Quality Standards for Theatre & Anaesthetic Services – Self Assessment

Ref / Quality Standard / Notes / SA Met? Y/N / SA Comments / Met?
Y/N / Reviewer Comments
XG-101
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/ Service Information
Patients should be offered written information about:
  1. Services provided, location and hours of opening
  2. Visiting hours and visiting arrangements
  3. How to contact the service
  4. Staff they are likely to meet
/ 1 Information should be written in clear, plain English and should be available in formats and languages appropriate to the needs of the patients and their carers.Information for children and young people should meet the Quality Criteria for young People Friendly Health Services (DH, 2011).
2 This Quality Standard relates to aspects of the service to which patients and visitors have direct access. / This column should be left blank - for use by reviewers at the visit / This column should be left blank - for use by reviewers at the visit
XG-102
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/ Procedure Information
For each procedure, patients should be offered written information, and the opportunity to discuss this, covering:
  1. Preparation for the procedure
  2. Types of anaesthesia available
  3. Staff who will be present at or who will perform the procedure
  4. Any side effects
/ 1 As XG-101.
2 Procedure information should be easily available to ward staff as well as sent to patients attending on an out-patient basis.
3 This QS links with QS XG-503 about consent procedures and should be appropriate to support patients in making informed consent. Information may be offered by surgical teams or by theatre and anaesthetic staff. Theatre and anaesthetic staff should be aware of the information available and should ensure that patients have been offered appropriate information.
4 Information may also cover other aspects of care, for example, how, when and by whom results will be communicated.
XG-103
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/ Privacy, Dignity and Security
Patients’ privacy, dignity and security should be maintained at all times, including security of clothes, dentures, hearing aids and personal belongings during examinations and procedures.
XG-104
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/ Communication Aids
Communication aids should be available to help patients with communication difficulties to participate in decisions about their care.
XG-196
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/ General Support for Service Users and Carers
Patients and carers should have easy access to the following services. Information about these services should be easily available:
  1. Interpreter services, including access to British Sign Language
  2. ‘Compliments and complaints’ procedures
/ 1 As XG-101.
2 This QS is about signposting to relevant services.
XG-199
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/ Involving Patients and Carers
The service should have:
  1. Mechanisms for receiving feedback from patients and carers about their treatment and care
  2. Mechanisms for involving patients and carers in decisions about the organisation of the services
  3. Examples of changes made as a result of feedback and involvement of patients and carers
/ The arrangements for receiving feedback from patients and carers may involve surveys, including the national patient survey, focus groups and /or other arrangements. They may involve Trust-wide arrangements as long as issues relating to Theatre and Anaesthetic Services can be identified.
XG-201
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/ Leadership
Theatre and Anaesthetic Services should have a Clinical Director, Lead Nurse, Lead Operating Department Practitioner and Lead Manager with responsibility for staffing, training, guidelines and protocols, service organisation, governance and for liaison with other services. / Leads for Theatre and Anaesthetic Services may also be leads for other areas, for example, critical care.
XG-202
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/ Service Leads
Leads for, at least, the following areas should be identified:
  1. Critical care, including high dependency care and outreach
  2. Acute and non-acute pain services
  3. Obstetric anaesthesia
  4. Care of children
  5. Major incidents
  6. Admissions and day care
  7. Pre-operative assessment
  8. Recovery
  9. Equipment management
/ 1 Leads may have responsibility for more than one area. Leads for other areas may also be identified, for example, for audit, education, logistics and sterile services, dental anaesthesia. Leads may cover both theatres and anaesthetic services or these responsibilities may be separate.
2 Leads for critical care and for care of children are duplicated in the Critical Care and Paediatric Anaesthesia Quality Standards respectively, and are repeated here for completeness.
XG-203
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/ Staffing Levels
The service should have sufficient staff with appropriate competences to deliver the expected number of assessments and procedures for the usual case mix of patients within expected timescales (QS XG-602). An escalation policy should be in place which ensures flexibility of staffing in response to fluctuations in demand and availability of staff.
