OR POLICY - NEW TEMPLATE (Revised)

WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
E. Lopez Street, Jaro, Iloilo City

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Email Address: wvsumedcenter@yahoo.com
“PHIC Accredited Health Care Provider”
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GENERAL POLICY OF THE OPERATING ROOM COMPLEX
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REGULATORY / STANDARD REFERENCE
SERVICE POLICY OF THE

OPERATING ROOM COMPLEX
Author: Marcos D. Bito-onon, M.D., MPG, FPSA, DPBPM

Chairman, Department of Anesthesiology
Assistant Hospital Director for Health Operations
Co Authors: Miguel Angelo G. Labyen, RN.

NURSE III OR Complex
Rogelio F. Navigar, RN
NURSE III, OR COMPLEX
Executive Lead: Dave Endel R. Gelito III, MD, MM

OIC- Medical Center Chief II
Status: Approval Date:
Ratified by:
Review Date:
This document is a property of WVSU Medical Center. Any unauthorized reproduction is strictly prohibited.
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DATE PAGES COMMENTS APPROVED BY
1. BACKGROUND
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The Operating Room Complex is a hospital unit where surgical procedures are performed by
surgeons under local, regional, or general anesthetic that essentially require safety. In
addition, specific diagnostic, therapeutic or invasive procedures are also performed by
specialists from variety of disciplines. It is a sterile, complex, dynamic, yet organized
environment.
The Operating Room is a major resource-generation unit in the hospital whose main work
load comes from various surgical disciplines encompassing general surgery, obstetrical and
gynecological, orthopedic and trauma, minimally invasive, urologic, neurologic, oral and
maxillofacial, plastic and reconstructive, breast, thoracovascular, colorectal, oncologic and
other surgical and related procedures.
Fundamental to the provision of optimal peri-operative care is the consideration for patient
safety during the administration of anesthesia and the performance of the surgical procedure.
The presence of trained personnel, complete documentation of the procedures performed, the
availability of reliable monitoring equipment, proper instrumentation and above all, an
environment where surgical asepsis is assured by best practices conforming to accepted
international standards, are critical success factors in the safe and efficient delivery of peri-
operative care.
2. POLICY OBJECTIVES:
It is the policy of West Visayas State University Medical Center to assure reasonable and
timely surgery capacity where emergent surgical intervention procedures receive the highest
priority. It is the goal of the Operating Room Complex to provide customer service
satisfaction, by incorporating a system for the efficient use of personnel, time and equipment
resources. Thus, the Operating Room Committee or Operating Room Management Team was
created to ensure coordinate and standardize care of patients undergoing surgical or other
invasive procedures. It is a committee of the medical staff. This Committee oversees clinical
practice related to Preoperative, intraoperative and Postoperative procedure care. It has the
authority to establish clinical procedure and policy within the Operating Rooms and
recommend policy related to those procedures outside of the Operating Room. It works
collaboratively with the quality improvement quality to monitor and improve care and ensure
patient safety.
2.1 COMPOSITION
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Members of the Operating Room Committee:

