OPERATING ROOM—PHYSICAL SET UP
Operating rooms or the theater block is one of the important special departments of a hospital. An operating room is a particular room where the surgery and the surgical procedures are conducted. This unit is designed as “Self contained block” with a series of rooms leading of a corridor with closed doors that separates it from the general wards but away from the thoroughfare of the hospital. Entrances are provided for bringing and sending patients, instrument trolley, surgical team and other staff members of the unit. Any cross traffics for people other than the workers of the unit are strictly avoided. All the categories of people working in the unit are provided with changing rooms where ordinary cloths can be changed for theater garments or clothing covered with clean gowns, caps and overshoes before entering the operating room or anesthetic rooms. The workers of the unit preserve special foot wear while working hours. This unit is provided with toilet rooms in addition to changing rooms. The surgeons and the sister in charge of the operating room are having their office rooms other than the staff room. Scrubbing room leads directly to the operating room. In some hospitals anesthetic room is separate which opens in to the operating room with serving doors so placed that the patient cannot see the operating room.
Sterilizing equipment is usually placed in an annex leading to the operating room; this arrangement keeps the actual theater free 2from unnecessary heat and stream and also minimizes noise. These annexes should be large enough to allow sufficient space for the laying up of instruments and other trolleys. A sink room or “utility” room is also necessary in which instruments, bowls, mackintoshes and other equipment can be cleaned after use. A linen room with a large table is a necessity for the sorting and mending of clean linen and for packing drums or making bundles. A stock room may be separated or combined with the linen room.
There should be ample cupboard accommodation. Large or specialized units may include an X-ray room and electric power points are provided in an area accessible to the theater for operating mobile X-ray plants. Separate multiple switch board is of advantage.
Labor-saving and hygienic construction facilitate the daily thorough cleaning which is necessary in all operating rooms. Walls and floors are commonly made with washable materials. The floors should contain “antistatic” material and slope towards a gulley and trapped drain so that the walls and floors can be washed down easily with a hose. As far as possible ledges and corners which may harbor dust are avoided in the construction of the building and in the fittings and furniture. Natural ventilation is seldom possible when a theater is in use, as dust and draughts must be excluded and therefore some form of artificial ventilation is needed. The “plenum” system is frequently used. Air from a reliable source is driven into the theater through filters to remove dirt and impure air is forced out and when necessary the incoming air can be warmed by passing it over heated pipes which can be controlled by the theater staff. If windows are large in order to give plenty of light from outside; blinds are necessary as a protection against too much sunlight in the summer and also to darken the theater when needed for certain operations. The theater needs an efficient system of artificial lighting and an emergency system should be available in the event of the electricity from the main failing. The table lighting is provided by a large shadowless lamp and mobile shadowless “spot lamps”. All electric switches in operating theaters and anesthetic rooms should be of the mercury “make and break” type in order to minimize the risk of an explosion caused by sparking.3
Theater furnishings and fittings should be made of stainless steel for quick and thorough cleaning. Trolleys of all types should be fitted with large casters made up of conducting rubber to minimize sparking from static electricity. The modern operating rooms are air conditioned and the walls and furnishings are of pleasing colors or white.
Special laundry facilities should be provided in the operating unit. This arrangement not only prevents the delay of getting fresh clean linen but also exclude the chance of mixing the linen with linen of other departments of the hospital. It also prolongs the duration of the use of the same linen, prevents much damage and loss and reduces the chances of infection. In short, operating room block is a self contained unit of the hospital pertaining to the staff and functioning. The operating room technique describe the methods of routine functioning of this unit.
Several operating rooms are seen in one unit because the special operations other than general surgery are done in their own rooms such as neurosurgery, orthopedic surgery, ENT operations, eye operations, paediatric surgery, thoracic surgery, gynecologic surgery, etc. Surgeons and nurses working in each room will be specialized in that branch of surgery. The nurse who is specialized in the operating room technique and the one who is the seniormost of them will be in charge of the unit. She controls the functioning of the operating room team work and the anesthetic section.
THE CATEGORIES OF PEOPLE IN THE OPERATING ROOM TEAM WORK
Surgeons: Specialized in the particular branch of surgery.
Assistant surgeons: Specialized but practising with the senior surgeon.
House surgeons: If it is medical college hospital.
Medical students: If any.
Other theater nurses: Specialized to work in special operating rooms.
- Head nurses
- Staff nurses
- 2nd and 3rd year nursing students.
- Operating room technicians.
- Other workers such as attenders, cleaners, dobhi, etc.
- The number of nurses and other workers depends upon the type of hospital and the number of daily operations.
- Anesthetic section functions in the equal level along with surgical team under the chief anesthetist. They include:
- Chief anesthetist (doctor)
- Other assistant anesthetist (doctors)
- House surgeons and medical students, if any
- Anesthetist nurse who is specialized in anesthesia
- Other staff nurses and nursing students (2nd and 3rd years)
- One or two attenders.
