Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5

No 8,20
OT and CSSD Date of Issue: 01-01-2016

SOP 8, 20: OT and CSSD

1. Purpose:
The purpose of this procedure is to develop a system for managing Operation Theatre for
quality patient care.

2. Scope:
The scope of this procedure covers the patients selected for surgical procedures.

3. Responsibility-

Operation Theatre Incharge:

a) He is responsible for administrative aspects of OT including the scheduling of
surgeries as per priorities and seriousness of posted cases.
b) He is responsible for developing and implementing that OT aseptic and environmental
sterility practices mentioned in the Infection Control and Hygiene procedure.
c) He is responsible for formulating the OT protocols and procedures.
d) He is assisted by the Nurse In-charge for OT for routine supervision of above
mentioned issues.
OT Assistant (Senior / Junior):
a) Is responsible for booking & rescheduling of cases to be performed in OT and
preparing the OT list for the next day.
b) Ensure all the instrument / linens are autoclaved / sterilized respectively to be used for
subsequent operation,
c) Performs routine Check & recording of proper functioning of equipments with the help
of checklist, later on signed by Officer In-Charge Theatre before commencement of OT
on daily basis,
d) Ensures that infected cases are taken at the end of the list of surgeries for the OT,
e) Ensures that OT is fumigated; instruments / equipments are disinfected and cleaned
after infected cases are operated,
Staff Nurses:
a) Is responsible for receiving & handing over of patient along with respective patient’s
case file, diagnostic reports duly filled and signed by concerned doctor / specialist,
b) Is responsible for briefing the patients & next of kin and filling of required consent
forms with full signature, date and time,
c) Is responsible for preparation of patient for operation including ensuring site shaving,
antiseptic application and draping of the site.

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

d) Is responsible for setting up of OT table for specific operation with required

instruments/ linen/ equipments,
e) Ensures the availability of cross-matched whole blood units before the commencement
of operation and same is recorded,
f) Is responsible for assisting the entire surgery team during the process of entire
operation,
Sweeper:
a) Responsible for Cleaning / Scrubbing of the OT, recovery room and associated area as
per procedure specifications provided by the infection control program.
b) Responsible for proper segregation of different categories of wastes generated after
every procedure and handing it over to the Biomedical Waste collection personnel.
c) Responsible for assisting OT I/C & Staff Nurse in Fumigation/ Sterilization/
autoclaving inside OT,

4. Standard Procedures

Sr. No Activity Responsibility Ref

document/Document
4.1 Scheduling of Surgery
4.1.1 The surgeon’s posting surgeries informs the OT Technician/ OT call
OT technician through an OT Call Register Surgeon register
for OT booking. This slip include the date and
type of surgery to be performed.
4.1.2 The OT Technician records the request in the OT technician OT booking register
OT Booking Register In case of any clash in
schedule or non-availability he informs the
concerned surgeon.
4.1.3 He forwards the details of the OT bookings to OT Technician
the OT Incharge and Anesthetist.
4.1.3 Operating List (for the next day is OT Incharge Operating list
consolidated at about 3.00 P.M. in the
afternoon of the previous day by the OT
technician and the same is approved and
issued by the OT In-Charge and prominently
exhibited on the notice Boards of the theatre.
4.1.4 Emergency cases are accorded priority by the OT Incharge
OT In-Charge of Operation Theatre.

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

This may require rescheduling of planned

surgeries which is intimated to the concerned
authorities.
4.2 Pre-operative Procedure
4.2.1 Surgeon gives written pre operative Staff Nurse
instructions to ward nurse e.g. Nil orally,
enema etc.)
4.2.2 Physical Preparations (Shaving of site, enema, Staff Nurse
bath, dress, valuables / jewellery) is done
4.2.3 Staff nurses receive the patient sent from the Staff Nurse
ward and transfers him / her to the pre-
operative area with the assistance of the
attendee.
4.2.4 Written Consent for Surgery is obtained Staff Nurse Consent
from the patients / patient’s relatives.
4.2.5 Staff nurse conducts the following pre- Staff Nurse Preoperative
operative checks. Checklist
Medications
Patient Identifications
Case Record and Investigation Reports /
Films
I.V. Fluids
Blood Requirements
Prophylactic Antibiotics (If prescribed)
4.3 Pre-operative Anesthetic Checks
4.3.1 A pre-operative evaluation of the patient is Anesthetist PAC form
done by the anesthetist for all cases posted
and admitted for surgery a day prior to the
surgery. In case the patient is not deemed fit
for surgery, the Surgeon and Nursing In-
Charge for OT is informed through the ward
nurses. In emergency case pre anesthesia
check up is done in emergency/OT.
4.3.2 Post receiving of the patient at the OT the Anesthetist Case Sheet
anesthetist verifies the identity of the patient
against details provided in the case sheet with
the patient and the OT nurse and does a quick

