Policy & Procedure Document

PART VIII — EMERGENCY & BUSINESS CONTINUITY (FMS / IPSG)

SEC 14 — OT Emergency Coordination (OT Scope)

Independent Policies 14.1–14.5

Operating Theatre Policy

POLICY 14.1 — Code Blue / Rapid Response Activation in OT

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + Resuscitation Liaison
Policy Code & Title OT-EMR-14.1
(Roles + Access + Crowd Control)
Related Policies: Hospital Code Blue policy, AHA CPR/ECC system of care, SEC 11.1 (discipline), SEC 13.1 (hazard reporting)

1.0 PURPOSE

  • 1.1 To ensure immediate, organized activation and management of Code Blue / Rapid Response events in the OT environment, where crowding, equipment density, and sterile conditions can quickly degrade resuscitation quality and safety.
  • 1.2 To ensure the OT response supports high-quality resuscitation systems and team performance concepts emphasized by current AHA guidelines and training resources. (cpr.heart.org)

2.0 SCOPE

  • 2.1 Applies to all OT areas (OR rooms, induction areas within OT suite, PACU interface areas if managed by OT for transfer).
  • 2.2 Covers: activation, role assignment, access control, crowd control, equipment positioning, documentation, and post-event debrief (OT scope).
  • 2.3 Clinical treatment algorithms follow hospital resuscitation policy and AHA guidelines; this policy governs OT logistics and safety systems. (cpr.heart.org)

3.0 DEFINITIONS

  • 3.1 Code Blue: Cardiac/respiratory arrest requiring full resuscitation response.
  • 3.2 Rapid Response / Medical Emergency Team: Escalation for deteriorating patient not yet in arrest (local names apply).
  • 3.3 OT Crowd Control: Restricting personnel to essential responders to preserve access, reduce confusion, and maintain safety.

4.0 POLICY STATEMENT

  • 4.1 Any staff member who identifies cardiac arrest or life-threatening deterioration in OT shall activate Code Blue / Rapid Response immediately—do not delay for hierarchy.
  • 4.2 OT shall implement structured role assignment and strict crowd control to preserve patient access and enable high-quality resuscitation performance, consistent with resuscitation systems-of-care emphasis.
  • 4.3 OT shall ensure immediate availability of resuscitation equipment (defibrillator, suction, oxygen, airway rescue resources per local scope) and clear access routes.
  • 4.4 OT shall document the event reliably and initiate debrief and incident reporting.

5.0 ROLES AND RESPONSIBILITIES

5.1 First Responder (any staff)

5.1.1 Recognize arrest/deterioration, call Code Blue/RRT, start basic actions within scope.

5.2 OT Charge Nurse (Incident Coordinator – OT)

  • 5.2.1 Controls access and crowd; assigns runner; ensures doors, corridors, and equipment pathways remain clear.
  • 5.2.2 Coordinates external team entry into restricted zones (PPE/attire quick compliance as feasible without delaying care).
  • 5.2.3 Ensures documentation pack is activated and preserved.

5.3 Circulating Nurse (Room Operations Lead)

  • 5.3.1 Directs room setup for resuscitation (space, equipment placement, waste control, sharps control).
  • 5.3.2 Coordinates with scrub/surgeon to protect the field/wound as appropriate and safe.

5.4 Scrub Nurse/Technologist

5.4.1 Maintains sterile field control and secures sharps; assists surgeon with safe wound protection/temporary closure measures if needed.

5.5 Anesthesia Provider

5.5.1 Leads airway/ventilation and resuscitation clinical management per hospital policy (clinical scope not duplicated here).

5.6 Surgeon/Proceduralist

5.6.1 Coordinates surgical field safety and decision-making to stop/temporize/close as required to enable resuscitation.

5.7 Runner (assigned)

5.7.1 Brings emergency cart items, obtains additional equipment/blood products, facilitates communications with lab/blood bank/ICU.

6.0 PROCEDURE (OT-SPECIFIC)

6.1 Activation and Initial Actions

  • 6.1.1 Call for help immediately: Activate Code Blue/RRT using the hospital’s activation method (button/phone).
  • 6.1.2 Announce clearly: “CODE BLUE — OR ___” or “RRT — OR ___.”
  • 6.1.3 OT charge nurse starts the OT Code Log (time, room, patient identifier per policy, caller, responders).

