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INDEX
Section Page
Policy - - - - - - - - - 4
Introduction - - - - - - - - 4
Scope of Policy - - - - - - - 5
2. Responsibilities - - - - - - 7
Consultation checklist - - - - - - 29
POLICY
INTRODUCTION
The Trust is committed to developing systems and processes that seek to match
demand and capacity for elective and emergency surgery. Effective planning and
management is essential to improve services to patients and ensure optimum use of
operating theatre capacity. More efficient use of the operating theatres and effective
scheduling will reduce waiting times for patients and avoid cancellations. Early
notification of operating lists can allow sessions to be fully utilised by surgeons and
enable the Theatre Manager to ensure any specialist equipment and staff are available.
¾ To ensure that the ‘Minimum Standards for Elective Surgery’, as agreed by the
Surgical Division, are adhered to.
¾ To establish an agreed set of procedures for identifying and listing PTL, cancer
and private patients;
¾ To identify teaching lists and facilitate case mix adjustment where necessary.
AREA OF POLICY
Surgical and Anaesthetic Directorates under the management of the Surgical Division.
OBJECTIVE
To facilitate forward planning of the operating lists for the theatre departments, Main
Theatres and Day Surgery Theatres ensuring maximum utilisation of available
resources whilst meeting the activity and performance targets of the Trust.
¾ The timetable for the notification of elective, emergency and trauma operating
lists to the theatre department;
1.1. Every booking coordinator and medical secretary will have access to the
up-to-date theatre timetable on the Theatre Timetable web page. This will
be updated regularly to reflect any changes to the planned format. The
Theatre Timetable web page may be found at:
http://webserver.ruh-
bath.swest.nhs.uk/departments/main_theatres/home_menu.htm
1.2. The elective surgery operating list will be produced on the theatre ORSOS
system.
1.3. Emergency and trauma lists will be accepted in hand written form but
should be booked to ORSOS theatre system prior to the patient being
called to theatre.
1.5. All questions regarding the patient and their operation should be
accurately and comprehensively answered when booking patients to the
ORSOS theatre system.
1.6. Elective operating lists must be submitted by 10am, 3 working days before
planned surgery.
1.8. Theatre One staff will enter all emergency lists on the theatre ORSOS
system at the earliest opportunity.
1.10. All emergency and trauma patients require a priority rating / NCEPOD
classification at the time of listing.
1.11. Booking coordinators will compile the list according to the guidelines set
out in Appendix 2.
1.12. All PTL, cancer and private patients must be identified on the theatre list
using the appropriate column.
1.13. PTL patients should, where possible, be listed first on the operating list.
1.14. Clinical priority will supersede PTL status in the list order.
1.17. All lists must be agreed with the operating surgeon before submission.
1.18. Electronic / hardcopy lists for elective surgery must be made available to
all clinical, nursing and management staff within the agreed timescale.
2. RESPONSIBILITIES
2.1. Booking coordinators will ensure that elective theatre lists are compiled
and submitted according to the List Submission Timetable in Appendix 3,
and that sign off by the relevant surgeon is received prior to submission
date.
2.3. The medical secretaries are responsible for providing their surgical teams
with access to up to date theatre lists.
2.4. The Theatre Information Team will monitor the receipt of lists within the
specified timescale.
2.5. The Theatre Information Team will inform the Elective Admissions
Manager of any missing or late list submissions via email.
2.7. The Theatre Manager and Day Surgery Manager will accept responsibility
for downward and outward dissemination of information pertaining to
forthcoming operating lists to all senior staff.
2.8. The surgical teams will accept responsibility for ensuring that a Loan
Equipment Request Sheet is completed and submitted for any specialist
equipment required.
2.9. Senior theatre staff / team leaders will be responsible for monitoring any
special requirements for forthcoming lists for the forthcoming week.
2.10. The Theatre One staff will enter the emergency lists onto the ORSOS
system at the earliest opportunity.