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

evaluation of the patient’s vitals and records

the same in the case sheet.
4.4 In Process Checks during Surgery
4.4.1 The Scrub Nurse controls the number of Scrub Nurse
sponges on the table. At the commencement
and the closure of the surgical incision, the
scrubbed nurse counts the sponges used and
satisfy herself that these are correct & inform
the surgeon accordingly.
4.4.2 The surgeon verifies himself that all swabs Surgeon Case Sheet
have been counted for, before the closure of
the surgical incision. In the case of any
discrepancy in the number of swabs, the
surgeon records this fact on the case sheet of
the patient and informs the Civil surgeon/
Deputy medical superintendent.
4.4.3 The surgeon keeps the scrubbed nurse Surgeon/ Scrub
informed of the location of swabs in the Nurse
operational field to facilitate her counting.
After the first count has been taken, the
scrubbed nurse and the surgeon carefully
check the number of swabs still in use.
Before the closure of the incision a final count
is to be done
4.4.4 The scrub nurse checks all the instruments on Scrub nurse
the operating table and the hemostat clamps
immediately before the operation. Under the
supervision of the surgeon the scrub nurse
checks the instruments and hemostat clamps
again before the closure of the surgical
incision
4.4.5 The scrubbed nurse counts all the needles on Scrub nurse
the table before the commencement of the
operation. As a rule, the scrubbed nurse does
not part with the second needle till the first is
returned to her by the surgeon. In the event of
more than one needle being in use at the same

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

time, the scrubbed nurse takes care to see that

all the needles are returned to her. The
scrubbed nurse makes a count of the needles
before the closures of the surgical incision. In
the event of any discrepancy, the surgeon is
informed promptly.
4.5 Post Operative Care of the Patient
4.5.1 Post operation the patient is shifted the Ward Nurses
Recovery Room or Post Operative Ward and
thereafter supervised by concerned specialist.
4.5.2 A provisional Surgery Note containing the Surgeon Surgery Note
details of the surgery is prepared by the
surgeon with his signature before the patient
is transferred out of OT complex.
4.5.3 Detailed post operative care instructions are Surgeon Case Sheet
documented in the case sheet by the surgeon.
4.5.4 The anesthetist orders the transfer of the Anesthetist
patient from recovery room towards (in case
the patient was shifted to recovery room) after
verifying his/her progress.
4.5.5 Anesthetist supervises the Post Operative Anesthetist
Patient in the Post Operative Ward (in case
patient was transferred to Post Operative
Ward) for the progress.
4.6 Operation Theater Asepsis and
Environment Management
4.6.1 The staff nurse conducts daily checks of the Staff nurse
cleanliness of the OT. She ensures that all
areas found soiled are again cleaned under her
supervision.
4.6.2 The staff nurse ensures that OT surfaces, Staff Nurse
tables and instruments are scrubbed with
disinfectant agents on a daily basis.
4.6.3 Staff nurse / OT Incharge ensures that the OT OT Incharge Fumigation Record
is fumigated on a weekly basis and / or after Register
each biohazard case. The details of the
fumigation will be recorded in the