6.2 OT Crowd Control and Access Rules

6.2.1 OT charge nurse establishes a “controlled perimeter”:

  • a) Inside room: only essential responders (code team lead, airway lead, compressor, defib operator, circulating nurse, recorder, surgeon/anesthesia as needed).
  • b) Outside room: runner + security/support only.
  • 6.2.2 Nonessential staff, observers, vendors exit immediately (Policy 11.1 discipline principles).
  • 6.2.3 Door remains closed as much as possible; entry is controlled by one designated person.

6.3 Room Setup During Arrest (Space & Safety)

  • 6.3.1 Clear hazards: remove clutter, manage cords to prevent trip hazards.
  • 6.3.2 Protect sharps and hot devices: electrosurgery pencils placed safely; sharps secured; smoke evacuation off if not needed.
  • 6.3.3 Ensure oxygen and suction are available and not leaking.

6.4 Sterile Field and Surgical Site Control

6.4.1 Surgeon/scrub perform the safest feasible “pause and protect” approach:

  • a) cover wound with sterile drapes/sponges as appropriate,
  • b) secure bleeding control if immediate,
  • c) make the patient accessible for resuscitation.

6.4.2 Infection prevention is maintained as feasible without delaying life-saving actions.

6.5 Documentation (Recorder)

  • 6.5.1 Use the OT Code Blue record (paper if needed).
  • 6.5.2 Record: time of collapse/recognition, activation time, first rhythm/defib times (from code team), key actions, transfer destination.
  • 6.5.3 AHA training resources emphasize measuring key response and performance metrics in mock codes and real events. (cpr.heart.org)

6.6 Transfer After ROSC or Termination (OT Interface)

6.6.1 If ROSC achieved or transfer decision made:

  • a) coordinate route clearance, elevator priority, and receiving team readiness (ICU/ED).
  • b) maintain monitoring and oxygen for transfer (anesthesia lead).

6.6.2 OT retains all documentation and ensures it is scanned/entered per MOI policy.

6.7 Debrief and Learning

  • 6.7.1 Immediate “hot debrief” within 10–15 minutes when feasible: what went well, what failed, equipment issues, crowd control issues.
  • 6.7.2 Report hazards (missing equipment, access control failure) into incident reporting/QPS.

7.0 DOCUMENTATION | 8.0 AUDIT | 9.0 REFERENCES | 10.0 APPENDICES

7.0 DOCUMENTATION / RECORDS

  • 7.1 OT Code Blue/RRT record (paper/electronic).
  • 7.2 OT Code log (charge nurse).
  • 7.3 Equipment checks and failure tags if used (Policy 12.5).

8.0 AUDIT / KPIs

  • 8.1 Time to activation from recognition (goal: immediate).
  • 8.2 Crowd control compliance (audit via debrief tool).
  • 8.3 Availability/readiness of defib and emergency equipment (daily checks).
  • 8.4 Completion of debrief and event review.

9.0 REFERENCES

  • 9.1 AHA CPR & ECC Guidelines (2025) and algorithms resources. (cpr.heart.org)
  • 9.2 AHA Systems of Care guidance (2025).
  • 9.3 AHA Mock Code Training Guide (2026) emphasizing measurement and performance review. (cpr.heart.org)

10.0 APPENDICES

  • 10.1 OT Code Blue / RRT Role Card (door poster)
  • 10.2 OT Code Blue Record (paper)
  • 10.3 OT Crowd Control Checklist
  • 10.4 OT Hot Debrief Form
Operating Theatre Policy

POLICY 14.2 — Massive Hemorrhage Activation

Department Operating Theatre (OT)
General Hospital
Owner OT Director/Chair + OT Nurse Manager + Blood Bank Liaison + OT QPS Lead
Policy Code OT-EMR-14.2
Related Hospital MHP/MTP, SEC 11.13 (blood loss), SEC 8 (handover)
(OT Logistics, Equipment Readiness, Documentation)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

  • 1.1 To ensure rapid, organized OT logistics for Massive Hemorrhage activation, supporting timely blood product delivery, equipment readiness, and traceable documentation.
  • 1.2 To ensure that hemorrhage response addresses known drivers of coagulopathy (hypothermia, acidosis, hypocalcemia) through logistics readiness and communication, consistent with trauma transfusion guidance. (ACS)

