Policy & Procedure Document

PART IX — SPECIALTY OT WORKFLOWS (OT Scope)

SEC 15 — Specialty Operating Theatre Workflows

Independent Policies 15.1–15.5

Operating Theatre Policy

POLICY 15.1 — Emergency / Trauma OR Workflow

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Director/Chair + OT Nurse Manager + Trauma Lead
Policy Code OT-SP-15.1
Related Policies: SEC 14.1 (Code Blue), SEC 14.2 (Massive Hemorrhage), SEC 11.3/11.4 (Counts/RSI), SEC 9 (IPC), SEC 12.2 (Loaners), SEC 12.5 (Remove from service)
(OT Readiness + Activation)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

  • 1.1 To ensure the OT team can rapidly activate an Emergency/Trauma OR with controlled access, reliable safety processes (ID, counts, specimens), and logistics support (equipment, blood product coordination, imaging readiness), without compromising essential patient safety standards.

2.0 SCOPE

  • 2.1 Applies to all trauma and emergency cases requiring immediate OR activation (polytrauma, penetrating trauma, uncontrolled hemorrhage, ruptured ectopic/AAA, emergent laparotomy, emergent thoracotomy, open fractures requiring urgent debridement).
  • 2.2 OT scope: room readiness, equipment, access control, counts/specimens/implants documentation, infection control in contaminated cases, and communication with support services.

3.0 POLICY STATEMENT | 4.0 ROLES AND RESPONSIBILITIES

3.0 POLICY STATEMENT

  • 3.1 OT shall maintain a ready “Trauma OR capability” (equipment, packs, staffing plan) 24/7.
  • 3.2 Emergency speed does not remove core controls: patient identification, specimen labeling, counts (or emergency exception documentation), and escalation pathways remain mandatory.
  • 3.3 OT shall control crowding and entry/exit to preserve movement paths and reduce errors.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 OT Charge Nurse (Trauma Activation Coordinator): activates Trauma OR, assigns roles, controls access/crowd, initiates trauma log.
  • 4.2 Circulating Nurse: leads room setup, documentation, counts process, specimens, equipment placement.
  • 4.3 Scrub Nurse/Technologist: sets instruments quickly, maintains sharps discipline, supports counts reliability under pressure.
  • 4.4 Runner: coordinates blood bank/lab/radiology communication and retrieves additional supplies rapidly.
  • 4.5 Security/FMS (interface): controls corridor/elevator priority if needed.

5.0 PROCEDURE

5.1 Readiness (Shift/Daily)

  • 5.1.1 Maintain a designated trauma instrument set (or rapid-access list) and consumables pack (suction canisters, suture, staplers, drains, hemostatic agents per hospital stocking).
  • 5.1.2 Ensure trauma OR has: working suction, ESU, smoke evacuation, warming devices (OT side), large waste bins, sharps containers, spill kit, and clean/dirty route readiness.
  • 5.1.3 Verify availability of emergency documentation pack (downtime forms if EHR down) and trauma specimen containers.

5.2 Activation

5.2.1 Trauma call received → Charge nurse assigns:

  • a) Circulator 1 (documentation + room lead)
  • b) Scrub 1 (setup lead)
  • c) Runner
  • d) Additional circulator/scrub if multiple cavities/teams expected

5.2.2 Start Trauma OR Activation Log: time called, room opened, team arrived, case start.

5.3 Patient Identification (OT Control)

  • 5.3.1 Two identifiers required whenever possible.
  • 5.3.2 If unidentified patient: follow hospital emergency ID protocol (temporary ID/trauma number) and apply that identifier consistently to all forms/specimens/implants until official reconciliation.
  • 5.3.3 Any ID uncertainty triggers stop and escalation to charge nurse.

5.4 Room Setup (Rapid but Controlled)

  • 5.4.1 Clear floor space for multiple teams and equipment.
  • 5.4.2 Prepare multiple suction lines if heavy bleeding expected.
  • 5.4.3 Pre-stage specimen containers (pathology + microbiology if contaminated wounds).
  • 5.4.4 Prepare imaging support workflow if C-arm expected (radiation PPE ready, badges worn).

5.5 Counts and RSI Controls (Emergency Modifications)

  • 5.5.1 If life-saving incision must occur before initial count: document “initial count not performed—emergency,” then implement strict item control immediately (sponge board, sharps box) and complete counts as soon as feasible.
  • 5.5.2 Final count remains mandatory; discrepancy triggers Policy 11.4.