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

Fumigation Register.
4.6.4 All personnel entering the OT will wear OT
gowns / dress including footwear and undergo
proper scrubbing procedure to ensure sterility
of the clean areas.
4.7 OT Documentation
4.7.1 The details of regarding Anesthesia are noted Anesthetist Anesthesia register
in the Anesthesia Register.
4.7.2 Anesthetist notes down all the drugs and Anesthetist Operation Theatre
consumables, which are used during the Indent register
surgery in the Operation Theater Indent
Register.
4.7.3 OT Nurse In-charge records the details of Surgery register for
each surgery performed in the various General surgery,
Surgery Registers as the case may be; OB&G Orthopedics
Surgery Register – General Surgery
Surgery Register – Obstetrics &
Gynecology
Surgery Register – Orthopedics
4.7.4 OT Nurse In-Charge prepares a monthly OT Nurse In
statement of surgeries performed and submits charge
the same to the OT in charge, civil surgeon.
4.7.5 Staff Nurses maintains the Psychotropic and Staff Nurse Psychotropic And
Narcotics Drugs Register for the control of Narcotics register
controlled drugs and substances as per
statutory requirements.
4.7.6 Staff Nurses maintains the inventory of Staff Nurse Inventory Register
OTconsumables and medicines.
4.7.7 Pharmacists will maintain the records of the Pharmacist Dead Inventory
nonfunctional / damaged equipments and Register
informs OT me /C and the Stores I /C. They
update the same in the Dead Inventory
Register.
4.8 CSSD
4.8.1 Receipt and Issue of Packs: CSSD Assistant Receipt & Issue
Receipt of items from various point of Register
generation from 9.00 am to 1.00 pm.

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

Issue of sterile packs from the CSSD from

3.00 pm to 6.00 pm.
However in departments like OT, ICU,
Emergency Department etc is exempted from
the above mentioned time dimensions since it
is difficult to restrict their activity within
specific time limit due to the emergency
nature of care provided by them.
4.9 General Cleaning of the Department
4.9.1 The general working area of the CSSD is Housekeeping
mopped everyday including the following staff
area within the CSSD environment.
Packing area
Sterile packs Storing
Decontamination area and sluice room
4.10 Generation of Items to Sterilize
4.10.1 The items to be sterilized at the Central CSSD Assistant
Sterile Supply Department are washed with
detergent, sorted and packed at the respective
point of generation (Wards, ICUs, Emergency
Department, OTs, and OPDs etc).
4.10.2 The Housekeeping staff is responsible for Housekeeping
transporting the prepared packs from the point Staff
of generation to the Central Sterile Supply
Department.
4.10.3 OT linen is send directly to the laundry for Laundry Staff
cleaning. The laundry washed linen are
received, packed and forwarded to the CSSD
for sterilization.
4.11 Return of Unutilized Packs: Respective
In case the packs which are sterilized in the Departments
CSSD remains unutilized in the respective
user departments for a period of 72 hours, the
same are returned to the CSSD department for
re-sterilization.
4.12 Maintenance and Calibration of
Equipment

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

4.12.1 Maintenance of the equipments are done as AMC Agency

per the annual maintenance contract (AMC)
entered into with the vendor of the respective
CSSD equipments. All details in these regard
are maintained by the Biomedical Equipments
Engineering and Maintenance Department of
the hospital.
4.12.2 All equipments used in the department are Hospital
appropriately calibrated at periodic intervals Manager/
to ascertain whether they are performing at Calibration
the expected level and a record of the same is Agency
documented in the department as well as with
the concerned clerk in the administrative
Department of the hospital.
4.13 Recall Procedure : CSSD Recall
Whenever a breakdown in the sterilization Technician Register
system is noted all packs sterilized by the
faulty machine is immediately called back
from the respective area where the sterile
packs has been supplied. The packs called
back are sent for re sterilization using a
proper machine.

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 Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN/OS/5
No 8,20
OT and CSSD Date of Issue: 01-01-2016

5. Records -

S.No Record Name Record No. Retention Period

1 OT call register
2 OT booking register
3 Operating list
4 Fumigation Record Register
5 Anesthesia register
6 Operation theatre Indent register
7 Surgery register for General surgery,
OB&G Orthopedics
8 Psychotropic and Narcotics register
9 Dead Inventory register

6. Process Efficiency Criteria -

Sr No. Activity Process Efficiency Criteria Benchmark/Standard/Target

1 Infection Surgical Site Infection Rate
Control
2 Scheduling Surgery Cancellation Rate
3 Utilization OT Utilization Rate
4 Utilization Major Surgeries per Doctor

7.0 References Documents

1. WHO Surgical Safety Checklist

2. Procedure for Hospital Infection Control (SOP 8)
3. Surgical Care at District Hospital

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