- Here also, type and number of staff members depends upon the number of daily operations.
Surgical team and anesthetic team function inseparable and the sister in charge of the operating room looks after the welfare of both sections.
GENERAL FUNCTIONS OF OPERATING ROOM NURSES
The theater nurse should aim at attaining an efficient standard of aseptic technique and such a well developed surgical conscience that she can be relied upon to carry out her work at all times and particularly under conditions of emergency, with speed, accuracy, and calmness. Such a desirable standard is not obtained without a thorough knowledge of the principles of sterilization and theater technique. Every nurse working in the theater needs to realize that the success of the surgeon's work depends largely on the careful reliable attention in detail shown by every member of the staff and the keenness, sharp observation, and dexterity which will make each member of the theater personnel an efficient unit, in the surgical team.5
In the theaters, nurses usually change into white shortsleeved dresses of over all type, theater caps covering the hair, masks, white shoes and stockings before beginning the preparation of instruments, apparatus, and lotions for the day's operations. Ward nurses, students and visitors when entering in the theater are also required to change or to cover their ordinary clothing with clean gowns, to wear caps and masks and to put on white rubber or canvas boots over their shoes.
Theater linen is used for patient's trolleys. Only the minimum of ward linen, e.g. the patients gown, should be brought to the theater and must always be freshly laundered. These precautions are necessary in order to reduce the risk of wound infection.
During operations: The sister or nurse who is to act as the “instrument nurse” scrubs up, covers her theater dress with a sterilized gown, and puts on sterilized rubber gloves.
The instrument nurse checks and arranges the instruments on the instrument table and passes them to the surgeon, as far as possible anticipating his needs. She also prepares ligatures and sutures, having them ready for the different stages of the operation. She passes mops and gauze pads to the surgeon and his assistant, is responsible for accounting for all swabs and instruments, including needles at any stage of the operation and in particular before any cavity is closed. During all bone operations, and for some surgeons during any type of operation, all instruments, swabs, all ligatures and sutures may be handled with forceps so that no sterile materials coming in contact with the wound, is touched by the gloved hands.
One, or if possible, two nurses who will not scrub up will act as runners or ‘circulating’ nurses. One of these should watch the instrument nurse and be ready to bring anything that she may require or to put any extra instruments in the sterilizers as directed. It will be one of the duties to keep the sterilizers filled with water and boiling and to see that the instruments are ready for the next case. She assists in placing the patient on the theater table if a theater porter is not a vailable.
The second runner hand over gowns, caps and gloves to the surgeon and assistants, removing these articles from the drums 6with long handled forceps. She also ties the gowns. She puts the lotions in the lot ion bowls and changes them as necessary. For some operations hot sterile normal saline solution is required. She replenishes the mops and pads as they are used and is responsible for checking the used swaps and displaying them on the counting stand. If a tourniquet is applied to a patient in the theater the time at which it is to be removed should be written down and subsequently entered in the patient's history sheet. When the other runner is in the sterilizing room she must watch the instrument nurse and be ready to attend to any needs. At no time during the operation should the theater be left without one runner.
The ward nurse in charge of the patient should see that all records such as case notes and X-ray films (with the consent to operation form uppermost) are brought to the theater with the patient. She should be able to answer questions concerning the preparation of the patient, e.g. when the premedication was given or when the patient had his last feed. She remains with her patient in the anesthetic room until the patient is unconscious. Then, with the anesthetist's permission she returns to the ward. If the local anesthesia or no anesthesia is planned, she will put on theater clothing and accompany the patient into the theatre. In some cases the entire preparation of the skin, beginning with shaving and cleaning with ether, may be undertaken in the theatre. Usually the final preparation only is carried out on the operating table. This may consists of vigorous sponging of the area with a gauze mop soaked in cetrimide and held with sponge forceps. This is followed by mopping with a dry swab and finally painting the area with surgical spirit or with an antiseptic such a s 2.5 percent iodine in spirit or Hibitane 0.5 percent in 70 percent alcohol. The ward nurse is responsible for taking any instructions regarding the care of the patient, from the surgeon or anesthetist, back to the ward sister.
Most theaters keep a daily register of operations in which the nature of the operation, its duration and the anesthetic used are entered up for each case. The book is usually signed by the instrument nurse and by th e anesthetist. Another operation register is maintained for the surgeon with the details of operations for each unit.7
Modern concept is that the energy and time of a qualified nurse is not wasted to work as a circulating nurse. But they can be improvised by competent technicians. Also the working personnel in the OR unit is not interchangeable from a ward to theater or from the theater to wards for temporary adjustments as practised in general wards.
The set up and functioning of the operating room is aimed at the maintenance of the aseptic condition of the unit, the successful surgery and an uneventful postoperative period of every patient.