5.6 Specimens and Forensic Items

  • 5.6.1 Specimen labeling must use the trauma identifier consistently.
  • 5.6.2 Foreign bodies (bullets/knife fragments) follow medico-legal chain-of-custody if hospital policy applies (sealed containers + signatures).

5.7 Contaminated/Dirty Trauma Cases (IPC Interface)

  • 5.7.1 Apply enhanced containment: limit equipment in room, cover devices where feasible, follow defined dirty route for instruments to CSSD, and apply terminal cleaning requirements.

5.8 Post-Case Turnover

  • 5.8.1 Document completion: counts, specimens, implants used, equipment failures, blood loss documentation reference (Policy 11.13).
  • 5.8.2 Perform terminal cleaning and restock trauma packs immediately to restore readiness.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 APPENDICES

6.0 DOCUMENTATION / RECORDS

  • 6.1 Trauma OR activation log.
  • 6.2 OT intraoperative record + counts + specimen log + implant traceability (if used).
  • 6.3 Incident report for: missing count, unresolved discrepancy, equipment failure, ID issues.

7.0 AUDIT / KPIs

  • 7.1 Time from activation to “room ready.”
  • 7.2 Completion of essential documentation (ID, counts, specimens).
  • 7.3 Trauma pack restock time (readiness recovery).

8.0 APPENDICES

  • 8.1 Appendix A — Trauma OR Readiness Checklist
  • 8.2 Appendix B — Trauma OR Activation Log
  • 8.3 Appendix C — Emergency ID Label Sheet (paper)
  • 8.4 Appendix D — Trauma Specimen/Chain-of-Custody Slip (if applicable)
Operating Theatre Policy

POLICY 15.2 — Obstetric Theatre Workflow

Policy Code OT-SP-15.2
Owner OT Nurse Manager + OB Theatre Lead
Related SEC 14.2 (Hemorrhage), SEC 11.3/11.4 (Counts), SEC 11.6 (Specimens), SEC 11.5 (Positioning), SEC 8 (handover)
(OT Side: Readiness, Instruments, Counts, Specimens)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

1.1 To ensure safe, rapid obstetric theatre readiness for emergency and elective cases while maintaining reliable OT processes (counts, specimens, documentation, equipment readiness) and supporting obstetric hemorrhage logistics.

2.0 SCOPE

  • 2.1 Applies to C-section (elective/emergency), postpartum hemorrhage surgical interventions, retained placenta procedures performed in OT, and obstetric emergencies requiring immediate theatre access.
  • 2.2 OT scope: room readiness, instrument readiness, counts, specimen handling, and workflow discipline.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 Obstetric theatre must remain “immediately ready” for time-critical emergencies (Category 1/urgent cases as defined by OB service).
  • 3.2 Counts and specimen labeling remain mandatory; emergency exceptions must be documented and reconciled.
  • 3.3 Hemorrhage readiness logistics are integrated into the OB theatre workflow (equipment availability + rapid blood product coordination per SEC 14.2).

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 OB OT Charge Nurse/Lead: maintains readiness, coordinates emergency activation, controls traffic.
  • 4.2 Circulating Nurse: leads setup, documentation, counts, specimen workflow, hemorrhage logistics log.
  • 4.3 Scrub Nurse/Tech: rapid setup, sharp control, consistent sponge management.
  • 4.4 Runner: coordinates lab/blood bank communication and retrieves supplies.

5.0 PROCEDURE

5.1 Readiness Standard (Always-On)

  • 5.1.1 Maintain OB-specific sets: C-section tray, uterine instrumentation tray (as per local list), suction readiness, warming devices, neonatal/infant receiving area interface (OT space control only).
  • 5.1.2 Maintain OB Hemorrhage Support Pack (OT logistics: extra suction, extra sponges, pressure bags, rapid infuser access if used in hospital).
  • 5.1.3 Ensure specimen containers ready (placenta, products of conception, tissue).

5.2 Emergency Activation

  • 5.2.1 Emergency call triggers immediate room opening and role assignment; document activation time.
  • 5.2.2 Minimize crowding; restrict observers/vendors.

5.3 Counts (High-Risk Sponge Environment)

  • 5.3.1 Use strict sponge board discipline; OB cases often use many sponges—avoid loose sponges.
  • 5.3.2 Perform counts at required stages; if emergency start occurs before initial count, document and reconcile ASAP; final count mandatory.

5.4 Specimen Workflow

  • 5.4.1 Placenta/tissue specimens: label with two identifiers and correct site description; complete specimen log.
  • 5.4.2 If medico-legal sensitivities apply (e.g., fetal remains), follow dignity and chain-of-custody rules per hospital policy.

