Theatres SOP June 2011

Revised Sept 2011

Theatres Standard Operating Procedures

Version No: / 2
Authorisation: / Theatres Care Group
Date of authorisation:
Date of issue: / June 2011
Review date:
Next review date: / June 2012
Pages: / 7
Produced by:
[Author(s) and/or SDU or Department / R Griffiths
L Villar
R Norman
C Stirling
Operating Theatres Department

Contents

Page

On Call Theatre Manager3

On Call Anaesthetic ODP Service3-7

On Call Surgical Scrub Practitioner Service for Cardiac and Neuro7

On Call Practitioner for Day Surgery Patient Advice Service8

Protocol - on-call Manager, including Major Incident Card 9-14

On-call Theatre Manager

The on-call theatre manager is available for advice and support for those working in and out of hours.

Out of hours it may be necessaryfor the on-call manager to come in and co-ordinate the theatre department. Normally this will be in the event of a Major Incident, or for a major trauma call which requires use of the Acute Emergency Theatre [AET] when a 2nd Cepod theatre needs to be opened / is already in use.

Before leaving the department to go off duty from 17.00 on weekdays it is necessary for the on-call manager to ensure that they check the staffing levels for the emergency theatres and liaise with the St James’s theatre Floor Co-ordinator on bleep 7475 for an update on what is happening within all areas including Day Surgery, Obstetrics Cardiac and Neuro theatres and the Recovery areas.

The contact details and name of the on-call manager will be clearly displayed on the staff allocations board in each theatre area.

A detailed protocol for the duties and responsibilities is available at the end of this document.

The on-call Manager can be contacted via switchboard: Air-call SG253 or

Mobile no. 07768752756

On Call Anaesthetic Practitioner

Background

Anaesthetic Practitioners (A.P) at St Georges Hospital NHS Trust provide an emergency out of hour’s on-call service to assist anaesthetists with patients that require emergency anaesthesia and or emergency surgery in the following areas:-

  • CEPOD theatre
  • Obstetrics theatre
  • Lanesbrough theatre (Neonates / Paediatrics)
  • Cardiac theatre
  • Neuro theatre
  • Major Trauma theatre
  • CT / MRI
  • Cardiac Catheter Lab
  • D.S.A
  • A & E
  • Wards ( If 6111 request)

This will require comprehensive and robust procedural guidelines to ensure delivery of a flexible, responsive and high quality service.

Conditions

1a. All qualified Anaesthetic Practitionerwill be contracted to undertake on-calls and can only withdraw from this commitment following approval by the Clinical Theatre Manager – Anaesthetics, with agreement from the Head of Nursing – Theatres.

1b. The off duty will be produced 6 weeks in advance to allow staff to make necessary arrangements.

1c. Only qualified ODPs / Anaesthetic Nurses are eligible.

In addition to a minimum of 6 months experience in anaesthetics after successfully completing their training, they should be assessed as competent in the following areas:

  • ILS
  • PILS
  • IV Administration
  • Massive haemorrhage

Setting up the anaesthetic equipment and assisting the anaesthetist in the following situations:

  1. Emergency Caesarean Sections
  2. Rapid Sequence Inductions
  3. Difficult Airways

2a. Evening Anaesthetic Practitioners on duty

There will be 6 Anaesthetic Practitioners on duty in an evening (17:00 – 20:00) to cover all emergencies. As well as responding to emergencies these Anaesthetic Practitioners will be responsible for ensuring all of the emergency areas are prepared ready for the night shift. The evening Anaesthetic Coordinator will delegate emergency duties according to the skill mix on duty.

3a. Night Anaesthetic Practitioners on duty

There will be a total of six qualified Anaesthetic Practitioners on duty, four resident on a night shift (20:00 – 08:00) and two on-call from home following a late shift (First on-call and Second on-call).

One of the Anaesthetic Practitioners on night duty will be dedicated for Obstetric emergencies and although they can assist the other Anaesthetic Practitioners with other emergencies and tasks they must always be able to immediately respond to Obstetrics.

The other 3 Anaesthetic Practitioners will cover CEPOD, 2nd CEPOD, Major Trauma, Neuro and Cardiac emergencies and will have the necessary skills to cover any 3 of these emergencies happening simultaneously.

