theatre must not be
permitted. The department must be easily accessible from the important wards, intensive care
(ideally on the same floor) with shortest possible route to the Accident & Emergency Unit.
The ideal siting is in the top floor of a hospital, as the area is free from bacterial communication.
CIRCULATION
Normally there are three types of traffic flow- (1) patient (2) staff (3) supplies, All these three
should be properly channelized.
PATIENT
Patients are brought from wards and they should not cross the transfer area in their ward
clothing which is a great source of infection. It is in this zone that changeover of the trolley
should be effected. The transfer zone will link up the pre-op and recovery areas.
SUPPLY
All sterile goods should have a different entry point reaching the clean corridor independently.
Soiled stuff should get out through the disposable corridor while Non disposable stuff should go
back through the supply only. This way the clean and dirty will not get mixed up. Leaving no
chance for any infection.
STAFF
The surgeon, nurse , anaesthetist and nursing orderly should enter through a separate routes of
either a set of changing rooms or through an air lock which should communicates with the
surgical corridor. A shoe change near the air lock is also a necessity.
AIR CIRCULATION
This should be so arrange that air flows from the clean to the unclean zones and never vice
versa. Otherwise, the clean areas get contaminated. Ventilation must be good.
COMFORT CONDITION
Operations sometimes may continue for a long period of about 5 to 6 hours, this is a nerve
cracking job with tremendous mental and physical strain. Hence, optimum comfort level is of
vital importance. Some amenities like pantry for refreshment should be made available to the
staff. This may be augmented by the provision of hot and cold meals from the main hospital
kitchen. The temperature should be 20-22 degree centigrade with 50 percent humidity. Staff
should also have some room where they can relax occasionally, the surgeon may like to dictate
postoperative note in his room.
ACCESS ZONES
The assumption that rigid staff discipline and rituals can enforce a gradient of decreasing
bacterial load is not justified by evidence. However, aseptic technique is an important aspect of
operating theatre techniques and it is common sense not to permit unrestricted access to all parts
of the department. But the use of the traditional term ‘’clean’’ sterile and dirty zones which have
long established architectural connotation are no longer appropriate. Hence the use of four access
‘’zones’’ as described below
General Access Zone-
Through which any authorized person entering the department is admitted, it includes the
entrance, reception, patient transfer area ,porters base, staff changing room, department
store, disposal hold and some offices .
Limited Access Zone-
Comprise the general circulations areas between the department entrance and operating suites
including post anaesthesia recovery area, staff base, staff rest room ,some offices, seminars
room/teaching facilities where appropriate, equipment parking, special storage and the exit bays
to each operating suite.
Operating Access Zone-
Defined as the zone which encompasses the operating area, and the preparation room . A
decreased bacterial load can be achieved by reducing the number of persons in the operating
zone to the minimum and ensuring sufficient directed ventilator air flow to the other access
zones.
Restricted Access Zones-
This is an area limited to those persons appropriately attired whose presence is related to
activities in the operating suite, it comprises the operating theatre, anaesthetic /induction room,
scrub up and gowning room, preparation/supply and utility rooms.
The project team need to determine the policy regarding access to the department. Should it be
decided to perpetuate a ‘’RED LINE’’ policy, then the design implicative of this must be taken
into account. e.g, the location of staff changing rooms. An acceptance of recent microbiological
research would suggest that, it is necessary to position changing rooms specifically to ensure that
staff and visitors are fully changed before entering the limited access zone.
ADMINISTRATION AND TEACHING
Account should be taking of the educational needs of nurse learners, medical students and
registrars who require to write patient’s note or hold confidential discussions.
PATIENT TRANSPORT
The method adopted for the transportation of patient from ward to operating department and vice
versa has considerate special implication for the design of the department e.g. whether trolleys or
beds are wheeled to the operating suites.
COMMUNICATION
Various options used to be considered to ensure an effective communication system within
the operating department. This includes provision of intercom in critical areas such as prep room,
department store, reception and recovery area , telephones with internal and external facilities in
convenient locations.
CLEANING
The brief must specify that the internal construction materials and finished selected should
minimize maintenance and cleaning costs. The designer require information on the anticipated
cleaning policies which can be taken into account when locating facilities for the storage of
cleaning material, equipment and provision of utilities for cleaning staff.