Staffing levels should be based on a competence framework covering staffing levels and competences expected (QS XG-206), and should ensure an appropriate skill mix of consultant anaesthetists, other anaesthetic medical staff, physicians assistants, operating department practitioners, theatre assistants, theatre nurses and porters. In Major Trauma Centres the trauma anaesthetic team should be separate from other emergency and elective teams. In hospitals with obstetric units the obstetric anaesthetic team should be separate to enable elective work to continue uninterrupted by emergency work and a named consultant should be responsible for each elective caesarean section list. / 1 This QS is not specific about the expected skill mix. A clear methodology should, ideally, be used to determine appropriate staffing levels. Benchmarking information may be helpful in determining appropriate staffing and skills mix.
2 Staffing establishment recommended by the Association for Perioperative Practice (2008) is:
“One qualified anaesthetic assistant practitioner for each session involving an anaesthetic
Two qualified scrub practitioners as a basic requirement for each session, unless there is only one planned case on the operating list
One trained circulating practitioner for each session
Two trained circulating practitioners where the operative procedure involves two cavities being opened simultaneously and has two operating teams at the operating table
One qualified post-anaesthetic recovery practitioner for the immediate postoperative period. There may be occasions when two qualified staff are required if there is a quick throughput of patients requiring minor procedures, such as in a surgical day unit.”
3 Obstetric theatre staff, whether midwives, nurses or ODPs, should be trained to the level recommended for general surgery / recovery. A midwife with no additional training does not have adequate competences for recovery duties.
XG-204
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/ Obstetric Anaesthesia Duty Anaesthetist
A duty anaesthetist competent to undertake duties on the delivery suite should be:
  1. Immediately available for emergency work on the delivery suite 24/7
  2. Resident on-site in units offering a 24 hour epidural service
  3. Able to delay other responsibilities should obstetric work arise
All duty anaesthetists should have completed an initial assessment of competence in obstetric anaesthesia (IACOA) or have equivalent competences before undertaking unsupervised obstetric work. / 1 This QS is applicable only to hospitals with on-site obstetric units.
2 The duty anaesthetist for obstetrics should not be solely responsible for critical care, cardiac arrests or general theatres.
3 Competence of locums should be assessed before undertaking unsupervised obstetric work (QS XG-207)
XG-205
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/ Acute Pain Team
An acute pain team should be available including:
  1. Consultant anaesthetist with sessional commitments to the team
  2. Specialist nurse with specific competences in the management of acute pain
  3. Other medical, nursing and operating department practitioner staff as required for the number of patients and the complexity of their needs
  4. Pharmacist with sessional commitments to the team
  5. Physiotherapist with sessional commitments to the team
/ 1 Secretarial and administrative support is covered in QS XG-299.
2 Evidence of compliance with this QS may be combined with QSs XG-203 and XG-206.
XG-206
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/ Competence Framework and Training Plan
A competence framework should cover expected competences for roles within the service. A training and development programme should ensure that all staff have, and are maintaining, these competences. The competence framework and training plan should cover all staff identified in QS XG-203, including at least:
  1. Moving and handling in the theatre environment
  2. Drug administration
  3. Plastering
  4. Resuscitation
  5. Use of equipment
  6. Care of children and young people
/ 1 Competences of medical staff will be covered by re-validation when fully implemented. The competence framework may cover medical staff, especially non-consultant non-training grade staff, until re-validation is complete.
2 The competence framework should be clear about the service’s approach to competence assessment and a summary of completion of competence assessments for different staff groups should be available.
3 This Quality Standard relates to competences expected for theatre and anaesthetic staff which are over and above those expected for all staff as part of mandatory training. There may, however, be some overlap with mandatory training programmes.