(a) The Chair of this Committee shall be a Physician from one of the surgical specialties or
subspecialties.
(b) Chairman or representatives of the specialty services (General Surgery, Orthopedics,
Obstetrics and Gynecology, Anesthesiology, Pediatrics, Medicine/Gastroenterology,
Pathology, and Radiology)
(c) OR nurse manager/supervisor – shares with the OR committee, hospital administration
and nursing service the responsibility for clarification, implementation and day-to-day
enforcement of approved policies and procedures.
(d) Representative from AHDHO
(e) Patient’s Safety Committee Chair
(f) OPD Ambulatory Representative
2.2 DUTIES
The Operating Room Committee or Operating Room Management Team (ORMAT) shall:
1. Serve as the policy-making and coordinating body on all matters pertaining to the OR
and PACU.
2. Formulate strategic and specific action plans in consultation and coordination with the
administration, nursing and medical staff.
3. Formulate policies and procedures pertaining to utilization of facilities, schedule of
surgical procedures and maintenance of a safe environment. Policies and associated
directives formulated and approved by the committee serve as guides for governing
the actions of surgeons, anesthesiologists and the Operating Room nursing staff while
in the OR suite.
4. Utilizes evidence-based medicine to recommend changes in the clinical practice.
5. Monitor medical staff compliance with operating room policies established for patient safety,
infection control, and smooth functioning of the operating rooms.
6. Develop and make recommendations to the medical staff administrative committee regarding
conduct of medical staff in the operating rooms.
7. Perform gap analysis, corrective actions and continuous improvement of the
Operating Room.
8. The operating room committee shall be a hospital committee and be appointed in accordance
with policies and procedures of the West Visayas State University Medical Center.
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2.3 MEETINGS & REPORTS
The Operating Room Committee shall meet every other month and submit reports to the
Medical Executive Committee on its activities.
3. SCOPE
This policy shall cover the operations of the Main Operating Room (MOR), the Out-Patient
Surgery Center/Ambulatory OR (OPSC), Perinatal Unit, and Post-Anesthesia Care Unit
(PACU).
The Policy Document includes the composition of the Operating Room Committee, infection
control within the complex, patient safety, and the processes that affect the patient flow at the
Operating Room Complex.
4. ACTIVITIES, PROCEDURES AND INTERVENTIONS
The West Visayas State University Medical Center manages a decentralized

Operating Room complex. The Obstetrics and Gynecology department does most
Cesarean deliveries at the Perinatal Unit and Out-Patient and ambulatory cases at the
Out-Patient Surgery Center. The administrative head of the OR and PACU is usually
a nurse.
The Operating Room Committee, is established to serve as the policy-making and

coordinating body on all matters pertaining to the OR and PACU. Only physicians
duly credentialed and accredited by the administration to perform procedures or
operations shall be allowed to use the facilities of the operating room.
4.1 General guidelines
4.1.1. All OR-PACU staff, personnel, doctors and students must be oriented with
the Policies and Procedures in the OR complex
4.1.2. Students must present themselves to the OR

Supervisor/Head Nurse before exposure to the area
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4.1.3. The Anesthesiologist only starts induction of patient once the surgeon is
already in the complex
4.1.4. One room is allotted for infectious cases such as: COVID-19, Chicken pox,
HIV and Mumps. This room is also reserved for stat cases.
4.1.5. The last cutting time shall be 4:00pm. A procedure done before 7:30 am and
after 4:00pm will be considered a stat case. Stat charges/rate will be imposed.
4.1.6. Informed Surgical Consent will be accomplished by the surgeon and

his/her designate, not by the Nurse, Nurses should only serve as witness.
4.1.7. Informed consent will be signed by able patients who are

4.1.7.1. of legal age (21 years old)
4.1.7.2. next of kin
4.1.7.3. Guardian, if patient is not of legal age.
4.1.7.4. Guidelines provided by Ethics Committee.
4.2.1 Scheduling
4.2.1. Schedule of elective cases Surgery for SERVICE CASES shall be:
4.2.1.1. Monday: General Surgery 7:30am-4:00pm
(Single Table)
4.2.1.2. Tuesday: OPTHA and ENT 7:30am-12:00pm
ORTHOPOEDICS 12:00pm-4:00pm
(Single Table)
4.2.1.3. Wednesday: OB-GYNE 7:30am-4:00pm
(Double Table)
4.2.1.4. Thursday: ORTHOPEDICS 7:30am-4:00pm
(Double Table)
4.2.1.5. Friday: General Surgery 7:30am-4:00pm
(Double Table)
4.2.1.6. Saturday: Out Patient Surgery 7:30am-12:00pm
Out Patient Orthopedics 12:00pm-4:00pm
4.2.2 Elective surgeries for PAY cases can be scheduled on any day from
Monday to Saturday from 7:30am – 4:00pm
4.2.3 First cases shall be always at 7:30 am, which is also the first cutting time. Last
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cutting is at 4:00pm
4.2.4 Booking of schedule for operations shall be done on first come, first served
basis. No cases shall be booked unless the patient has been admitted.
4.2.5 Cases not started within 30 minutes after scheduled time without any
communication from the surgeon and/or anesthesiologist shall be automatically
cancelled and may follow the available room after all elective cases. OR
charge nurse informs the Resident and the latter informs the surgeon/
anesthesiologist for any change of schedule
4.2.6 Surgeries are booked and scheduled by the Surgeon, Resident Physician and
ward nurses by calling up the OR charge nurse on duty or designate.
4.2.7 All bookings are registered in the OR schedule book stating the date and
time of operation, name and room of the patient, kind of operation, the
surgeon, anesthesiologist, the person booking the operation, the person
receiving the schedule and the date and time scheduled.
4.2.8 Floor nurses, surgeons, residents always inform the OR charge nurse for
any changes of room, time of surgery, cancellation or postponement of
surgery.
4.2.9 Charge nurse or designate receiving the notice of cancelled/postponed cases