SAFETY CONSIDERATIONS
One of the most important of these which influence the planning of operating department
are fire regulations. with the increased use of volatile anaesthetics, the risk of explosion is high
and proper precautions need to be taken. The planners must take fire safety into account and
agree with local fire authority measures to be adopted e.g. means of escape in case of fire and
access for the fire services and protection from spread of smoke.
The possible sources are as follow:-
1. Direct contact-open fire from gas, sterilizers
2. Faulty loose electrical suction and apparatus
3. Static electricity which is produced due to friction with the floor or either with shoes or wheels
or moving equipment.
OTHER ENGINEERING SERVICES
Ventilation, air condition, heating hot and cold water, piped oxygen/medical gases and
electricity are the major services which are to be provided with ever changing technology and
developing medical sciences, lot of new gadgets are coming into use and hence the electricity
layout should be flexible enough to take care of new developments. Conceal conduit wiring
should be provided as a means of fire protection.
LIGHTING OF OPERATING THEATRE
This need to be carefully planned ,as most of the operations are performed under artificial
light .For lighting considerations, operating theatre has three distinct functional areas, each
having specific requirement thus:-
1. The surgeon field
2. The anaesthetics field
3. The general lighting
➢ Surgeon field- This is the important area where lighting should reach near perfection.
The problem is that the actual operation is often at the bottom of a cavity with a slant axis
6 to 12 inches deep. The heads of the surgeon and his assistants continuously intervene
in the light source and the objects. The operation feed is also changes as the operation
proceeds. Hence, there is need to have a highly flexible illumination system capable of
being redirected easily and instantly.
➢ Anaesthetics Field- The anaesthetist gets important indications of the patient’s
condition by visual examination of his face, eyes, lips e.t.c. Here, lighting must be
approximates to daylight , too more red may give rise to glare or unduly favorable
conditions. While too much blue will create the reverse impression. Besides, the
anaesthetist will have to read and keep track of monitoring instruments and this makes
good day light conditions imperative.
➢ General Lighting- This must be such that the theater staff can select and manipulate
instrument with care. There is advantage in having large elements of daylightnen, this
create pleasant working condition for staff who might feel trapped without any windows
to the world outside. Of course arrangements for darkening should also be made.
➢ Window- These should be dust proof with rubber gaskets and double glazing for air
conditioning purposes. The opening should be up to 15percent of floor area.
➢ Door- The door should be wide enough for easy movement of stretchers and trolleys.
These could be double action and two-leaf type with 5feet widths
➢ Floors- The floor must be able to withstand the rolling loads of heavy operating tables
and mobile x-ray machines. It should be strip resistant under wet conditions and
impervious to frequent cleaning with scrubbing machines. Terrazzo tiles or cement based
pared in place finish are suitable where floor structure is not liable to movement.
➢ Walls/Ceiling- All rooms in the operating suite should have impervious wall and ceiling
furnishes able to withstand wet cleaning. A semi-matt wall surface reflects less light than
highly gloss finish and it is less tiring to the eyes of the theatre team. With this in mind
the light colour is important also for the wall, ceiling and floors. pale green or blue is
acceptable as strong colour will distort the colour rendering of light sources and should
be avoided.
OPERATING THEATRE TECHNIQUE
PREAMBLE
The operating theatre is unique in the sense that the experience nurse does demonstrate
some aspect of nursing to a degree not seen elsewhere. The operating team consists of surgeons,
anaesthetists, nurses and other auxiliary workers (male and female). These personnel’s co-
operation is a happy professional atmosphere to achieve safe environment for the patient’s
surgery. The student nurse should be familiar with the layout of the operating theatre or theatre
suite in her training school.
The operating theatre team should maintain speed, accuracy and efficiency with strict
aseptic technique in carrying out all theatre procedures.
The operating theatre has its various packs and sets which are too numerous to include in
this paper. Students are however advised to refer to the instruments set book available in the
operating theatre to help them in trolley setting and knowledge of instruments.
OPERATIVE
During the surgical procedure efforts should be directed at confirming contamination to the area
around the sterile field.
Organic debris of blood, sputum, pus are decontaminated promptly to prevent soiled organisms
becoming dry and airborne.
Sponges are discarded into appreciative containers.
Circulating nurse uses gloves or an instrument to handle and counts soiled sponges. Other used
articles are placed in proper containers.