2.0 SCOPE

  • 2.1 Applies to all OT cases with suspected or confirmed life-threatening bleeding (trauma, obstetric hemorrhage, vascular surgery, major oncology, unexpected bleeding).
  • 2.2 Defines OT operational steps; clinical transfusion decisions are governed by the hospital MHP/MTP and anesthesia/surgical teams.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 OT shall maintain a ready hemorrhage response system: MTP activation pathway, blood runner role, rapid infusion/warming equipment access, and clear documentation.
  • 3.2 Activation shall not be delayed by uncertainty when bleeding is rapidly evolving; OT supports early escalation and clear communications.
  • 3.3 OT documentation must capture activation time, products received (logistical tracking), and key communications.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 Surgeon/Anesthesia (Clinical Leaders): decide activation; OT supports rapid logistics.
  • 4.2 OT Charge Nurse (Coordinator): assigns runner, contacts blood bank per pathway, coordinates additional staff/equipment, manages room traffic.
  • 4.3 Circulating Nurse: maintains hemorrhage log, coordinates specimen transport for urgent labs, tracks timing and communications.
  • 4.4 Runner: physically retrieves blood products, delivers specimens, coordinates with blood bank and lab.
  • 4.5 Blood Bank Liaison: ensures blood product preparation and communication path.

5.0 PROCEDURE

5.1 Pre-Case Readiness (Daily/Shift)

  • 5.1.1 Confirm location and readiness of: rapid infuser (if used), fluid warmers, blood warmer, pressure bags, large-bore IV supplies (anesthesia), suction availability, extra canisters, warming blankets, and emergency hemorrhage pack.
  • 5.1.2 Confirm MTP contact numbers and activation script are visible in each OR.

5.2 Activation Steps (OT Logistics)

5.2.1 When MTP is activated (per clinical leader request):

  • a) charge nurse assigns runner,
  • b) runner contacts blood bank with required identifiers/location and confirms delivery method,
  • c) circulating nurse starts MTP Log (time activated, who activated, blood bank contact time).

Structured checklists are commonly used in MTP operations to ensure correct communications and documentation. (clinicaldata.nzblood.co.nz)

5.3 Blood Product Receipt and Tracking

  • 5.3.1 On receipt of products, OT logs: time received, product type, quantity, and condition of transport container.
  • 5.3.2 Maintain chain-of-custody per blood bank policy (signatures as required).
  • 5.3.3 Ensure unused products are returned promptly per blood bank rules to reduce wastage.

5.4 Supportive Logistics (OT Scope)

  • 5.4.1 Temperature management readiness: ensure patient warming devices available to mitigate hypothermia risk (logistics). (ACS)
  • 5.4.2 Lab coordination: ensure urgent samples are labeled with two identifiers and transported quickly (runner).
  • 5.4.3 Documentation readiness: ensure blood loss estimation tool is actively updated (Policy 11.13).

5.5 Deactivation and Post-Event Actions

  • 5.5.1 When MTP is stopped, document stop time and final product summary (logistical count).
  • 5.5.2 Ensure incident review for major hemorrhage cases via QPS if delays or failures occurred.

6.0 DOCUMENTATION | 7.0 AUDIT / KPIs

6.0 DOCUMENTATION

  • 6.1 MTP activation record (time, caller, location).
  • 6.2 MTP Log: products received/returned; transport times; lab dispatch times.
  • 6.3 Final blood loss documentation (Policy 11.13).
  • 6.4 Incident report if delay, wrong product delivery, or documentation failure occurs.

7.0 AUDIT / KPIs

  • 7.1 Time from activation to first blood product arrival (trend).
  • 7.2 Completeness of MTP log documentation.
  • 7.3 Product wastage rate (trend).
  • 7.4 Equipment readiness compliance (rapid infuser/warmers availability).

