TheatrePracticeStandardsGeneric1

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Generic Theatre Standard No 08 - Catheterisation of Female Patients ............................... 46 Generic Theatre Standard No 09 - Care of the Deceased In the Operating Department ..... 48 Generic Theatre Standard No 10 - Fire Prevention ............................................................. 57 Generic Theatre Standard No 11 - Dealing with Hazardous/Non Hazardous Spillages ....... 60 Generic Theatre Standard No 12 - Management of Clinical Waste ..................................... 61 Generic Theatre Standard No 13 - Management of Clinical Specimens .............................. 62 Generic Theatre Standard No 14 - Management of Latex Allergy Patients in the Operating Department .......................................................................................................................... 69 Generic Theatre Standard No 15 - WHO Surgical Safety Checklist .................................... 71 Generic Theatre Standard No 16 - Stocking up of Theatres. ............................................... 78 Generic Theatre Standard No 17 - Theatre Etiquette .......................................................... 79 Generic Theatre Standard No 18 - Use of Mobile Phones in the Operating Theatres ......... 80 Section 2 – Theatre Management / Coordination ................................................................ 81 Generic Theatre Standard No 19 - Consent and Refusal of Consent .................................. 81 Generic Theatre Standard No 20 - Managing Conscientious Objection .............................. 82 Generic Theatre Standard No 21 - Organ Donation Procedures for RCHT Theatres .......... 83 Generic Theatre Standard No 22 – Management of Operating Lists ................................... 84 Generic Theatre Standard No 23 - Booking Emergency Theatre Cases ............................. 88 Generic Theatre Standard No 24 - Incident Reporting ......................................................... 89 Generic Theatre Standard No 25 - Controlled Drugs in the Operating Department ............. 90 Generic Theatre Standard No 26 - Pharmacy delivery and stock rotation ........................... 91 Generic Theatre Standard No 27 - Photography and Video ................................................ 92 Generic Theatre Standard No 28 - Radiation Protection...................................................... 93 Generic Theatre Standard No 29 - Visitors to the Operating Theatre .................................. 94 Section 3 – Human Resources ............................................................................................ 95 Generic Theatre Standard No 30 - Mandatory training responsibilities ................................ 95 Generic Theatre Standard No 31 - The Management of Staff who are expectant and new mothers ................................................................................................................................ 96 Appendix 1. Governance Information ................................................................................ 102 Appendix 2. Initial Equality Impact Assessment Form ....................................................... 104 Theatre Practice Standards - Generic Page 2 of 105
1. Aim/Purpose of this Guideline 1.1. All healthcare professionals have a duty to set a standard by which to practice. With a focus on clinical effectiveness and evidence based care theatre staff must be able to demonstrate the ability to audit care and theatre practice. The care that is delivered and improvements in practice must be based on evidence and best practice guidance. 1.2. The aim of this policy is to outline the standards of care that must be delivered to each individual patient to ensure a high quality of care is provided to patients entering all Trust Operating Theatres. 2. Clinical Responsibilities NMC The code: Standards of conduct, performance and ethics for nurses and midwives HCPC Standards of conduct, performance and ethics; Standards of proficiency - Operating department practitioners Claims Management Policy Valid From: 22/05/2012 - To: 22/05/2015 Supporting Staff Involved In An Incident Complaint Or Claim Valid From: 20/06/2011 - To: 01/06/2014 3. Objectives To ensure that a standard of care is delivered to each individual that is equitable and fair. To identify the standards of care to be delivered to patients through all the areas within the operating theatres i.e. anaesthetic room, Operating Theatres and the Post Anaesthetic Care Unit. To enable auditing of theatre practice and patient care throughout all areas. To ensure all staff are aware of standards of care to be delivered to patients whilst in the Operating Department. To provide information to all staff of the departments expectation of the standards of care to be delivered to all patients. 4. Scope 4.1. These standards of care will apply to all Operating Theatres across Royal Cornwall Hospital Trust sites. 4.2. All new members of staff will receive an electronic copy of the standards applicable to the area they will work in. All staff will be able to access the care standards via desktops in operating departments. 5. The Guidance The guidance is contained in the following sections as detailed in the table of contents. 6. Monitoring compliance and effectiveness 6.1. Practice against the set standards will be reviewed monthly for all theatre suites and reported at the Clinical Matron meeting. Theatre Practice Standards - Generic Page 3 of 105
