Theatre design
Outline
• Introduction
• Principles of theatre design
• Optimization of location and spaces
• The importance of the sterile surgical field
• Theatre environment
• Laparoscopic theatre
• Robotic theatre
• Theatre etiquette
• Conclusion
Introduction
• Before the operating room: magicians, priests and physicians
• Mesopotamia, Egypt, India, China
• Greece: the first surgical training program
• Rome: the birth of the operating tent
• Islamic medicine: the first surgical suites
• Middle ages: the barber surgeon
• Napoleonic wars, civil war
• GERMANY, FRANCE, AUSTRIA, ENGLAND, AMERICA 1800 –
1900
• Historically designed to encourage large audiences of observers
• Surgeons wore outdoor clothes with no consideration given to
sterility
• Outcomes less than satisfactory
• WORLD WAR I
• WORLD WAR II AND THE KOREAN WAR
• An operating theater (also
known as an operating
room (OR), operating
suite, or operation suite) is
a facility within a hospital
where surgical operations
are carried out in an
aseptic environment.
• Contemporary operating
rooms are usually devoid
of a theater setting,
making the term
"operating theater" a
misnomer in those cases.
• OT complexes are designed and built to carry out investigative,
diagnostic, therapeutic and palliative procedures of varying degrees
of invasiveness. Many such set ups are customized to the
requirements based on size of hospital, patient turnover and may be
specialty specific.
• The aim is to provide the maximum benefit for maximum number of
patients arriving to the operation theatre. Both the present as well as
future needs should be kept in mind while planning.
• Modern operation theatre, safety checklists, acceptable theatre
etiquette and theatre instrument sterilization process have made
significant positive impact on outcomes of surgery
Types of OT
• The single theatre suite with OT, scrub-up and gowning, anaesthesia
room, trolley preparation, utility and exit bay plus staff change and
limited ancillary accommodation.
• The twin theatre suite with facilities similar to 1, but with duplicated
ancillary accommodation immediate to each OT, sometimes sharing a
small post anaesthesia recovery area.
• OT complexes of three or more OTs. with ancillary accommodation
including post anaesthesia recovery, reception, porter’s desk, sterile
store and staff change.
Types of OT
• Based on sterility
• Ultra sterile
• Sterile
• Septic
• Based on construction
• Modular
• Non modular
• Timing of surgery
• Routine
• Emergency
Principles of theatre design
• Optimization of location and spaces
• The importance of the sterile surgical field
• Theatre environment
Optimization of location and spaces
• Should be away from traffic (cul-de-sac) while maintaining optimum
patient flow (closeness to surgical wards) should be considered (minimize
transit time, increase efficacy and productivity in the theatre)
• Close proximity to A & E, ICU, surgical wards, radiology department
• Theatre should have easy access to sterile services and sufficient space for
all necessary equipment to be stored
• Good flow should be extended to staff (in the location of their changing,
rest and office areas) and surgical equipment (to and from sterile services)
• Reception area for patient safety checks, area to be anaesthetized and
recovery area
surgical
wards
ICU
CSSD
Operating
Theatre
Radiology
A&E
Day case
ward
The importance of the sterile surgical field
• The heart of theatre design
• Clean and contaminated areas should be
separated into zones- minimizing cross
contamination between clean and dirty zones
• Construction material should be smooth and
easy to clean
• The operating suite divided into zone
• Specialized air management system contributes
to gradation of cleanliness within these zones
Zoning
• Protective zone: It includes
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Changing room for all the concerned persons
Transferring passage for the materials, equipment, and the patient
Rooms for administrative staff
Storage & record maintenance
Pre- and postoperative
Intensive and Coronary Care Units
Storage rooms to keep the sterilized objects
• Clean zone: Links the protective zone to the aseptic zone
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Clean rooms
Storage room for equipment
Rooms designed for surveillance, maintenance, and firefighting
Exit areas in case of emergencies exists
• Aseptic zone: houses the operating rooms
• Disposal zone: separate exit for disposing contaminated linen /used materials and instruments
Ideal layout of theatre suite
• There should be separation of clean and dirty traffic flow within
theatre. Clean areas and corridors should be separated from the dirty
areas such as sluice containing soiled material
• The clean areas should allow access to changing facilities in the
theatre with a separate dirty corridor for removal of soiled material
• Anesthetic room should be adjacent to the theatre
• Dedicated room for staff breaks
• Recover area for post op care of patients
Traffic flow
• Supplies should flow from
clean corridor to operating
room to the disposal
corridor
• Soiled material should not
re-enter the clean area.