5.5 Hemorrhage Logistics (OT Side)

  • 5.5.1 If Massive Hemorrhage activated, implement SEC 14.2 (runner, product receipt log, returns).
  • 5.5.2 OT documents activation logistics and times; clinical transfusion remains under clinical team.

5.6 Post-Case Recovery

  • 5.6.1 Restock OB trays and hemorrhage pack immediately to maintain readiness.
  • 5.6.2 Document any deviations or near misses (counts, specimen labeling, delay causes).

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 Activation time + case start time.
  • 6.2 Counts record.
  • 6.3 Specimen labels/log.
  • 6.4 Hemorrhage logistics log (if activated).

7.0 AUDIT / KPIs

  • 7.1 Time to OB theatre readiness for emergency calls.
  • 7.2 Count compliance and discrepancy rate.
  • 7.3 Specimen labeling completeness (target 100%).

8.0 APPENDICES

  • 8.1 Appendix A — OB Theatre Readiness Checklist
  • 8.2 Appendix B — OB Emergency Activation Log
  • 8.3 Appendix C — Placenta/POC Specimen Labeling Guide
  • 8.4 Appendix D — OB Hemorrhage Logistics Log (OT)
Operating Theatre Policy

POLICY 15.3 — Pediatric Surgery Workflow

Policy Code OT-SP-15.3
Owner OT Nurse Manager + Pediatric Service Liaison
Related SEC 11.5 (positioning), SEC 12.4 (warming cabinets), SEC 11.3/11.4 (counts), SEC 9 (IPC)
(OT Side: Equipment, Warming, Counts)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

1.1 To ensure pediatric cases are supported by OT-specific safety controls: correct-sized equipment readiness, heat loss prevention logistics, safe positioning supports, and high-reliability counts for small sharps/instruments.

2.0 SCOPE

  • 2.1 Applies to neonate/infant/child cases performed in OT and OT-governed procedure rooms.
  • 2.2 OT scope: equipment readiness and size matching, warming and environmental logistics, counts and small-item control, documentation.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 Pediatric cases require proactive OT preparation because small patient size increases risks of heat loss, pressure injury, and retention of small items.
  • 3.2 OT shall use pediatric-appropriate positioning and padding, maintain warming readiness, and strengthen small-item count discipline.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 Charge Nurse: ensures pediatric pack availability and staffing.
  • 4.2 Circulator: verifies correct equipment sizes, warming plan logistics, pediatric documentation fields.
  • 4.3 Scrub: ensures small sharps/instruments are controlled and counted reliably.

5.0 PROCEDURE

5.1 Pediatric Room Readiness

  • 5.1.1 Verify availability of pediatric-sized: BP cuff sets stored in OT, positioning supports, small drapes, suction tubing as needed, and pediatric instrument sets.
  • 5.1.2 Ensure warming logistics: warm blankets available (Policy 12.4), warming devices ready, minimize unnecessary room cooling (coordinate with engineering limits if applicable).

5.2 Positioning (OT Side)

5.2.1 Use pediatric pads and avoid compressive straps; protect occiput and bony prominences; document devices used.

5.3 Counts and Small Items

  • 5.3.1 Apply enhanced sharps control because pediatric needles/blades are small and easily lost.
  • 5.3.2 Use a sharps counter box and “announce when opened” discipline.
  • 5.3.3 If device components are detachable, treat as countable items per local list.

5.4 Skin Protection and Device Pressure Risk

5.4.1 Prevent device-related pressure injury (tubing, probes, straps) by routine checks during prolonged cases (document reassessment for high-risk).

5.5 Post-Case

  • 5.5.1 Ensure full reconciliation of small sharps; discrepancies trigger Policy 11.4.
  • 5.5.2 Restock pediatric packs immediately.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 Pediatric equipment size verification (checklist tick).
  • 6.2 Warming devices used (OT side).
  • 6.3 Counts record with small-item notes.
  • 6.4 Positioning devices and reassessment times when needed.

7.0 AUDIT / KPIs

  • 7.1 Pediatric pack readiness compliance.
  • 7.2 Small-sharps discrepancy rate.
  • 7.3 Documentation completeness.