notes
down the name of the person cancelling and/postponing the case; date and time
notice has been received and countersigns it. The charge nurse informs the
residents to facilitate “to follow” cases.
4.2.10 Patients scheduled for surgery must be admitted at least a day before the
scheduled day of surgery. Confirmation of schedule must be made upon
admission; otherwise, such operations shall be cancelled and the slot shall be
available to other cases. Patient must be admitted before booking of schedule.
4.2.11 Floor nurses should inform the OR charge nurse ahead of time for any pre-
operative orders indicated for the actual surgery such as intra-operative
cardiac
monitoring, frozen section, x-ray and should be indicated in the OR schedule.
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4.2.12 All procedure done in the OR such as dressing, casting, etc. should have an
OR
schedule slip.
4.2.13 Service cases are scheduled every Monday to Saturday following the first cutting
time at 7:30am and the last cutting time at 4:00pm, but gives way to
emergency/stat cases if necessary. Last cutting of 4:00 pm may not apply to
accommodate service elective case, if such case happens.
4.3 Patient Safety
4.3.1 Peri-Operative Care
4.3.1.1 All In and Out-Patients scheduled for Operative Procedures should have
Identification bands, which should be confirmed by the Circulating nurse
Through checking of ID bracelet and verbal affirmation of the patient.
4.3.1.2 Identification of sedated patients should be confirmed through checking of ID

bands and verbal affirmation of the Floor Nurse in Charge.
4.3.1.3 The nurse should be knowledgeable about the procedure to be performed in

order to anticipate the things to be prepared in the Operating Room theatre.
4.3.1.4 The nurse utilizes the preference kardex of surgeons and anesthesiologists in
preparing for the procedure and updates the preference kardex of surgeons
and anesthesiologists as needed.
4.3.2. Surgical Safety Checklist
4.3.2.1 The WVSU-MC Operating Room Complex surgical safety checklist form was adapted
from WHO SURGICAL SAFETY CHECKLIST first Edition.(2017 check new version)
4.3.2.2 Operating Room Complex WHO SURGICAL SAFETY CHECKLKIST should be

accomplished in every operation and must be attached in the patient’s chart.
4.3.2.3 . The Circulating nurse will be the checklist coordinator and will be responsible
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for filling in the surgical safety checklist sheet and for calling out the sign-in,
time out and sign out respectively
4.3.2.4. The surgical safety checklist sheet should include the patient’s name, age &
sex, date of birth, room number, name of the surgeon/s and anesthesiologist,
case number, date of the operation, name and signature of the circulating nurse
and the date and time of the start and end of the operation.
4.3.2.5. The surgical safety checklist sheet should be filled in accordingly before the
start of the operation for the patients’ data and along the course of the operation
as applicable.
4.4.3. Sharps, Sponges and Instrument Count
4.4.3.1. Control count must be done concurrently by the scrub nurse and circulating nurse
prior to the case and updated as each item is added to the field in each case.
4.4.3.2. Incorrect Count must exist when the number of items on the field does not
correspond to the number of items on the count sheet.
4.4.3.2.1. Notification of the attending surgeon, surgical team, charge nurse, head nurse
and supervisor.
4.4.3.2.2. Search of the surgical field, wound and floor. Linen and trash must be
searched using universal standard precautions. The entire operating room
team is responsible for assuring that a search is made to locate the object
4.4.3.2.2. If the above searches prove negative, an x-ray is to be taken of the wound
before the patient leaves the O.R. All extraneous equipment will be removed
from the field to assist the radiologist with the foreign body identification.
4.4.3.2.3. The X-ray will be interpreted by the Attending Surgeon and Radiologist. This
w ill be documented. X-ray charges must be charged to the hospital.
4.4.3.5. Sponges packed in a wound