2.11. The Trauma Coordinator will ensure that the trauma lists are entered onto
the ORSOS system at the earliest opportunity.
2.12. The Theatre Information Team will retain primary responsibility for making
any changes to the operating lists after the submission date.
2.13. The Booking coordinators will immediately inform Theatre Reception via
Cancelled Ops Group email address if any changes are made to the
operating lists after the submission date. New lists will then be printed
and circulated by the Theatre Information Team.
2.14. The Theatre Information Team will ensure adequate copies of the daily
operating list are available for all staff.
2.16. At the end of each operating session one list will be returned to the
Theatre Information Team detailing any changes in list order and any
cancellations.
2.17. Theatre Reception / DSU Recovery must e-mail details of all cancelled
patients to the appropriate booking co-ordinator to facilitate re-booking via
the Cancelled Ops e-mail address.
Changes to operating lists are inevitable and can be made at any time provided
the following procedure is followed.
3.1. List changes including all cancellations should be entered onto the
ORSOS system at the booking coordinators’ earliest opportunity.
3.2. The Theatre Information Team is responsible for making any last minute
(within three working days) changes to operating lists. Any last minute
changes required by the surgical or anaesthetic teams should be
requested by clinicians via Theatre Reception.
3.3. Should the Theatre Information Team or a booking coordinator make any
changes to an operating list after it has been submitted they will
immediately inform Theatre Reception via email who will print and
circulate new copies of the list.
3.4. The Theatre Information Team will inform the relevant manager and senior
nurses for Main Theatres and Day Surgery Unit of any changes to the
relevant department’s lists.
3.5. Ward clerks or senior ward staff should immediately inform Theatre
Reception / Day Case Unit of all hospital and patient initiated
cancellations. This information will immediately be passed on to the senior
theatre staff for the relevant area and the changes noted on the operating
lists.
3.6. Any changes in the order of the operating list must be highlighted to the
Theatre Team Leader, surgeon, anaesthetist, Patient Admissions Centre
and ward staff immediately.
3.8. Theatre Reception will ensure that all appropriate staff have an up to date
copy of the operating list incorporating any alterations.
3.9. All operating list changes must be documented on the master copy which
is returned to the Theatre Information Team at the end of the session.
3.10. All Booking coordinators and the Theatre Information Team must ensure
that all cancelled operations are immediately and accurately recorded on
ORSOS.
3.13. No PTL patients may be cancelled without authorisation from the Elective
Admissions Manager. The Elective Admissions Manager must
immediately be informed of all PTL patients who potentially may be
cancelled by the hospital for non-clinical reasons. All PTL patients must
be offered a new treatment date, in accordance with the Trust Access
Policy, before they are discharged.
3.14. Wherever possible all patients cancelled by the hospital on the day of
surgery or after their admission should be offered a new treatment date
before they are discharged.
3.15. The Trust procedure for compliance with the NHS Plan 28 Day Guarantee
must be followed for all patients cancelled by the hospital at the last
minute for non-clinical reasons.
3.16. The Elective Admissions Manager and booking coordinators will ensure
that all 28 Day Guarantee patients are offered a new treatment date within
28 days.
Any changes to the theatre list, including cancellations, should be recorded immediately
on TDS, ORSOS and in diary to ensure that PAS data is accurate at all times
Surgeon & anaesthetist to review theatre list at least 3 working days prior to surgery to
ensure that lists are booked appropriately & information is accurate
Theatre Information Team / booking coordinator to be informed of any changes required
Theatre staff to review theatre list at least 3 working days prior to surgery to ensure that
theatre lists are booked appropriately & efficiently
Theatre Information Team to record all changes to theatre list & reasons for cancellation
within 3 working days of surgery. New copies of updated lists to be printed and
circulated.
Theatre list to be returned to Theatre Information Team on day of surgery to ensure that
PAS data is accurate at all times
It is the responsibility of the booking coordinators and the Elective Admissions Team to
cover all theatre lists (with the exception of Theatre 1 and Theatre 2) on notification of
surgeon leave or unavailability.