POSTOPERATIVE CLEANING
At the conclusion of operation, all items which come in contact with the patient and/or sterile
field are considered contaminated. Gown and gloves are placed in receptacles by personnel
before leaving the operating room .All linen, soiled or not are placed in laundary bag. Used or
soiled sponges and other contaminated articles are placed in plastic or paper bags for disposal.
All dirty instruments are put by the (gloved) scrub nurse into a bowl or tray and taken to the
utility room for washing. Special care is to be taken while handling and
Discarding used syringes, needles and blades to prevent injury to theatre and hospital personnel.
Suction bottles are emptied and cleaned with disinfectant and detergent. Soiled areas on the
operating table, anaesthetist machine and other equipment are cleaned with disinfectant. Fresh
cloth are used for each case and either discarded or cleaned and autoclave at the end of the day.
The floor is washed with chemical disinfectant IZAL 1:600 i.e. 0.16 percent and then mopped
dry.
A clean mop is used for each. These mops are clean and disinfected/dried case at the end of the
day.
WEEKLY CLEANING
This require vigorous cleaning of the entire operating suite including the operating rooms,
storage rooms, offices, corridors, ceilings and walls. Particular care is given to areas where
refuse and dirty linen are stored before disposal.
Sinks and walls around them, faucets, soap and lotion dispensers are cleaned thoroughly using
scoring powder (vim) and disinfectant
Drains pipes and over flows are cleaned with washing soda and water .All equipment and
furniture are thoroughly cleaned by mechanical scrubbing .
Transportation and storage carts need extra careful, attention to wheels and casters.
Autoclave interior and sterilizer are cleaned
Air-conditioning grills are vacumed and cleaned
Needle dishes done, cleaned dried and autoclaved sterilized.
Sterile articles are checked for patency and any out of date articles (after 2 weeks) are re- packed
and sterilized.
CLEANING AFTER AN INFECTED CASE
An infected case should be done at last, both on routine and emergency lists. When
possible a separate theatre is set aside for it.
All unnecessary equipment are removed from the theatre leaving the very essential apparatus.
Only necessary instruments are used .
Disposable gowns, drapes and gloves are used if possible. Few theatre personnel are allocated
To the case and once a case is started movement in and out of the theatre is prohibited. At the
end of the surgical procedure two large disposable paper or plastic bags are provided. One black
bag for all the used gowns and linen and another yellow bag for all used and left over swabs,
gloves, needles ,blade s and sutures.
These bags are then taken to the disposable area of the sluice room. The laundry is also dully
informed about the infected material.
The scrub nurse with her gloves on should put all the instruments used for the procedure in a
bowl of strong Jik disinfectant. Suction bottles and tubes are also soak in the same solution.
These are left for 24hours in the sluice room after which they are thoroughly washed, dry
.autoclaved and put back into circulation. Theatre is washed thoroughly with morigard / izal 1 in
600 and fomalin 1 percent and left un-used for 24hours.A notice is display on the entrance door
to notify personnel that an infected case has been operated on (indicating date and time).Theatre
staff and hospital matron’s office are duly informed.
The two nurses who assisted in the case will go to the changing room, remove their theatre
outfit, have a shower if possible, put on freshly laundered clothing prior to proceeding with
other cases.
THEATRE MANAGEMENT
Management is a field of behavior in which manager’s plan, organises staff, direct, control
human and material resources in an organised group effort in order to achieve desired and group
objectives with optimum efficiency and effectiveness. However, management can be defined as
working through other people to achieve goal.
FUNCTIONS OF MANAGEMENT
1. Planning- planning is predetermining future .planning is deciding in advance about what
to do, how to do it, when to
2. Organizing- is establishing structure. It involves grouping tasks producing authority,
responsibility structures creating channels of communication and creating coordinating
mechanism.
3. Staffing-staffing is hiring and assigning people to carry out tasks, it is filling and keeping
filled position in the organization structure. It is human resource management.
4. Leading- leading is influencing, commanding and motivating people to perform task for
goal achievement.
5. Controlling – controlling is maintaining , comparing and correcting organizational
performance towards goal achievement.
ORGANISATION AND MANAGEMENT IN THE OPERATING THEATRE
Organisation is necessary in the operating theatre department in order to integrate a complexity
of skills, expertise and technology in the interest of patients requiring surgery. It must be planned
round a central point which in the operating theatre should be the patient undergoing surgery, the
patient is unaware of the implications of standards of design and care in the theatre has placed
his trust temporarily in people many of whom he never see.