8.0 REFERENCES | 9.0 APPENDICES

8.0 REFERENCES

  • 8.1 ACS TQIP transfusion guidance (coagulopathy drivers and OR role). (ACS)
  • 8.2 Example MTP checklist illustrating structured activation communications and documentation. (clinicaldata.nzblood.co.nz)

9.0 APPENDICES

  • 9.1 Appendix A — OT MTP Activation Checklist (one-page)
  • 9.2 Appendix B — OT MTP Log (products/time/returns)
  • 9.3 Appendix C — Runner Script Card (blood bank + lab + radiology numbers)
Operating Theatre Policy

POLICY 14.3 — OT Evacuation / Shelter-in-Place

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + FMS/Safety + Security
Policy Code OT-FMS-14.3
Related Policies: Hospital disaster plan, SEC 13.2 Fire safety

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

1.1 To define safe, disciplined OT evacuation and shelter-in-place actions that protect patients mid-procedure, staff, and visitors, with clear decision authority and documentation.

2.0 SCOPE

  • 2.1 Applies to all OT suite areas and all patient status types: pre-op holding, intraoperative, immediate post-op awaiting transfer.
  • 2.2 Covers partial evacuation, horizontal/vertical evacuation, staged relocation, and shelter-in-place.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 OT shall maintain an evacuation/shelter plan integrated with the hospital emergency management program.
  • 3.2 Decision-making for a patient mid-procedure must be coordinated between surgeon and anesthesia, with OT leadership and emergency management support; emergency planning guidance emphasizes planning for surgical areas where procedures may need to be aborted/temporized/relocated. (ASPR TRACIE)
  • 3.3 Shelter-in-place is used when leaving is unsafe; guidance emphasizes selecting interior rooms with minimal windows/vents and adequate space. (osha.gov)
  • 3.4 During evacuation, hazardous materials and oxygen/flammable gases should be secured/turned off when safe to do so (facility guidance examples include shutting doors and turning off oxygen/flammable gases). (ors.od.nih.gov)

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 OT Charge Nurse: evacuation coordinator for OT; controls patient tracking board; assigns runners; coordinates with security.
  • 4.2 Surgeon/Anesthesia: decide clinical feasibility to stop/temporize/continue for each patient; communicate status to coordinator. (ASPR TRACIE)
  • 4.3 FMS/Safety Officer: provides hazard intelligence (fire/smoke/structural/utilities) and routes.
  • 4.4 Security: controls corridors, elevators, access, and crowd.
  • 4.5 Circulating Nurse: prepares patient for movement (lines secured, portable oxygen as ordered), secures documentation.

5.0 PROCEDURE

5.1 Triggers

5.1.1 Fire/smoke, structural damage, chemical hazard, security threat, utilities failure requiring relocation, civil defense instruction, or incident command activation.

5.2 Evacuation Categories (OT Practical)

  • 5.2.1 Category A — Immediate evacuation: imminent life-safety threat (uncontrolled fire/smoke/structural).
  • 5.2.2 Category B — Urgent relocation: threat rising; move stable patients first, then those requiring support.
  • 5.2.3 Category C — Shelter-in-place: external hazard or unsafe corridors; maintain patients in safest internal OT zones.

5.3 Patient Prioritization (OT Tracking Board)

5.3.1 OT charge nurse maintains a live list of patients with status:

  • a) in procedure (critical),
  • b) closed/ready for transfer,
  • c) pre-op holding,
  • d) anesthesia induction stage.

5.3.2 Patients ready for transfer are moved first; patients mid-procedure require surgeon/anesthesia decision on temporize/close/continue. (ASPR TRACIE)

5.4 Evacuation Steps

  • 5.4.1 Announce evacuation instruction (code/command).
  • 5.4.2 Stop nonessential activity; clear corridors; remove visitors.
  • 5.4.3 Secure hazards when safe (oxygen off where appropriate, doors closed). (ors.od.nih.gov)
  • 5.4.4 Move patients using defined routes (horizontal first when possible); assign escorts.
  • 5.4.5 Document destination and transfer time; maintain chain-of-custody of documentation.

5.5 Shelter-in-Place Steps

  • 5.5.1 Move to designated interior OT shelter locations if instructed.
  • 5.5.2 Close doors; limit ventilation openings as directed; maintain patient monitoring. (osha.gov)
  • 5.5.3 Maintain controlled access and privacy.

5.6 Post-Event Recovery

  • 5.6.1 Account for all patients/staff/visitors.
  • 5.6.2 Report equipment damage and hazards; initiate incident reports.
  • 5.6.3 Conduct debrief and update plan.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 REFERENCES | 9.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 OT evacuation log (patient list, locations, times).
  • 6.2 Incident command communications record (as available).
  • 6.3 Event debrief and corrective actions.