8.0 APPENDICES

  • 8.1 Appendix A — Pediatric OT Readiness Checklist
  • 8.2 Appendix B — Pediatric Small-Item Count Addendum
  • 8.3 Appendix C — Pediatric Positioning Pad Map
Operating Theatre Policy

POLICY 15.4 — Orthopedic Implant Surgery Workflow

Department Operating Theatre (OT)
General Hospital
Owner OT Nurse Manager + Ortho Service Liaison + CSSD + Supply Chain
Policy Code OT-SP-15.4
Related Policies Policy 11.7 (implant traceability), Policy 12.2 (loaner trays), Policy 11.3/11.4 (counts), SEC 11.8 (smoke), SEC 13.5 (radiation)
(Traceability, Loaner Trays, Counts)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

1.1 To ensure orthopedic implant cases are supported by a high-reliability system for:

  • a) implant/prosthesis traceability,
  • b) loaner/vendor tray governance and completeness,
  • c) counts reliability in high-instrument environments, and
  • d) documentation readiness for recalls and audits.

2.0 SCOPE

  • 2.1 Applies to all orthopedic implant cases (arthroplasty, trauma fixation, spine implants where under OT ortho service pathway, plates/screws, prostheses, meshes used by ortho).
  • 2.2 OT scope: logistics and documentation controls; clinical implant choice remains surgeon-led.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 No implant case proceeds without confirmation that trays are processed and released (CSSD) and that implant traceability capture is ready (stickers/UDI/lot/serial).
  • 3.2 Loaner tray late arrival that prevents full processing triggers escalation and may delay the case to protect patient safety.
  • 3.3 Implant insertion moment requires a focused verification and documentation readiness.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 Charge Nurse: confirms trays and implants readiness, assigns runner, controls vendor presence.
  • 4.2 Circulator: leads traceability capture, maintains implant log, coordinates verification at opening/insertion.
  • 4.3 Scrub: preserves packaging/labels until captured; maintains instrument organization.
  • 4.4 CSSD/Supply Chain: release status and recall pathway readiness; loaner tray tracking.

5.0 PROCEDURE

5.1 Pre-Case (48–24 hours preferred; minimum per local rule)

  • 5.1.1 Confirm loaner trays delivery and IFU presence; start loaner tray tracking form.
  • 5.1.2 Verify CSSD processing completed and trays released (no “rushed shortcuts”).
  • 5.1.3 Confirm implant sizes/options present; identify potential LASA packaging confusion and segregate.

5.2 Intraoperative Implant Verification

  • 5.2.1 Before opening: verify implant name/type, side/site, size/model, expiry, packaging integrity.
  • 5.2.2 Before insertion: repeat verification for laterality-sensitive components.

5.3 Traceability Capture (Mandatory)

5.3.1 Capture stickers/UDI/lot/serial and place into traceability form and/or EHR registry; ensure completeness before patient leaves OR (or within immediate post-op documentation window).

5.3.2 If multiple components, capture each component (cup, liner, stem, head, screws) per device type.

5.4 Counts Reliability (Heavy Instruments/Small Components)

  • 5.4.1 Use instrument count sheets and component lists; treat detachable components as countable.
  • 5.4.2 Any discrepancy triggers Policy 11.4.

5.5 Vendor/Observer Control

5.5.1 Vendor presence is limited and supervised; no touching sterile field; no photography; sign visitor log.

5.6 Post-Case

  • 5.6.1 Complete implant documentation reconciliation and implant log entry check.
  • 5.6.2 Post-use loaner tray inventory check and return documentation.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 Loaner tray tracking and release confirmation.
  • 6.2 Implant traceability form + implant log/registry entry.
  • 6.3 Counts record including component accountability.

7.0 AUDIT / KPIs

  • 7.1 Implant traceability completeness rate (target 100%).
  • 7.2 Loaner tray on-time delivery and processing compliance.
  • 7.3 Component discrepancy rate.

8.0 APPENDICES

  • 8.1 Appendix A — Ortho Implant Case Readiness Checklist
  • 8.2 Appendix B — Loaner Tray Tracking + Completeness Sheet
  • 8.3 Appendix C — Implant Traceability Multi-Component Form
  • 8.4 Appendix D — Ortho Small-Component Count Addendum
Operating Theatre Policy

POLICY 15.5 — ENT / Shared Airway Field

Policy Code OT-SP-15.5
Owner OT Nurse Manager + ENT Service Liaison
Related Policy 11.8 (smoke), Policy 12.3 (ESU safety), Policy 13.2 (fire safety), Policy 11.3/11.4 (counts), Policy 11.6 (specimens), Policy 11.1 (discipline/access)
(OT Side: Smoke, Sharps, Specimen, Counts)

1.0 PURPOSE | 2.0 SCOPE

1.0 PURPOSE

1.1 To manage ENT cases where the airway and surgical field are shared with anesthesia, by strengthening OT controls for:

  • a) smoke/plume management,
  • b) fire risk behaviors in oxygen-enriched environments,
  • c) sharps protection in tight operative spaces,
  • d) specimen labeling accuracy (small tissue fragments), and
  • e) counts reliability (small sponges/needles).