4.4.3.5.1. If a wound is temporarily packed with a sponge, the surgeon is to
announce to the scrub and circulating nurse that a sponge is packed in
the wound and the number. The circulator will record this on the count
sheet. When the packing is removed from the wound, the surgeon will
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announce that it has been removed from the wound. The circulating
nurse will record the information and note the time.
4.4.3.5.2. If a patient is to be packed with sponges that will be left in place, it is to

be documented in the Nurse’s notes that the patient is leaving the O.R.
with the wound packed. Indicate the number and type of sponges in the
wound and the surgeon packing the wound. Notify receiving unit nurse
of the number and type of sponges retained.
4.4 Handling and Care of Surgical Specimens
4.4.1 The proper handling and care of specimens begins during the preoperative phase of
patient care and preparations including all communications should involve the
surgical team.
4.4.2 The surgical team should coordinate the information concerning the specimen(s) to
include:
4.4.2.1 Confirming the type of specimen, e.g. frozen section, aerobic or anaerobic
specimen to be placed in preservative.
4.4.2.2 Confirming with the surgeon other types of diagnostic studies to be performed,
including Gram stain, acid fast and mycological and etc.
4.4.2.3 Informing the Histopatology beforehand for any specimen for frozen section a
day before the surgery by the Floor Nurse. The O.R nurse makes the follow-up.
4.4.2.4 Anticipating the number of specimens and Identifying the type and size of needed
container(s) including whether the containers should be sterile or clean.
4.4.2.5 Identifying the need and type of preservative.
4.4.2.6 The surgical team should be aware of any cultural preferences of the patient
concerning the specimen, eg certain religions require an amputated body part to
be given to the patient. This information should be documented in the patient’s
chart.
4.4.2.7 Specimen from routine operating room procedures must be handled and
preserved properly to protect the specimen as well as to prevent self-
contamination before sending to the laboratory.
4.4.2.8 All specimens are forwarded by the assigned resident to the Laboratory,
Bacteriology and/or Histopathology.
4.5.3 Disposition of tissues and dismembered parts of the body: To coordinate with Waste
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Management Comm
4.5.3.1 All tissues, specimens, culture smears from the patient are to be forwarded to the
laboratory unless otherwise ordered by the surgeons.
4.5.3.2 All dismembered body part/s are disposed and endorsed
properly to the folks of the patient and are instructed
accordingly by the nurse in charge.
4.5.4 Preservation:
4.5.4.1 All specimens are to be preserved either in 10% formalin solution or normal
saline as indicated before
transporting to the histopathology section, unless ordered otherwise.
4.5.4.2 All specimens for culture and sensitivity, gram staining or for cytology are
sent immediately to the laboratory.
4.5.4.3 . A histopathological report must be accomplished before the specimen is
forwarded.
4.5.4.3 The documentation accompanying the specimen container
should be maintained in a manner that ensures patient confidentiality.
4.5.5 Identification
4.5.5.1 All specimen for examination should be properly labelled and entered into a
log book stating the following:
4.5.5.1.1 name and room number of patient

4.5.5.1.2 kind of specimen
4.5.5.1.3 date specimen was taken
4.5.5.1.4 name of surgeon/assist
4.5.5.1.5 name of scrub nurse/circulating nurse
4.5.6 For Frozen section
4.5.6.1 The Circulating nurse should confirm with the surgeon

preoperatively and intraoperatively that the specimen is designated for
frozen section.
4.5.6.2 The pathology department should be notified preoperatively of the
surgical procedure(s) in which a specimen for frozen section will be
transported to the department.
4.5.6.3. Specimens designated for frozen section should not be placed in a
preservative solution.
4.5.7 Non-routine specimen should be handled with extra care.