3b. Paediatric Emergencies

The Anaesthetic Practitioner on duty for obstetrics will normally be the most experienced paediatric Anaesthetic Practitioner. When a paediatric emergency occurs the Anaesthetic Coordinator should allocate the most appropriate Anaesthetic Practitioner to respond, this may involve an Anaesthetic Practitioner relieving the obstetric Anaesthetic Practitioner for the duration of the case.

3c. Duties of the Anaesthetic Coordinator on a Night shift

The Anaesthetic Coordinator (AC) will lead the night team and deploy the Anaesthetic Practitioners to emergencies as they arise. The AC will be responsible for calling the First and Second on-call Anaesthetic Practitioners in from home to ensure that there is always an Anaesthetic Practitioner free and available to respond to emergencies (Co-ordinating with the practitioner in charge of theatres, the anaesthetist in charge and where necessary the theatre manager on call). This process should be proactively managed to avoid compromising service provision and patient safety. The AC will organise the night team to provide each other with breaks and ensure fair distribution of the work load. The AC will also be responsible for completing the “Night Duty Tasks” as detailed below:-

  • Night Duty Checklist
  • Anaesthetist request board
  • Preparing for major cases the following day
  • Completing the On-call book
  • Handing over any issues to the daytime AC

3d. First On-call

The First On-call Anaesthetic Practitioner will provide emergency cover from outside of the Hospital but must be able to arrive within 45 minutes of receiving a request. An on call room will be provided on site for anybody that cannot meet this requirement. The First On-call Anaesthetic Practitioner should be “called in” as soon as the 3 (excluding the obstetric Anaesthetic Practitioner) night duty Anaesthetic Practitioners are busy dealing with emergencies. The first On-call Anaesthetic Practitioner will carry an “air call” pager at all times when On-call, they will collect this on the day they are on call from the anaesthetic coordinator and return it at the beginning of their next shift.

3e. Second On-call

The Second On-call Anaesthetic Practitioner will provide emergency cover from outside of the Hospital but must be able to arrive within 45 minutes of receiving a request. An on call room will be provided on site for anybody that cannot meet this requirement. The Second On-call Anaesthetic Practitioner should be “called in” as soon as the 3 (excluding the obstetric Anaesthetic Practitioner) night duty Anaesthetic Practitioners and the First On-call Anaesthetic Practitioner are busy dealing with emergencies. The second On-call Anaesthetic Practitioner will carry an “air call” pager at all times when On-call, they will collect this on the day they are on call from the anaesthetic coordinator and return it at the beginning of their next shift.

The names and corresponding contact air-call numbers for each on-call period will be clearly displayed on the allocations board in St James’ Wing and Paul Calvert theatres.

3f. Transport

It is expected that on-call staff should be able to attend the hospital within 45mins of being called using their own transport. However, where a staff member lives further away from the hospital, they should give the management team advance notice of this for each of their on-call shifts and on-call room will be made available. Staff who live within 45mins but do not have their own transport may request a taxi journey, using the appropriate authorisation process, this will be through the Trust’s designated provider (Greyhound) and not other taxi firms.

3g. Payment

Payment will as per agenda for change agreement.

4a. Weekend Anaesthetic Practitioners on duty

There will be 6 Anaesthetic Practitioners on duty during the daytime (08:00 – 20:00) at weekends to cover all emergencies. As well as responding to emergencies these 6 Anaesthetic Practitioners will be responsible for completing the weekend maintenance schedule. The AC will plan these activities as well as ensuring a fair division of the workload and appropriate arrangements for breaks. In addition to the 6 Anaesthetic Practitioners on duty for emergencies there will be two additional Anaesthetic Practitioners, one for orthopaedic trauma and one for plastic trauma.

5a. Bleep numbers
  • Anaesthetic Coordinator – Bleep 8425
  • Obstetrics – Bleep 6650
  • Major Trauma –Bleep 8124
  • CEPOD – Bleep 6400
  • All Neuro, Cardiac and any other emergency calls should go to the anaesthetic coordinator on Bleep 8425

1st & 2nd On-call pager numbers

  • SG 950
  • SG 951
  • SG 952
  • SG 953
  • SG 954
  • SG 955

On-call Surgical Scrub Practitioner Cardiac & Neuro Theatres

On-call staff called in or working after 10pm and beyond may require transportation in a taxi. Taxi’s may only be authorised by the On-call Theatre Manager 08.00-23.30 and the Practitioner in Charge in St James’ Wing from 23.30 – 08.00.