Page 1: New Bookmark Drugs Table of Content
Page 4 and 5: MEMBERSHIP OF THE WORKING PARTY Dr
Page 6 and 7: SECTION I - SUMMARY AND RECOMMENDAT
Page 8 and 9: SECTION III - INTRODUCTION Patients
Page 10 and 11: purchase these services. They must
Page 12 and 13: SECTION VI - PREPARATION FOR THE TR
Page 14 and 15: A patient who remains hypotensive d
Page 16 and 17: A patient who has been made physiol
Page 18 and 19: 4. Other equipment • suction •
Page 20 and 21: important to involve those who take
Page 22 and 23: REFERENCES 1. Association of Anaest
Page 24 and 25: APPENDIX II TRANSFER CHECKLIST FOR
Page 26 and 27: 21 Portland Place, London W1B 1PY T
Page 28 and 29: Storage of Drugs in Anaesthetic Roo
Page 32 and 33: 6.2. Overall performance against th
Page 34 and 35: • Clean theatre clothing should b
Page 36 and 37: • Protective face shields must be
Page 38 and 39: Generic Theatre Standard No 02 - Op
Page 40 and 41: • Please read NJR Manual and Trai
Page 42 and 43: 13. Positioning of the Patient •
Page 44 and 45: Generic Theatre Standard No 04 - In
Page 46 and 47: Example of Environmental Theatre Cl
Page 48 and 49: 3. Between case cleaning procedures
Page 50 and 51: 6.1. Floor scrubbing machines • C
Page 52 and 53: • Personnel participating within
Page 54 and 55: Generic Theatre Standard No 06 - Ma
Page 56 and 57: Generic Theatre Standard No 06A - M
Page 58 and 59: Generic Theatre Standard No 06B - M
Page 60 and 61: lood, CSF or brain tissue, should b
Page 62 and 63: Exceptions: None References: • Af
Page 64 and 65: • Environment/equipment cleaning
Page 66 and 67: Generic Theatre Standard No 06F - M
Page 68 and 69: Generic Theatre Standard No 06G - M
Page 70 and 71: Generic Theatre Standard No 06H - M
Page 72 and 73: Generic Theatre Standard No 07 - De
Page 74 and 75: Generic Theatre Standard No 08 - Ca
Page 76 and 77: Generic Theatre Standard No 09 - Ca
Page 78 and 79: • The deceased patient should be
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11 Leakages from the oral cavity, v
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• Mormonism o It is essential tha
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FAITH CONTACT ADDRESS TELEPHONE NO
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• The active electrode must alway
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Generic Theatre Standard No 11 - De
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Generic Theatre Standard No 13 - Ma
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• The labelled container must be
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• Staff Responsibility • All st
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• It is the responsibility of the
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6. Induction of anaesthesia • See
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4. Time Out - Before start of surgi
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• The registered anaesthetic prac
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• The Senior Surgeon/Operating Cl
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Generic Theatre Standard No 16 - St
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Generic Theatre Standard No 18 - Us
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3. Planned over-running sessions
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Generic Theatre Standard No 23 - Bo
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Generic Theatre Standard No 25 - Co
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Generic Theatre Standard No 27 - Ph
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Generic Theatre Standard No 29 - Vi
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Generic Theatre Standard No 31 - Th
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• Advice should be obtained from
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8. Harassment and Bullying • Dign
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Appendix 1. Governance Information
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Appendix 2. Initial Equality Impact
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