4.5.7.1Medico-legal specimen:
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4.5.7.1.1 The specimen is properly labeled by the Scrub Nurse/Circulating nurse who
endorses it to the Supervisor and/or Head Nurse or Designate for safe
keeping. The information contained in the label includes the following:
4.5.7.1.1.1 Name and age of the patient / Room number
4.5.7.1.1.2 Date of operation
4.5.7.1.1.3 Attending Surgeon /Surgeon’s Assist/ Anesthesiologist /Circulating
and ScrubNurse
4.5.7.1.1.4 Operative Procedure
4.5.7.1.1.5 Type of specimen
4.5.7.1.2 Pellet:
4.5.7.1.2.1 . Forceps should not be employed in removing a pellet from body as
it produces false striae. A pellet covered with blood should not be
washed or wiped. It should be placed on a piece of gauze or
specimen bottle in its original condition.
4.5.7.1.3 Medico-legal specimens can only be retrieved and claimed with all of the
following requirements:
4.5.7.1.3.1 Court Order
4.5.7.1.3.2 Written and signed order by the Attending Surgeon
4.5.7.1.3.3 Patient’s consent or nearest of kin
4.5.8 Intra-uterine Fetal Death – Neonatal Death:

4.5.8.1 As soon as the fetus is delivered, A Notice of Death form is accomplished in 3 forms,
as well as, Release of Body form (3 copies).
4.5.9 Amputated Extremity:
4.5.9.1 Amputated limbs shall be properly wrapped, labelled and documented before being sent
out of the operating room via the dirty corridor to the ward for appropriate disposal.
4.5.9.2 If amputated extremity is to be given to the patient’s significant others, the receiving
party is properly instructed and such release of specimen is recorded in the log book.
4.5.9.2 . Immediately placing the specimen into the container and labeling the container
reduces the risk of losing the specimen during clean-up of the O.R. Verbal
confirmation of patient and specimen information between the surgeon, scrub
nurse and circulating nurse and will aid in ensuring that the specimen has been
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retrieved, secured, and properly labeled.

4.5.9.3. It is properly labeled and brought to the laboratory, unless otherwise ordered.
4.5.9.4 A requisition form should accompany all specimens delivered to the pathology or
laboratory department.
4.5.9.5 A specimen log book should be used to record each specimen to include name of
specimen, name of patient, date, procedure, name of surgeon, purpose, name of staff
dispensing the specimen and the receiving person.
4.5 Infection Control

4.6.1Guidelines for Infection Control in the Operating Room Complex ( based on
Infection Control Policy)
4.6.1.1 The Operating Room functions to provide a controlled environment for the
performance of surgical procedures. Surgical wound infections are the
second most common healthcare associated infections and may involve
either the incision or adjacent structures. Most surgical wound infections
results from microbial contamination (endogenous or exogenous source) of
the wound during surgery. Operating Room procedures are designed to
provide the maximum reduction of exogenous microorganisms that could
contaminate the surgical wound. Personnel and their compliance with
surgically aseptic procedures are a critical component in the prevention of
surgical wound infections.
4.6.1.2 The guidelines were designed primarily against bacterial infections but the
recommendations also consider viruses and other microorganisms.
4.6.1.3 . The guidelines should consider safety of patients as well as the Operating
Room Personnel.
4.6.1.4 In implementing the guidelines, it should always be considered that the certain
patients and situations are at low risk for post-operative infections, while
others may be at high risks.
4.6.2 Pre-Operative preparation for the patient

4.6.2.1 Pre-operative shower
4.6.2.1.1 Should be done by all patients for elective surgery within 12 hours prior to
the operation
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4.6.2.1.2. Done before shaving and giving pre-op medications
4.6.2.1.3 Should be done in the supervision of the Floor Nurse, includes shampooing hair.
Preferably, antiseptic surgical skin cleanser should be used.
4.6.2.2 Shaving
4.6.2.2.1 Done immediately before the surgical procedure and preferably in the
OR theatre. The preferred method is clipping
4.6.2.3 Skin Drapes
4.6.2.3.1 Sterile Cotton fabric drapes should be used as a general rule
4.6.2.3.2 Use of disposable sterile drapes does not reduce infection rate
4.6.2.4 Skin preparation with in the Operating Room Complex
4.6.2.4.1 The area around and including the operative site should be washed with
an antimicrobial pre-operative skin preparation applied from the center
to the periphery to remove superficial flora, soil, and debris. This should
reduce the skin reservoir of microorganisms to sufficiently low levels.
The standard skin preparations may change with staff Surgeons’
preference.
4.6.2.4.2 Povidone Iodine, and/or chlorhexidine solutions are used as preparatory