7.0 AUDIT / KPIs

  • 7.1 Drill completion and performance score.
  • 7.2 Time to account for all OT patients.
  • 7.3 Documentation completeness.

8.0 REFERENCES

  • 8.1 ASPR TRACIE: evacuation/sheltering/relocation guidance for OR planning. (ASPR TRACIE)
  • 8.2 OSHA shelter-in-place guidance (interior room selection principles). (osha.gov)
  • 8.3 NIH evacuation/shelter guidance (turn off oxygen/flammable gases; cease operations). (ors.od.nih.gov)
  • 8.4 Saudi civil defense evacuation/shelter regulatory concepts (operations room, risk areas).

9.0 APPENDICES

  • 9.1 Appendix A — OT Evacuation Decision Tool (in-procedure / induction / post-op)
  • 9.2 Appendix B — OT Patient Tracking Board Template
  • 9.3 Appendix C — OT Evacuation Log
  • 9.4 Appendix D — Shelter-in-Place Quick Guide Poster
Operating Theatre Policy

POLICY 14.4 — Utility Failure Contingency

Department Operating Theatre (OT)
General Hospital
Owner OT Nurse Manager + FMS/Engineering + IT Lead + HIM/MOI
Policy Code OT-BCP-14.4
Related Policy 12.8 (IT Downtime), SEC 13.3 (medical gas safety), SEC 12.5 (remove from service)
(Power / Medical Gases / IT Downtime Response)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

  • 1.1 To maintain safe OT operations during utility failures through immediate risk control, escalation to engineering/IT, case flow decisions, and controlled documentation.
  • 1.2 Utility failure planning is a recognized facility management requirement; CBAHI standards include having a utility system management plan and ensuring emergency power covers critical areas including medical gas systems and alarm systems. (istitlaa.ncc.gov.sa)
  • 1.3 Power failure preparedness considerations are addressed in ASPR TRACIE utility failure tip sheets. (ASPR TRACIE)

2.0 SCOPE

  • 2.1 Applies to power failures (mains/generator/UPS issues), medical gas failures/alarms, HVAC/temperature/humidity excursions affecting OT safety, water interruptions affecting cleaning/sterile processing interfaces, and IT/EHR downtime (linked to Policy 12.8).
  • 2.2 Applies to planned outages and unplanned events.

3.0 POLICY STATEMENT

  • 3.1 OT shall respond to utility failures using a structured “detect → stabilize → escalate → decide flow → document → recover” approach.
  • 3.2 OT shall protect patients mid-procedure by prioritizing life-sustaining equipment continuity and safe case decisions with surgeon/anesthesia leadership.
  • 3.3 OT shall coordinate with engineering/IT and document failures and actions taken.
  • 3.4 IT downtime response follows Policy 12.8; unanticipated downtime should be treated as an emergency planning event. (cpr.heart.org)

4.0 PROCEDURE

4.1 Immediate Recognition and Escalation

  • 4.1.1 Any staff member identifies alarm/failure and informs charge nurse immediately.
  • 4.1.2 Charge nurse notifies engineering/IT and starts OT Utility Failure Log (time, affected rooms, systems).
  • 4.1.3 Assign runner for communications and supply retrieval.

4.2 Power Failure (OT Operational Steps)

  • 4.2.1 Confirm emergency lighting and essential equipment function.
  • 4.2.2 Protect patient: maintain airway/ventilation/monitoring (clinical team), ensure cords and trip hazards managed.

4.2.3 Case flow decision:

  • a) continue critical cases if stable power on emergency circuits,
  • b) hold new inductions and elective starts until stability confirmed,
  • c) prepare for relocation if emergency power insufficient.

4.2.4 Engineering provides status; OT documents decisions.

(Emergency power for critical areas is an accreditation expectation in CBAHI FMS standards.) (istitlaa.ncc.gov.sa)

(ASPR TRACIE provides planning considerations for electricity outages.) (ASPR TRACIE)

4.3 Medical Gas Failure / Alarm

  • 4.3.1 Follow Policy 13.3 operational steps: check for disconnects/leaks, switch to cylinder backup where applicable under anesthesia/engineering guidance, restrict new case starts.
  • 4.3.2 Escalate to engineering immediately; document alarm time and affected rooms.
  • 4.3.3 Treat oxygen-related failures as potential fire and life-support risk; coordinate with fire safety controls.