• Soiled linen and trash
collection area should be
separated from personnel
and patient traffic areas for
infection control purposes
Important Points
• The sterilized materials are transported from a sterile area to the
operation theater on a covered cart, thus preventing any
accumulation of the dust particles on their surfaces.
• Before entering the operation theater, all supplies/materials must be
removed from their shipping or transported containers.
• All the blood-coated or soiled instruments/equipment must be
transported in a covered wrap or container from the operating room
to the decontamination or reprocessing area.
• Care must be taken that the soiled instruments/equipment must not
to be stored with the sterilized goods.
Theatre environment
• Temperature kept between 20 and 22 degrees
Celsius
• Humidity should be between 30% and 60%
• Clean filtered air from ceiling close to theatre table
and leave by door flap. Flow from high pressure to
low pressure on floor
• Adequate light, backup battery in case of electrical
failure. Should be possible to reduce lighting
Theatre air ventilation
• Ventilation should be on the principle that the direction of
air flow is from the operation theatre towards the main
entrance.
• There should be no interchange air movement between
one OT and another.
• Efficient ventilation will control temperature and humidity
in OT, dilute the contamination by micro-organisms and
anesthetic agents.
• Three main types:
• Turbulent mixing airflow ventilation
• Plenum ventilation
• Laminar flow ventilation
Turbulent mixing airflow ventilation
• When mixing ventilation systems,
clean air is supplied to the OR
environment through the ceiling or
vertical wall diffusers and extracted,
usually at the floor level.
• Such systems mainly rely on dilution
to remove the OR environment's
contaminants, characterized by fully
mixed and unstable airflow patterns
throughout the entire OR.
Plenum ventilation
• This system relies on
pressure being greater inside
theatre than outside.
• Provision of clean air is via
wall/ceiling diffusers and let
out of vents above floor
level.
• Less reliable in maintaining
an aseptic environment
through opening of doors of
movement of personnel in
and out of theatre.
Lamina airflow
• Reduces risk of
bacterial
colonization,
moves in
parallel lines
with absence
of mixing
Ventilation system
Laparoscopic theatre
• Laparoscopic surgery is
also known as keyhole
surgery or minimally
invasive surgery.
• It is a technique that
allows surgeons to
treat or explore organs
of the body through
keyhole incisions.
Laparoscopic theatre
Minimally invasive surgeries are performed using
laparoscopic equipment .
Generally more space is required
Operating room setup includes
1. The hardware and instruments
2. Dedicated interventional laparoscopic operating
rooms .
3. A sufficient backup of instrumentation to cover
for equipment failure
4. Facilities for intra operative imaging
Robotic theatre
Robotic theatre
• Robotic surgery is surgery carried out using mechanical arms
controlled by the surgeon and bearing surgical instruments and a
camera, especially to avoid the need for large incisions.
• Three main types of surgical robots available:
1) Supervisory-controlled Robotic Surgery Systems (e. g. the ROBODOC®
system from CUREXO Technology Corporation)
2) Shared-control Robotic Surgery Systems
3) Telesurgical devices: e.g. the da Vinci Robotic system, the ZEUS Surgical
System.
• Robotic surgery
preparation needs
longer operating room
time compared to
conventional
surgeries.
• Several pieces of
equipment, each being
extremely bulky
require large operating
room space.