4 Section f of this QS overlaps with the Paediatric Anaesthesia Section of the Standards for the Care of Critically Ill and Critically Injured Children in the West Midlands. It is included here for completeness.
XG-207
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/ New Starters, Agency, Bank and Locum Staff
Before starting work in the service, local induction and a review of competence for the expected role in assessments and procedures should be completed for all new starters, agency, bank and locum staff.
XG-208
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/ Emergency Service
Staff with appropriate competences should be available outside planned sessions including:
a.On call consultant anaesthetist
b.On-site anaesthetist of grade CT3 or above (or equivalent)
c.Emergency theatre service
Competences for emergency work should be maintained through appropriate Continuing Professional Development and / or daytime job-planned work. / Theatre teams in Trauma Units should be encouraged to undertake rotation to Major Trauma Centre in order to maintain competences in the management of patients with trauma.
XG-209
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/ Staff monitoring
Arrangements should be in place for monitoring and reviewing staff sickness, vacancy and turnover levels.
XG-210
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/ Team building
The service should encourage a range of activities to develop team building and multi-professional working.
XG-299
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/ Administrative, Clerical and Data Collection Support
Administrative, clerical and data collection support should be available during working hours to support all aspects of theatre and anaesthetic services, including the acute pain team. / The amount of administrative, clerical and data collection support is not defined. Clinical staff should not, however, be spending unreasonable amounts of time which could be used for clinical work on administrative tasks.
XG-301
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/ Support Services
Timely access to the following services should be available:
  1. IT support
  2. Hospital porters
  3. Patient transport
  4. Security
  5. Cleaning
  6. Linen supplies
  7. Logistics and sterile services
  8. Pharmacy, covering advice and supply of drugs and medical gas testing
  9. Infection control advice
  10. Medical records
  11. Pathology
  12. Imaging
  13. Plastering (if not part of theatre and anaesthetic service)
  14. Electronic and Bio-Medical Engineering
/ 1 Timely is not strictly defined, but availability of these services should not unreasonably delay the patient pathway.
2 Electronic and Bio-Medical Engineering support may be combined with arrangements for equipment management (QS XG-402).
XG-302
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/ Blood and Transplant
Appropriate arrangements should be in place for:
  1. Supply and storage of blood products
  2. Other NHS Blood and Transplant storage requirements (if applicable)
/ Arrangements should comply with NHS Blood and Transplant requirements. The storage requirement may vary depending on the service provided, for example, bone donation, heart valves or skin grafts.
XG-401
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/ Facilities and Equipment
The service should have appropriate facilities and equipment to deliver the expected number of assessments and procedures for the usual case mix of patients within expected timescales (QS XG-602). Facilities and equipment should comply with all relevant Standards and should ensure:
a.Appropriate privacy, dignity and security for patients (QS XG-103)
b.Appropriate separation of children and adults
c.Immediate availability of resuscitation equipment for children and adults which is checked in accordance with Trust policy
d.Availability of specialist equipment when required
e.In-theatre imaging when required / Specialist equipment includes, for example, implants and prostheses.
XG-402
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/ Equipment Management
The service should have arrangements for equipment management covering:
a.Procurement and management of equipment and consumables
b.Installation assurance
c.Calibration, operation and performance of equipment
d.Equipment maintenance (service contracts and maintenance schedules) covering planned maintenance and 24/7 breakdown or unscheduled maintenance
e.Contingency plans in the event of equipment breakdown
f.Monitoring and management of equipment failures and faults
g.Ensuring safety warnings, alerts and recalls are circulated and acted upon within specified timescales
h.Programme of equipment replacement and risk management of equipment used beyond its replacement date / These arrangements should link with Trust-wide arrangements for governance of medical equipment.