solutions in the Operating Room.
4.6.2.5 Endotracheal Tubes and Anesthesia Conduits
4.6.2.5.1 Should be sterile and ET tubes should be inserted using aseptic technique.
4.6.2.6 Catheters and Tubes
4.6.2.6.1 Urethral catheters and open venous access lines should be done at the
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operating room.
4.6.2.6.2 Must be done using aseptic technique
4.6.2.7 Miscellaneous
4.6.2.7.1 Fingernails should be kept short and free of nail polish.
4.6.2.7.2 OR personnel with active skin lesions or upper respiratory tract infections
should not participate in the operative procedure.
4.6.2.7.3 The number of OR personnel allowed in the personnel allowed in the OR

must preferably be limited to those whose presence is necessary for the
proper conduct of the surgical procedure.
4.6.2.7.4 No cell phones, bags, jewelries are allowed in the Operating Room
Theatre. These are kept inside locked cabinets provided in the quarters.
4.6.2.7.5 No food is allowed inside any Restricted Operating Room environment.
The only designated areas for eating are the Male and Female Doctor’s
Lounge and at the area where the Refrigerator for food are.
4.6.3 THE OPERATING ROOM PERSONNEL
4.6.3.1 Must be familiar with and adhere to the policies set forth in the Infection Control
Manual
4.6.3.2 . Must report promptly any suspected or confirmed infectious diseases and
conditions, occupational injury or infectious exposures.
4.6.3.3 Must be free from active infection
4.6.3.4 Must report promptly any suspected or confirmed infectious diseases and
conditions, occupational injury or infectious exposures.
4.6.3.4 . Must adhere to good hygiene practices, such as daily bathing and wearing a
clean scrub uniform daily.
4.6.3.5 Must follow Hospital’s Policy on “STANDARD PRECAUTION” for protection
against blood borne pathogens.
4.6.3.6 Must report any Needle stick Injuries or splash incidents and mucous membrane
to the infection control nurse
4.6.4 FOR AFFILIATE MEDICAL AND NURSING STUDENTS AND VISITORS
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4.6.4.1 Observation of surgical procedures for medical education purposes is an integral

part of a teaching institution.
4.6.4.2 Visiting surgeons, hospital staff, nursing and medical students and product
representatives may receive authorization for observation/ participation on a case
to case basis. Requests are submitted by the requesting party to the Operating
Room Committee Chairman and Hospital Administrator or designate not later
than 24 hours in advance.
4.6.4.3 All requests approved must also have the approval of the Anesthesiologist
and Surgeon.
4.6.4.4 It is the requesting party’s responsibility to inform the patient of the observing
personnel and a written signed consent is obtained and filed in the patient’s chart.
4.6.5 OR PERSONNEL ATTIRE
4.6.5.1 All Operating Room Personnel should wear the prescribed attire at all times within
the Operating Room. These consist of:
4.6.5.1.1 Clean Scrub Suits – preferably “pants style suit”
4.6.5.1.2 Operating Room Cap should be worn to fully cover the hair at all times
4.6.5.1.3 Surgical Masks should always cover the mouth and the nasal openings.
4.6.5.1.4 Clean Operating Room Shoes (Covered footwear) or shoe covers which are washed
every night.
4.6.5.2 All personnel entering the restricted areas of the Operating Room will be attired in
Operating Room scrub suit attire. No one in street clothes will be permitted in the suite at
any time. Wearing of street clothes underneath the scrub suit is not allowed.
4.6.5.3 All attire will be fresh each day and changed if it becomes wet or soiled.
4.6.5.4 OR personnel should change out of the prescribed OR attire before going out of the OR.
4.6.5.3 Shoe covers are worn when gross contamination is anticipated.
4.6.5.3 Masks will be worn at all times in the operating rooms and sub-sterile. Masks must fully
cover the mouth and nose and be worn if sterile instruments are exposed, or if an
operation is about to begin or underway. Masks will be changed each shift and not worn
dangling around the neck.
4.6.6 HAND SCRUBBING
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4.6.6.1 The hands of the members of the Surgical Team are a potential reservoir for
microorganisms for surgical site infections, but the pre-operative scrub of the hands
combined with the use of surgical gloves, minimizes the hands as a potential reservoir.
4.6.6.2 Equipment: Nail cleaner, sterile brush, antimicrobial hand scrub solution.
4.6.7 GOWNING AND GLOVING
4.6.7.1 Proper gowning and gloving techniques shall be observed by all OR personnel. The
practice of Closed Gloving Technique should be encouraged.
4.6.7.2 Punctured OR gloves are to be replaced as soon as detected.
4.6.7.3 Double gloving by OR personnel is recommended for procedures on proven HIV or HBV
carriers, patients and personnel.
4.6.8 OPERATIVE PROCEDURE