It is the responsibility of the Orthopaedic Project Manager to cover all trauma lists
(Theatre 2) on notification of surgeon leave or unavailability.
It is the responsibility of the Theatre Manager / Assistant Divisional Manager for Surgery
to cover all emergency lists (Theatre 1) on notification of surgeon leave or unavailability.
5.1.2 The Elective Admissions Team Leader will inform the relevant
manager for Main Theatres or Day Surgery Unit and the
Anaesthesia Directorate Coordinator of all changes at the weekly
Theatre Meeting.
5.2.8 When reallocation within the speciality is not possible, the Elective
Admissions Team, subject to six weeks notice, will be offered the
opportunity to offer any available sessions to alternative
directorates or the Private and Overseas Patients Coordinator.
5.3.2 The Theatre Information Team will ensure the Theatre Timetable
Web Page displays up to date information regarding available
operating lists, and inform members of the Elective Admissions
Team of available sessions.
5.3.3 All surgical directorates and the Private and Overseas Patient
Coordinator will be invited to take up any of the cancelled sessions,
subject to adequate notice.
5.3.4 Medical staff wishing to use a vacant session should inform their
booking coordinator who will apply for allocation of the session.
5.3.7 The Elective Admissions team leader will be responsible for ensuring that
there is bed availability before they request additional theatre sessions.
6.1. The Theatre Information Team will monitor and record all cancelled operating
sessions.
6.2. The Theatre Information Team will, on a weekly basis, inform the appropriate
theatre manager and Elective Admissions Manager of the number of theatre
sessions utilised and cancelled in each theatre department according to
speciality. This information will be reported to the PTL Meeting, on a weekly
basis, and to the Surgical Division and Theatre Management Group, on a
monthly basis, highlighting the amount of potential operating hours not utilised
by the Trust.
6.3. The Theatre Information Team will ensure that an accurate record of the start
and finish time of each procedure and theatre session is maintained, including
any reasons for delay.
6.4. The Elective Admissions Manager and Main Theatres Manager will monitor and
analyse the start and finish times of each operating session. This information
will be reported to the Surgical Division and Theatre Management Group, on a
monthly basis, highlighting the amount of potential operating hours not utilised
by the Trust.
6.5. The Theatre Information Team will ensure that an accurate database of
cancelled operations is maintained.
6.6. The Elective Admissions Manager and Main Theatres Manager will monitor and
analyse all cancelled operations. This information will be reported to the PTL
Meeting, on a weekly basis, and to the Surgical Division and Theatre
Management Group, on a monthly basis. Cancelled operations data will also be
made available to all Trust employees as part of the monthly Performance Pack.
6.7. All requests for electronic operating logs or theatre data should be addressed to
the Theatre Information Team with reasonable notice. Requests should detail
the specific information required.
The following minimum standards will be applied to all elective surgical lists from 1
November 2003. Where these standards are not met the list will not be able to start and
postponements of cases are likely to result. It is the responsibility of all members of the
team to ensure these standards are met.
1. Operation lists must be available by 10:00 three working days before the date of
surgery (as per operational practice).
2. No subsequent list changes may be made without discussion with the relevant
theatre team leader, senior anaesthetist, senior surgeon and ward staff.
3. Patients must be in hospital before the list start time and must arrive in sufficient
time to allow the preparation required before anaesthetic assessment.
4. Provision must be made for patients to be seen in an appropriate clinical area. This
area should provide privacy and a site for examination.
5. All hospital notes and x-rays must be available.
6. Baseline results must be available in the notes (where indicated this includes ECG,
FBC and U&E).
7. Pre-medication and routine drugs must be given by the ward staff, as prescribed. If
they are not given the anaesthetist must be contacted directly before the patient is
transferred to theatre.
8. A recent set of observations must be available before the patient leaves for theatre.
The anaesthetist should be informed of any abnormalities noted.
9. An appropriate bed must be available and irreversibly allocated before the patient is
transferred to theatre.