Theatre etiquette
• Arrive on time
• Theatre attire
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Scrubs
Shoes
Hats
Jewelry
“Magic gowns”
• Know the team you are
working with
• Don’t hesitate to ask questions
pertaining to something you
think may be wrong
• Use scrub room door
• Introduce yourself
• Don’t use your phone
• No pictures
• Join team brief to discuss the
list/cases
• It is good practice to ask the
anaesthetist’s permission before
positioning the patient and to
maintain the patient’s dignity as much
as possible by minimizing exposure.
• Your first scrub of the day must always be a full five-minute
scrub.
• Don’t ever rush scrubbing in or cut corners
• If you accidentally touch anything non-sterile at any point, you
have to start all over again!
• Always wear a visor mask to protect your eyes
• Most hospitals now promote double-gloving for surgical
procedures
• Always get something to eat before the first case
• Know fainting is a genuine risk
• Use the washroom before case
Maintenance in the Operation Theater
• The machinery must be surveyed at least every week.
• Proper ventilation should be checked regularly and the filters should be changed
as required.
• At the time of maintenance or inspection or observation of any fault in the
working of the operation theater, the members of The Infection Control team
should be informed.
• The theater should be thoroughly examined by the members of the team and
appropriate measures must be taken to maintain the infection control protocols.
• The operation theater must only be functional after being carefully evaluated and
cleared by the infection control team.
• Back-up facility for operation theater in all aspects should be present in any setup
to provide any uninterrupted sessions at the time of maintenance or any fault
observed
The authority for standardization
• HeFRA
• Postgraduate college accreditations
• Various surgical, anesthesia and nursing manuals
• The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)
• Accreditation Association for Ambulatory Healthcare- AAAH.
• The department of health and social security (DHSS) in UK
Usual areas of deficiency in existing OTs
• No reception area.
• No separate rooms for
• Surgeons and Jr. doctors
• Anaesthesiologist
• OT attendants
• Not enough number of change rooms
for different class of people.
• Inappropriate size & type of doors
etc.,
• Lack of laminar flow& mandatory air
exchange systems in OT.
• Lack of standard OT protocol.
• No separate Central Sterile Supply
Department (CSSD)
• Waiting Area and Recovery
• Not well equipped
• Lack of basic amenities
MANAGEMENT OF MODERN THEATRE
• Operating theatre management focuses on maximizing
operational efficiency at the facility, to maximize the number of
surgical cases that can be done on a given day while minimizing the
required resources and related cost .
• Efficient management aims to
• Ensure patient safety and the highest quality of care
• Provide surgeons with appropriate access to the OR
• Maximize the efficiency of operating room utilization, staff, and materials to
reduce costs
• Decrease patient delays
• Ensure
• Safe disposal of dirty linen & waste products.
• Rapid transfer of instrument to & fro CSSD.
• Adequate pharmaceutical supply & monitoring of requisition.
• Close liaison with the electronics, CSSD, theatre staff clean control unit.
• Adequate staff welfare & promotion to enhance efficiency.
• Regular checks and maintenance of equipment.
Conclusion
• In the present era of evidence based medicine, it becomes imperative to
give maximum importance to planning an operation Theatre Complex.
• Efforts should be made to conform to the standards laid down by local
bodies and international agencies
• New OTs and hospitals that are being established can not be expected to
fulfil all theoretical requirements as new ideas are constantly being
developed. By the time they are incorporated into buildings, fresh ones
take their place on the drawing board.
• The use of theatres is changing with the increased use of laparoscopic
surgery (and potentially robotic surgery)and the design of operation rooms
should respond to these and forthcoming changes.
Thank you
References
• Harsoor, S S1,; Bhaskar, S Bala2. DESIGNING AN IDEAL OPERATING ROOM
COMPLEX. Indian Journal of Anaesthesia: May–Jun 2007 - Volume 51 Issue 3 - p 193-199
• Operating theatre design: Michael Essex-Lopresti, Lancet, 1999:353:100710
• https://www.optimus-ise.com/historical/history-of-the-operating-room/
• Bali R. Operating Room Protocols and Infection Control Oral and
Maxillofacial Surgery for the Clinician. 2020 Jun:173-194. PMCID:
PMC7882240.
• https://geekymedics.com/theatre-etiquette/