XG-403
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/ Delivery Suite Equipment
The following facilities and equipment should be available within the Delivery Suite:
  1. At least one fully equipped obstetric theatre
  2. Blood gas analysis and the facility for rapid estimation of haemoglobin and blood sugar
  3. Monitoring equipment for the measurement of non-invasive blood pressure and invasive haemodynamic monitoring
  4. Equipment for measuring ECG, oxygen saturation and temperature
  5. Rooms should have oxygen, suction equipment and resuscitation equipment, including a defibrillator. All equipment must be checked in accordance with Trust policy.
  6. Rooms should have active scavenging of waste anaesthetic gas to comply with COSHH guidelines on anaesthetic gas pollution.
  7. Supply of O rhesus negative blood available 24/7 for emergency use
  8. Blood warmer allowing the rapid transfusion of blood and fluids.
  9. Access to cell salvage equipment.
  10. Patient controlled analgesia equipment and infusion devices for post-operative pain relief
  11. Ultrasound imaging equipment for central vascular access, transversus abdominis plane (TAP) blocks and epidural cannulation of patients as well as high risk and bariatric women
  12. Intralipid, Sugammadex and dantrolene with their location clearly identified.
/ 1 This QS is applicable only to hospitals with on-site obstetric units.
2 Staffing of the obstetric theatre is covered in QSs XG-203 and XG-204.
XG-404
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/ IT system
IT systems for storage, retrieval and transmission of patient information should be in use. Theatre and anaesthetic staff should have access to:
a.Pre-assessment information
b.Theatre management system
c.Trust Patient Administration System
d.Emails and the Trust intranet and policies
e.On-line medical and other relevant information
System connectivity should be sufficient to ensure that patient details are entered once only. / 1 The theatre management system should either include appropriate clinical information to support clinical audit (QS XG-702), including information on post-operative complications, or this should be covered by a separate system.
2 IT security is covered by QS XG-601
XG-405
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/ Moving and Handling Aids
Moving and handling aids should be available and appropriately maintained. / Availability of moving and handling equipment is not specified in detail but availability of moving and handling equipment should not unreasonably delay the patient pathway or achievement of expected timescales (QS XG-602).
XG-406
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/ Specialist Equipment
The service should have access to appropriate equipment, moving and handling aids and patient gowns to meet the needs of:
a.Bariatric patients
b.Adults and children with physical disabilities
XG-501
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/ Referral Information
Guidelines on information to be sent with each referral should have been agreed and circulated to all referring GPs and referring hospital clinicians.
XG-502
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/ Patient Pathway Guidelines
Guidelines should be in use covering:
a.Pre-assessment, including antenatal referrals
b.Pre-operative care
c.Assessment prior to anaesthesia and procedure
d.Range of anaesthetic techniques normally offered for each procedure
e.Use of WHO Safer Surgery Checklist
f.Anaesthetic assistance throughout the procedure.
g.Monitoring during anaesthesia and recovery
h.Post-operative care
i.Post-surgery review
j.Recognition and treatment of complications, including involving other services as required
k.Anaesthesia in the CT and MRI environment
l.Use of ultrasound during anaesthesia
m.Anaesthesia in the plaster room
n.Wrong site block tool kit
o.Handover to post-anaesthetic care
These protocols should be explicit about responsibilities at each stage of the assessment and procedure and about handover between stages of the patient pathway. Protocols should be specific about indications and arrangements for day case and short-stay surgery and enhanced recovery. / 1 Guidelines may be combined with clinical and infection control guidelines or may be separate.
2 Guidelines should ensure that in major trauma cases, an appropriately competent anaesthetist and anaesthetic assistant are present throughout the anaesthetic procedure.
XG-503
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/ Consent
The Trust consent procedure should be in use. / This QS links with QS XG-102 about patient information. Theatre and anaesthetic staff may not have direct responsibility for informed consent for all patients but do have a role in checking that informed consent has been obtained prior to surgery. Theatre and anaesthetic staff may be responsible for informed consent for some patients.
XG-504
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/ Clinical Guidelines
Clinical guidelines should be in use covering at least:
a.Management of patients with allergies