The names and corresponding contact air-call numbers for each on-call period will be clearly displayed on the allocations board in St James’ Wing and Paul Calvert theatres.

On-call pagers

  • Cardiac on call scrub staff - SG 134, SG 734, SG 944, & SG 943
  • Neuro on call scrub staff - SG 941,SG 942, AMH 127, AMH 130.

Payment

Payment will as per agenda for change agreement.

Transport

Taxi codes for on-call staff from Neuro and Cardiac theatres: out-bound journey, AMW2010. The code for all other theatre areas is STJ2010

The codes will be changed frequently and the use of taxis will be monitored.

The on call manager should be contacted if staff are going to work beyond 10pm because of the impact their rest time (11 hours) might have on the department the next day.

For in-bound journeys for on-call staff, the staff members will book their taxis directly with Greyhound, using the specific in-bound taxi code.

For out-bound journeys the staff members will follow the new authorization process (between 08.00- 23.30the on-call Clinical Manager will need to authorise booking a taxi; and from 23.30 - 08.00 the practitioner in charge in SJW will authorize).

When the staff member rings the Clinical Manager / practitioner in charge in SJW they will need to give their mobile telephone number to Clinical Manager / SJW person. This will be given over to the Greyhound booking agent, and they will ensure that the text message is sent to the staff members’ mobile phone.

If a staff member is returning home on public transport, and are unable to return to the hospital quickly enough using public transport, then they should follow the new authorization process, and if approved the taxi will be booked through Greyhound. No other taxi firms should be used.

Day Surgery On-call Practitioner for Patient Advice Service

The Day Surgery Unit [DSU] providesout of hours on-call advice and support for DSU patients who are discharged home following their surgical procedure.

Conditions

The service will operate from Monday to Saturdayfrom 19.00hrs – 08.00hrs. When there is operating on a Saturday, the service will be provided until 08.00 on the following Monday.

The on-call practitioner is not required to attend the Trust during an on-call period as this service is soley to give patients advice and support for the first 24 hours post discharge.

The service is provided by qualified ODP and RNs. Training and competency assessment is provided before staff are rostered for on-call duties.

All contact and actions with patients will be documented on an on-call advice log sheet.

Payment

Payment will as per agenda for change agreement.

Contact Numbers

DSU on call phone07956 571 308

PROTOCOL FOR THE ON CALL THEATRE MANAGER

The on-call Theatre Manager is to be available for advice and support in and out of hours.

Depending on the nature of a call, it may be necessary to come in and co-ordinate the theatre department. Normally this will be in the event of a Major Incident, or for major trauma call which requires use of the Acute Emergency Theatre [AET] when a 2nd Cepod theatre needs to be opened / is already in use.

Before leaving the department each afternoon it is necessary for the on-call manager to ensure they check the staffing levels for the emergency theatres and if necessary, to liaise with the St James’s theatre Floor Co-ordinator on bleep 7475 for an update on what is happening within all areas including Day Surgery, Obstetrics Cardiac and Neuro theatres and the Recovery areas.

The on-call Manager can be contacted via switchboard, Aircall SG253. Mobile no. 07768752756.

The on-call manager must carry the air-call at all times in and out of hours.

  1. Role of the on-call manager for Major Incident

Incident Role / On-call Theatres Manager / Action Card No. X

MAJOR INCIDENT DECLARED

  1. In the event of a Major Incident declared, you will be contacted via SG253 from the hospital switchboard.
  2. Go to the Emergency Department Reception to collect Action Card and identification armband.
  3. Return to St James Wing theatres reception area and with the Theatre Coordinator (Consultant Anaesthetist on-call )

Ensure that the Head of Nursing [SG423], all Clinical Theatre Managers, scrub and anaesthetic floor co-coordinators in all operating theatre suites (inc. PC, Lanes, AMW, SJW and DSU) are informed that a Major incident has been declared.

Ensure that all surgeons in all operating theatres (inc. PC, Lanes, AMW, SJW and DSU) that a Major incident has been declared

decide on the need to stop or cancel operating lists, and if so nominate a theatre practitioner to put this into effect.