10. The patient must have been seen and marked appropriately by the operating
surgeon before induction of anaesthesia.
11. If appropriate post-operative care (both in terms of site and nursing) is not available
anaesthesia and surgery cannot proceed.
Guidelines:
These are strongly encouraged but do not form a minimum standard.
1. Patients will receive written information about their anaesthetic before admission.
2. Any patient about whom there is reason for concern should be discussed with an
anaesthetist (for example but not only: any patient with disease that limits exercise
tolerance, BP systolic > 180, diastolic >100, predicted difficult airway, gross obesity).
3. The guidelines on anaesthesia monitoring and PACU as published by the AAGBI are
adopted.
Ð
PAEDIATRIC PATIENTS
With the exception of latex allergy patients paediatric cases should always be listed
first
Ð
DIABETIC PATIENTS
Listed first if neither of the above cases are scheduled
Ð
PTL / URGENT PATIENTS
To be listed immediately after patients with clinical requirements. To be listed first if
none of the above cases are scheduled
Ð
Ð
LOCAL ANAESTHETIC CASES
To be placed at the end of a general anaesthetic list should none of the cases below be
scheduled
Ð
Where possible DSU request that similar operations be listed together e.g. Tonsillectomy
Hysteroscopy
EMEAs
STOPs
Vein surgery etc.
Author : Heather Cooper Date: April 2007
Job title: Theatre Manager Version: 1
Page 20 of 29 Review date: April 2009
Royal United Hospital Bath NHS Trust
Operating Theatre List
In order to gather useful, accurate and timely information for bed, duty, theatre and
waiting list management purposes, the following points have been suggested and
agreed:
¾ Operating Theatre Lists will be submitted at least 3 working days prior to the list
date
¾ Changes to the Operating Theatre List must be entered onto the ORSOS system
¾ Any changes to the lists after submission must be e-mailed to the Theatre
Information Manager after updating the ORSOS system
Monday Wednesday - 10 am
Tuesday Thursday - 10 am
Wednesday Friday - 10 am
Thursday Monday - 10 am
Friday Tuesday - 10 am
Saturday Wednesday - 10 am
Date: Theatre:
Main
am pm All day PAW DSU
Theatres
Session
start time:
Scheduled Replacement
Surgeon: Surgeon:
Specialty: Specialty:
LA
In-patient
GA
Day case
Mixed
Mixed
Paediatrics
Anaesthetic Department
Please note that changes to the theatre timetable will only be made once this form has been
authorised and returned to the Theatre Information Team
Theatre Information Team
Signature & date
Patient name
Surgeon
Operation date
(if known)
Equipment required
Please return form to Band 7 Theatre nurse for appropriate specialty or department
Supplier:
Order number:
Date ordered:
Signature:
Delivery date:
Collection date:
Checked in by:
Signature:
Signature:
Name:
Time:
Signature
Prosthesis Used
Date:
Patient number:
Prosthesis Stickers
PATIENT CANCELLATION
66 Appointment inconvenient (patient cx)
2 Unfit for surgery (patient cx)
5 Operation not required (patient cx)
77 Patient had operation privately
78 Patient treated by Alternative Provider (APO)
16 Patient died prior to theatre
17 Patient refused operation
76 Unable to contact patient
1 DNA
CHANGES TO ORSOS
36 Patient transferred to another theatre
41 Clerical error (not a cx)
Author : Heather Cooper Date: October 2007
Job title: Theatre Manager Version: 1
Page 28 of 29 Review date: October 2012
Royal United Hospital Bath NHS Trust
Name of Policy and Procedure
CONSULTATION CHECKLIST
Author; please attach this to each copy of the policy being sent to a meeting for
comments.
Dear Chairman, please would you review this policy at your committee and return any
amendments / comments to ____________________________ by _____ / _____ / _____
Yes No N/A
Are there any elements of this policy which present
operational issues that require further discussion? If yes,
please provide a contact name for the author.
___________________________________