This imposes a great responsibility on those who planned and those who work in the theatre
(surgical team), not because they will be unrecognized but because the patient has given them
complete trust. In simple term, this is what good management of the patient in the operating
department is share by surgeon, anaesthetist and perioperative nurses. Each has a specific field of
responsibility as part of a team, although some tasks such as checking instruments, swabs and
packs are shared. The surgeon decides if and when to operate and the procedure to perform, the
anaesthetist is responsible for the patient’s safety survival under anaeathesia during the operation
and immediate post-operative period. The perioperative nurse provides staff, instruments,
equipment and co-ordinates technical services for the team.
Operating department manager:- The senior nurse responsible for operating department
services, influences to a great extent how working relationships develop between members of the
medical, nursing and technical team.
This person should be a good leader experienced in all aspect of theatre technique having
managerial skills and qualification of kindness, tolerance and total commitment. The capacity to
plan ahead with good judgment and the ability to accept constructive criticism is very important.
There should always be a willingness to adapt to new development in surgery and theatre
technique. The need for loyalty to the patient and other member of the team is obvious. The
importance of good communication between the operating department, manager and members of
the team can not be over emphasized. He should tackle problems and contentious issues as soon
as possible; it should not be shelved, otherwise morale can suffer as a result of resentment or
misunderstandings. In short, he should be a good manager but essentially a leader of a nursing
and technical team.
STAFF
Operating department personnel must aim to achieve the highest possible standards in their work.
Strict asepsis would perhaps not be achieved during tonsillectomy operations as compared with a
bone graft, but the same amount of care must be taken during the preparation for each.
Commitment to the work requires high personal standards to set an example to others, dexterity,
accuracy and efficiency are vital.
The ability of nurse to be part of an operating team and contribute towards a happy professional
atmosphere helps toward the attainment and maintenance of the high standard required.
Preparation of the operating theatre between cases and operating sessions will be the
responsibility of non-medical members of the team. The policy for cleaning and standards
required should be agreed between the operating department manager and domestic manager.
This will include major cleaning such as walls, ceiling and general 24 hour cleaning of the
operating department.
Domestic staff should be employed to care for staff changing rooms, rest rooms and office for
serving beverages and light refreshments to staff in accordance with a policy agreed with the
catering manager. ‘’care’’ in this context includes duties such as general tidiness, the disposal of
nonsurgical rubbish and the replenishment of supplies items such as linen. These are not duties
for which skilled operating department staff should be employed.
Tasks undertaken by operating department porters vary considerably from hospital to hospital. In
some cases their duties will be restricted to transfer of patients between the wards and operating
department: in others their work may extend to movement of patient within the limited access
zone. However, it is preferable that these porters are part of the operating department
establishment, rather than being provided on an adhoc basis from the general portering pool.
Operating department committee/theatre users committee:
The operating department manager has overall accountability for the services provide, including
management of a financial budget, but there is need for multidisciplinary committee to advise on
overall management of the department.
Essentially it is advisory to the unit general manager but may have an executive functions, some
of the functions includes:-
- Development and monitoring of the management budget
- Ensuring most effective use of facilities and staff
- Keeping under review the incidence of post-operative infection.
- Recommending the purchase of new instruments and equipment within financial
constraints.
- General monitoring of the standards of care and skill in the department.
- Make proposals for changes in the organization of the department as part of their
advisory role, which may affect other departments in the hospital.
- Advise on staffing patterns and training programmes.
The chairman of this committee should be nominated by the unit general manager. A
small group is more efficient and therefore it is suggested that the remaining members should
normally be restricted to the operating department manager, representatives of the surgical
and anaesthetic consultants and the unit general manager or his deputy. Other members can
be co-opted as required for example (SDU) sterile and disinfectant unit manager, ward
nursing representatives, microbiologist, pharmacist, radiologist, domestic manager or
supervisor and the hospital work officer. It is important that these specialist are invited to
attend when matters of their particular concern are being considered. Similarly, they should
also have access to the committee at any time to resolve any matter which required
discussion. The committee should meet regularly, ideally monthly, minutes should be kept
and circulated to interested parties.