4.4 HVAC / Environmental Excursions

  • 4.4.1 If temperature/humidity/pressure controls fail beyond defined thresholds, OT and IPC/engineering determine whether sterile cases can proceed or must pause/relocate based on facility risk assessment.
  • 4.4.2 Document excursion, duration, and decision.

4.5 Water/Plumbing Failure Affecting OT

  • 4.5.1 Coordinate with engineering/IPC/CSSD for impact on cleaning, hand hygiene sinks, reprocessing transport routes.
  • 4.5.2 Apply interim controls (hand hygiene alternatives per IPC policy, adjusted turnover processes) until restored.

4.6 IT / EHR Downtime

  • 4.6.1 Activate OT IT downtime procedure per Policy 12.8 (paper packs, labeling, back-entry).
  • 4.6.2 ISMP notes the need to be ready for unanticipated EHR downtime events. (cpr.heart.org)

4.7 Recovery and Return to Normal

  • 4.7.1 Confirm stability with engineering/IT.
  • 4.7.2 Resume elective flow only after confirmed safe.
  • 4.7.3 Complete documentation reconciliation (Policy 12.8 for IT).
  • 4.7.4 Debrief and report recurring defects.

5.0 DOCUMENTATION | 6.0 AUDIT | 7.0 REFERENCES | 8.0 APPENDICES

5.0 DOCUMENTATION

  • 5.1 OT Utility Failure Log (time, rooms, system, actions, resolution).
  • 5.2 Maintenance tickets and engineering reports.
  • 5.3 Incident reports if patient risk, delays, or near misses occurred.

6.0 AUDIT / KPIs

  • 6.1 Response time to notify engineering/IT.
  • 6.2 Time to stabilize operations (trend).
  • 6.3 Number of utility failures affecting case starts/cancellations.
  • 6.4 Drill and readiness compliance.

7.0 REFERENCES

  • 7.1 CBAHI FMS standards excerpts on utility system management plan and emergency power covering critical areas and medical gas systems. (istitlaa.ncc.gov.sa)
  • 7.2 ASPR TRACIE: utility failure tip sheet (electricity) and planning resources. (ASPR TRACIE)
  • 7.3 Utility failure incident planning guide example (hospital utility systems). (emsa.ca.gov)
  • 7.4 ISMP commentary on preparing for unanticipated EHR downtime. (cpr.heart.org)

8.0 APPENDICES

  • 8.1 Appendix A — OT Utility Failure Log Template
  • 8.2 Appendix B — Power Failure Quick Actions Card (OT)
  • 8.3 Appendix C — Medical Gas Alarm Quick Actions Card (OT)
  • 8.4 Appendix D — HVAC Excursion Decision Note Template
  • 8.5 Appendix E — IT Downtime Link Sheet (Policy 12.8 cross-reference)
Operating Theatre Policy

POLICY 14.5 — Infectious Outbreak / Surge OT Workflow

Department Operating Theatre (OT)
General Hospital
Owner OT Director/Chair + OT Nurse Manager + IPC Lead + FMS/EVS Lead
Policy Code OT-IPC-14.5
Related Policies SEC 9 (IPC), SEC 13.8 (visitors), SEC 8 (handover), SEC 12 (equipment), SEC 14.3 (shelter/evac)
(Routes, Zoning, Terminal Cleaning)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

  • 1.1 To protect patients and staff and sustain essential surgical capacity during infectious outbreaks/surges by implementing controlled routes, zoning, PPE workflows, equipment minimization, and enhanced cleaning/terminal cleaning processes.
  • 1.2 MOH operating room infection control guidance supports structured OR IPC measures that can be used to build outbreak workflows (zoning, IPC measures, and operational approaches). (jed-s3.bluvalt.com)