  1. Nominate another member of staff to call in additional theatre staff if appropriate.
  2. Liaise with Sterile Services Manager on Bleep 6759 to ensure continued clean supply of instruments.
  3. Establish and maintain a close link with the Consultant in charge of the Emergency Department to manage theatre capacity.
  4. Together with the Theatre Coordinator (Consultant Anaesthetist) receive from the Emergency Departmenta prioritised list of patients for operation. Decide on number of lists and theatres to be opened, and staff accordingly.
  5. Assess the need for additional staff, drugs, supplies and gases and liaise with Bank, Pharmacy and Procurement colleagues as appropriate.
  6. Depending on the needs of theatres, identify anaesthetic and recovery nursing staff to work in the Emergency Department or ITU if requested by the Nursing Coordinator.
  7. Ensure that forensic evidence is kept, labelled for individual patients. Material should be bagged as follows:

All clothing and linen in clear plastic bags

All dressings and clinical waste in yellow plastic bags

Any foreign bodies in universal containers

Consider staff fatigue, including your own, and ensure that staff who have taken roles are relieved at reasonable. All valuables in brown envelopes.

  1. Consider staff fatigue, including your own, and ensure that staff who have taken roles are relieved at reasonable intervals.

MAJOR INCIDENT STAND DOWN AND DEBRIEF

  1. Attend the hot debrief processes for all staff immediately after the incident.
  2. Work with the on-going DMT to reschedule any cancelled operations in a clinically appropriate manner.

2THEATRES EMERGENCY SERVICES

2.1Emergency theatres available

Out of hours Monday – Friday the following theatres open:

  • St James’ Wing: Plastics, Cepod theatre x2
  • Paul Calvert Theatres: Trauma (17.00 -21.00) / Acute Emergency Theatre (AET) 24/7)
  • Lanesborough Wing: Obstetrics Theatre
  • Neuro Theatres: operate an on call system after 18.00
  • Cardiac theatres: operate an on call system after 18.00

Weekends emergency theatres are open:

  • SJW: Plastics (10.00-1700)

Cepod theatres X 2 , one theatre starting at 08.30, the other operating from 10.00 to 17.00 [Neonates are operated on in Lanesborough theatres].

  • PCT: Trauma (09.00- 17.00)

Acute Emergency Theatre 24/7

  • Lanesborough Wing: Obstetrics 24/7
  • Neurosurgery theatres: Operates an on-call system. Theatre 1 is normally used as the emergency theatre. The keys are kept inside Team Leaders office hanging inside the wall mounted cabinet. Neuro on call
  • Cardiac theatres: Operate an on call system. Theatre 1 is normally used as the emergency theatre. Theatre keys are kept in CITU.

2.2The theatre staffing levels at night areas follows:

CEPOD:

  • 4 qualified theatre staff
  • 1 assistant theatre practitioner
  • 1 anaesthetic ODP

AET:

  • 1 qualified theatre staff
  • 1 assistant theatre practitioner
  • 1 anaesthetic ODP

In addition to the above there is an ODP on-call, the Theatre Manager on-call 24/7, as well as a full obstetrics team on site and the cardiac team on-call.

After 9pm the AET or CEPOD theatre should only be opened for life or limb threatening cases. Should a second life or limb threatening case present a second theatre will be opened using the remaining staff. At this point the on-call manager for Theatres will be contacted, who will put a third team on standby should a third life or limb case present meaning a third theatre must be opened before the other two cases have finished. The third team will include staff from the cardiac on call team and may include backup from the obstetrics team; however this support will be dependent on the obstetrics emergency workload at the time.

  • Anaesthetists:

The anaesthetist carrying Bleep 8011 (Duty Floor anaesthetist) prioritises the patients to be operated on. Generally there are enoughanaesthetists out of hours and weekends. The following anaesthetic cover is available out of hours and weekends:

1 Reg in Gynae

1 Reg in Cardiac

1 Reg in Neuro

1 Senior Reg in St James

1 Senior Reg in PICU

There are 5 consultants on call (Trauma, Gynae, Cardiac, Neuro, PICU).

In the event of a second theatre needed to be opened the respective consultant will be called.

  • Surgeons:

Will negotiate prioritising of emergency patients with the anaesthetists and if taking precedence over another patient on the list will have the courtesy to inform their colleagues

3.SSD

St James’ Wing SSD is staffed 24/7. Supervisor can be contacted on ext 0255 or bleep 6759.

4.POST ANAESTHETIC RECOVERY SERVICES

4.1Staffing

LW, Cardiac and Neuro Recoveries shut at 8pm. (Cleaning up time till 8:30) PC Recovery shuts at 9pm and LW5 Recovery shuts at 7pm.