2.0 SCOPE

  • 2.1 Applies to ENT airway cases: tonsil/adenoid, airway endoscopy under OT governance, head/neck surgery where ESU used near oxygen delivery, tracheostomy, and similar shared-field procedures.
  • 2.2 OT scope: room discipline, smoke evacuation, sharps workflow, specimens, counts, access control.

3.0 POLICY STATEMENT | 4.0 ROLES

3.0 POLICY STATEMENT

  • 3.1 ENT shared airway cases are treated as high-risk for fire (oxidizer + ignition + fuel). OT enforces fire prevention controls and room discipline (Policy 13.2).
  • 3.2 Smoke evacuation must be used during plume generation (Policy 11.8).
  • 3.3 Small sharps and small sponges require enhanced control and counting discipline.

4.0 ROLES AND RESPONSIBILITIES

  • 4.1 Charge Nurse: ensures high-risk setup readiness (smoke evac, fire readiness, suction, extra sharps controls), restricts access.
  • 4.2 Circulator: coordinates smoke evacuation readiness, documentation, specimen workflow; monitors hazard conditions (prep pooling, oxygen-enriched drapes).
  • 4.3 Scrub: maintains sharps control and “one at a time” passing discipline; ensures small items remain visible and controlled.
  • 4.4 Surgeon/anesthesia interface: OT supports the shared-field safety pause (OT does not dictate clinical oxygen settings; OT enforces environmental/fuel/ignition discipline and escalation).

5.0 PROCEDURE

5.1 Pre-Case Setup (High-Risk Readiness)

  • 5.1.1 Confirm: smoke evacuator present and functional; capture device available.
  • 5.1.2 Confirm: ESU pencil holster available and used; ignition sources controlled when idle.
  • 5.1.3 Confirm: suction readiness and spare canister; wet sponges/field protection materials available per local fire-risk practice.

5.2 Fire Prevention Behaviors (OT Side Controls)

  • 5.2.1 Ensure alcohol prep is dry before draping; prevent pooling in head/neck area.
  • 5.2.2 Keep drapes arranged to avoid oxygen trapping under drapes when possible (work with team).
  • 5.2.3 If any unsafe condition is observed (wet prep + ESU activation imminent + oxygen flow under drape), OT calls “STOP” and escalates to the team leader immediately.

5.3 Smoke Evacuation (Mandatory During Plume)

  • 5.3.1 Smoke evacuation ON whenever plume generated; inlet positioned close to source.
  • 5.3.2 If visible smoke persists, correct immediately (move inlet closer, check tubing/filter).

5.4 Sharps and Small Item Control

  • 5.4.1 Use a sharps counter box and strict passing technique; announce blades and needles.
  • 5.4.2 Do not leave sharps on drapes; do not “park” blades on the field.
  • 5.4.3 Use small-sponge control boards if used; avoid loose sponges in throat packs.

5.5 Specimen Handling (Small Tissues)

  • 5.5.1 Label specimens immediately with two identifiers and correct site; use read-back verification between scrub and circulator.
  • 5.5.2 For multiple small specimens, use sequential container numbering and log (1,2,3…) to prevent mix-ups.

5.6 Counts

  • 5.6.1 Perform counts per policy; ensure throat packs are counted and documented explicitly (if used in your facility—include as a countable item).
  • 5.6.2 Any discrepancy triggers Policy 11.4.

6.0 DOCUMENTATION | 7.0 AUDIT | 8.0 APPENDICES

6.0 DOCUMENTATION

  • 6.1 Smoke evacuation use (Y/N), ESU/fire risk notes if any.
  • 6.2 Sharps and sponge counts including special items (throat pack if applicable).
  • 6.3 Specimen log with sequence identifiers.

7.0 AUDIT / KPIs

  • 7.1 Smoke evacuation compliance in ENT cases.
  • 7.2 Sharps injury/near miss trend in ENT cases.
  • 7.3 Specimen labeling completeness.
  • 7.4 Count discrepancies in ENT cases.

8.0 APPENDICES

  • 8.1 Appendix A — ENT Shared Airway “High-Risk Setup” Checklist
  • 8.2 Appendix B — ENT Small Specimen Sequencing Log
  • 8.3 Appendix C — ENT Fire Risk Pause Script Card
  • 8.4 Appendix D — ENT Small Item Count Addendum (throat pack field if applicable)

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