2.0 SCOPE

  • 2.1 Applies during declared outbreak/surge periods (e.g., airborne/droplet/contact transmissible pathogens, high community transmission, or internal cluster).
  • 2.2 Applies to OT suite workflows: patient movement, staff movement, OR assignment, PPE don/doff, cleaning/terminal cleaning, and documentation.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 OT shall implement enhanced IPC controls during outbreaks, including dedicated routes, designated ORs when feasible, strict traffic discipline, and documented terminal cleaning sign-off. (jed-s3.bluvalt.com)
  • 3.2 OT shall minimize personnel and equipment in rooms used for outbreak cases to reduce contamination burden and simplify effective cleaning.
  • 3.3 OT shall coordinate with IPC for pathogen-specific precautions and with EVS/CSSD for cleaning and reprocessing workflow changes.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 IPC Lead: defines precautions, PPE requirements, and outbreak case workflow expectations.
  • 4.2 OT Charge Nurse: implements routing, staffing, and OR assignment; enforces access restriction.
  • 4.3 Circulating Nurse: coordinates room setup with minimal equipment; ensures checklist completion; coordinates terminal cleaning sign-off.
  • 4.4 EVS/Housekeeping Lead: ensures enhanced cleaning and terminal cleaning is completed and documented.
  • 4.5 CSSD Liaison: ensures contaminated instruments are transported safely with correct containment and route.

5.0 PROCEDURE

5.1 Outbreak Activation and OR Assignment

5.1.1 On outbreak activation, OT identifies:

  • a) designated outbreak OR(s) if feasible,
  • b) designated route(s) for patient entry/exit,
  • c) designated don/doff points,
  • d) designated recovery/transfer workflow (PACU vs direct to ICU/ward) per hospital plan. (jed-s3.bluvalt.com)

5.2 Routes and Zoning

  • 5.2.1 Use controlled routes to minimize exposure to other patients and clean areas.
  • 5.2.2 Maintain OT zoning discipline (restricted/semi-restricted/unrestricted) and enforce door/traffic control.

5.3 PPE Workflow (Operational)

  • 5.3.1 PPE stations are prepared at entry points; don/doff sequence follows IPC instruction for the pathogen.
  • 5.3.2 PPE compliance is enforced; breaches are reported as hazards.

5.4 Equipment Minimization and Protection

  • 5.4.1 Bring only essential equipment into the outbreak OR.
  • 5.4.2 Cover high-touch equipment where feasible and safe to do so; ensure cleaning after case per device IFU and IPC policy.

5.5 Case Conduct Controls

  • 5.5.1 Limit personnel to essential team members; restrict observers/vendors.
  • 5.5.2 Maintain sterile field discipline and reduce door opening.

5.6 Post-Case Cleaning and Terminal Cleaning

  • 5.6.1 Use enhanced cleaning for outbreak cases and perform terminal cleaning per IPC/EVS protocol; document completion and sign-off before next case. (jed-s3.bluvalt.com)
  • 5.6.2 Ensure waste segregation and linen handling follow transmission-based precautions.
  • 5.6.3 Instruments transported in closed containers via defined dirty route to CSSD.

5.7 Documentation and Communication

  • 5.7.1 Document isolation status, PPE used (where required), route used, and terminal cleaning sign-off.
  • 5.7.2 Communicate outbreak status and precautions during handover (OT→PACU/ICU).

5.8 Surge Capacity Adjustments

  • 5.8.1 OT leadership coordinates with hospital incident command for elective surgery reduction, prioritized urgent lists, staff redeployment, and extended hours if needed.
  • 5.8.2 OT ensures staff fatigue and safety considerations remain in effect.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 REFERENCES | 9.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 Outbreak case checklist (route, PPE readiness, minimal equipment, terminal cleaning sign-off).
  • 6.2 Terminal cleaning record (EVS signature + OT verification).
  • 6.3 Incident reports for PPE breaches or route failures.

7.0 AUDIT / KPIs

  • 7.1 PPE compliance audit (spot checks).
  • 7.2 Door opening/traffic compliance in outbreak OR.
  • 7.3 Terminal cleaning completion compliance and turnaround time.
  • 7.4 Staff exposure incidents (trend).

8.0 REFERENCES

  • 8.1 MOH: Infection Control Guidelines in the Operating Room (evidence-based IPC measures for OR workflows). (jed-s3.bluvalt.com)

9.0 APPENDICES

  • 9.1 Appendix A — Outbreak Case Workflow Checklist (OR + transport + cleaning sign-off)
  • 9.2 Appendix B — Route Map Template (clean vs outbreak route)
  • 9.3 Appendix C — PPE Station Setup Checklist
  • 9.4 Appendix D — Terminal Cleaning Sign-Off Form (Outbreak Case)

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