POLICIES
In conjunction with the operating department committee /theatre users committee, the manager
should prepare procedure manuals based on agreed policies and standards. There are codes of
practices which gives guidelines for the preparation of such manuals and it deals with hazards
and safety. Procedures; which should be covered includes;
1. Accident to staff, major accident/incident procedures
2. Arrangement for catering in the department
3. Complains, grievances and disciplinary procedures
4. Supplies and disposal includes linen
5. Fires safety, health and safety at work and other safety matters including procedures for safe
guards against wrong operations and checking swabs and instruments, safety practices to avoids
hazards such as use of x-ray apparatus, radio-isotopes and laser.
6. Handling of laboratory specimens, infection control
7. Patients care including documentation, transport, lifting, organ transplantation.
8. Work department including arrangement for repair and maintenance
PATTERN OF WORK
The pattern of work in an operating department should be organised so as to provide cost
effective, utilization of accommodation. Operating time and manpower consistent with the best
interest of patients and staff. This will be simplified if the manager establishes a management
information system from which standards can be maintained and from which accurate costing
can be derived without additional effort.
The system is patient based and is oriented around a form which records the patient’s progress
through the operating department, identifying key staff who provide the care ,procedures carried
out and the use of consumables. The system enables a range of data to be collected for operating
department management purposes, including data for management planning, costing, manpower
deployment, monitoring of standards and statistical returns. The data output includes costs of
surgical specialty by individual clinicians, by patient and by procedure, new sessions, additional
consultant, utilization of theatres and sessions, change in procedures, scheduling of operating
sessions e.t.c.
The operating department management system will supplement other management procedures
e.g. patient records or the requisitioning of supplies and stock control.
OPERATING LIST/SCHEDULES
Preparation of operation list by medical staff in collaboration with the operating department
manager and ward sister should ensure that typed copies are available for distribution for all
department concerned not later than the afternoon previous to the morning on which operation
are due to take place. The schedule drawn up should be realistic and one which can be
reasonably expected to be completed by the surgeons within a defined period (clarke et.al 1984)
point out that ‘’in any theatre, staff have domestic responsibilities and are often unwilling or
unable to work beyond their allotted time’’. Surgical staff can assist greatly the task of nurse
managers by ensuring a prompt start, by limiting the length of operating list to members capable
of completion in a session and by early notification of unavoidable alteration to the list.The
lewin committee(1970) considered that the average length of an elective operation session should
be between three and a half or four hours (3hr 30min-4 hours) with the afternoon session starting
at a time which allows it to finish by 7hours.
Abbreviation should never be used on an operation list which may be generated as a hard copy
using computer data or typed. The following should be included:-
- Patient’s surname and first name
- Age/sex
- Registered hospital or unit number
- Nature, site and side of operation
- Theatre where the operation is taken place
- Ward or unit
- Date and time of operation
- Name of surgeon
- Name anaesthetist
- Note if there are special requirements
NB- Last minute changes to operation list cause concern and possible risk of error.
A firm policy should be laid down by the operating Department Committee /TUC for the
procedure to be adopted for any changes to the operation list in order that all relevant personnel
are informed.
RECORDS
It is vital that accurate records are kept of operations performed and the personnel involved,
nursing care and any accidents or incident which occur.
Operation Records:- Information should be entered either in a bound book or on a specially
designed sheet which can be filed in a loose leaf folder. Pages should be numbered and the space
allocated for each entry should be reprinted with serial number of the operation. The design of
the book or sheet will vary according to local policy, but specific sections should be provided for
the following information: date, patient’s surname and first name, age, sex, hospital or unit
number, ward or unit, operation performed, time of operation commenced and finished,
Anaesthetic- local/general, signatures of surgeons, surgeon’s assistant, anaesthetist, nurse
anaesthetist, signatures of scrub nurse and person who checked the final scrub, insruments and
needle count (usually circulating nurse), specimen taken, Tourniquet time, general additional
comments/ remarks.
Nursing Care Records – it is important that the patient’s medical and nursing records should
accompany him at all times. Following surgery, the medical staff will enter details on the case
records including operation performed, anaesthetic given and drains/packs in position.
Instructions for immediate post–op care will be entered on the nursing record.
Accident Record- where an accident or incident involving a patient or member of staff has
occurred, full details must be entered in the official accident book on the designated form.