4.6.8.1 The Surgical Team must undertake the necessary measures to ensure that the operation is
performed expeditiously and within the acceptable duration.
4.6.8.2 Strict observation of proper surgical technique (asepsis, homeostasis, avoidance of

tension and dead space, gentle handling of tissue, judicious use of drapes and proper
use of electro coagulation) must be ensured by the surgical team.
4.6.8.3 Drapes are used to establish a sterile field and as barriers to prevent microorganisms
outside the operative area from entering a wound.
4.6.8.4 Disposable surgical drapes are used for infectious cases.
4.6.8.5 Linens are received, inspected and processed.
4.6.9 OPERATING ROOM ENVIRONMENT

4.6.9.1 The care of the patient during surgery requires movement of patients, personnel, and
material within the surgical suite. Planning and controlling these movements assist in the
containment of contamination. Only authorized personnel are allowed in the restricted
areas. “Authorized” personnel are those assigned to Surgical Services to include:
4.6.9.1.1 Perioperative Nurses and Surgical Technicians

4.6.9.1.2 Anesthesiologists
4.6.9.1.3 Surgeons, Residents, and Medical and Nursing Students.
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4.6.9.2 Traffic control is aided by a three-zone concept:
4.6.9.2.1 Unrestricted areas which include the reception area, locker rooms, lounges,
pantry and offices.
4.6.9.2.2 Semi-restricted areas which includes the storage areas for clean and sterile
supplies, work areas for storage and processing of instrument and corridors to
restricted areas of the suites. Traffic is limited to authorized personnel and
patients. Personnel are required to wear gown and hair covering. The Holding,
central supply room, and Autoclave Areas are considered semi-restricted support
areas. Outside clothes may be worn in these areas, but persons entering these
areas are kept to a minimum.
4.6.9.2.3 Restricted areas include the rooms in which the surgical procedures are
performed and the corridors to these rooms. Proper surgical scrub attire and
name identification
are mandatory in the restricted areas.
4.6.9.3 Unnecessary traffic is not permitted. All doors must be kept closed except as needed for
passage of equipment, personnel, and patients.
4.6.9.4 Design and Traffic Patterns:

4.6.9.4.1 Entry into the locker/ change area precedes entry into the surgical lounge.
4.6.9.4.2 Inner cartons and packages should be removed from outer cartons before
materials are distributed to storage areas.
4.6.9.4.3 Patients transported to the OR via ward stretchers are transferred to OR
stretchers.
4.6.9.4.4 Beds, carts, machines, equipment and other apparatus that came from outside
should be cleaned with damp cloth soaked with an appropriate disinfecting agent
prior to bringing them inside the Operating Room.
4.6.9.4.5 Movement of personnel in and out of the Operating Room is kept to an
absolute minimum while surgery is in progress.
4.6.9.4.6. Doors to the Operating Room are closed except when personnel are entering or
exiting.
4.6.9.4.7. Traffic control practices should be only modified during emergencies.
4.6.9.4.8. Use of an air-conditioning unit in the OR is desirable. If windows need to be
opened, windows should not open directly or adjacent to hospital corridors.
4.6.9.4.9. Floor stretchers should NOT be used in transporting the patient to the Operating
Room.
4.6.10 For Infectious Cases
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4.6.10.1. Operating Room 2 is allotted for Infectious Cases such as:

4.6.10.1.1. Chicken pox, Measles, Herpes zoster
4.6.10.1.2 HIV
4.6.10.1.3 Mumps
4.6.10.2 Patients with Tetanus/Rabies case are done in the private room (done at bedside).
4.6.10.3. Post-operatively, patients of infectious cases are transferred to ICU ISOL, if not, to a
private room with a private duty nurse/back to wards if service. The transfer is arranged
beforehand between the Floor Nurse and the Floor Supervisor, if an elective case; and,
between the O.R Charge Nurse and Floor Supervisor for stat or emergency cases.
4.6.11 PATIENT CLASSIFICATION

4.6.11.1 Contaminated (INFECTIOUS) or dirty cases are done in Operating Room 2 and
should be done as last case of the day.
4.6.11.2 In cases of emergency surgery, adjustments are made.
4.6.11 .3 Only PTB cases treated for 2weeks can be admitted at OR for elective surgery.
For PTB patients:
4.6.11.3.1. Clinically diagnosed cases – both negative for direct sputum smear
microscopy (DSSM) and Gene expert test, may be admitted for elective
surgery 5 days of daily treatment.
4.6.11.3.2 Bacteriology confirmed cases – DSSM positive and/or Gene expert
positive, may be admitted for elective surgery once repeat DSSM results
convert to negative (after treatment duration of 2 weeks or more.
4.6.11.3.3. Clearance from attending physician or from the TB DOTS physician is
also encouraged prior to schedule of surgery in newly diagnosed PTB
cases
4.6.11.3.4. Procedures should be scheduled for patients with suspected or
confirmed TB disease when a minimum number of HCWs and other
patients are present in the surgical suite, and at the end of the day to
maximize the time available for removal of contamination.
4.6.11.3.5. An N95 disposable respirator should be used by HCW when dealing

with infectious or potentially infectious TB patient in Operating Room
complex.
4.6.11.4. All infectious cases such as mumps/measles, varicella, untreated PTB for
stat/emergency major surgeries are done at Room 2.
4.6.11.5 Cases of Rabies and Tetanus are done at bedside.
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4.6.11.6 In cases of intra-operative detection of infectious cases, terminal cleaning of the

Operating Room and disinfection time is given at least two hours.
4.6.11.7. The Operating Room Team must be informed by the floor nurses of the patient’s
condition if it’s an infectious case. The floor Nurse informs the Operating Room
Team of the patient’s condition, whether the patient is an infectious or non-
infectious case.
4.6.11.8.When infectious cases are detected only at the receiving area upon transferring in
the Operating Room, the procedure is rescheduled as last case and significant members
of the team are well informed.
4.6.11.9. Patients with communicable infections are not admitted at the Post Anesthesia Care
Unit. A private single room with Private duty Nurse is arranged with the Floor Nurse
Supervisor on Duty prior to scheduling. For service cases, patients will be placed in a
designated isolation area in the wards.
4.6.12 SANITATION
4.6.12.1. Prior to the first scheduled procedure of the day, all horizontal surfaces,
Including furniture, counter tops equipment and surgical lights should be damp-
dusted with a detergent germicide and disinfectant.
4.6.12 2. During surgical procedures, contamination should be confined and contained
around the sterile field.
4.6.12.3. At the conclusion of the surgical procedures, proper disposal of all materials
should be done. All used linens and wastes properly segregated and contained in
an appropriately identified bags inside the Operating Room theaters before being
brought to the Material Recovery Facility (MRF).
4.6.12 4. The end-of-the-case clean up or routine-case–clean up should be performed after
each procedure.
4.6.12 5. Daily Terminal Cleaning is done during the night shift.
4.6.12 6. At the completion of the day’s schedule, all operating rooms, corridors, scrub and
sub-sterile utility areas should be terminally cleaned using chemical disinfectants
and mechanical friction. All wheels of stretchers, machines and tables are cleaned
as well.
4.6.13 HANDLING OF INFECTIOUS WASTES, LINENS AND SHARPS
4.6.13.1. Infectious wastes and all potentially contaminated, disposable items are disposable
in accordance with the hospital policy.
4.6.13.2. Soiled linen will be placed in an impervious linen bag of sufficient quality to
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contain used/soiled linen.

4.6.13.3. Needles, syringes and sharps are to be disposed of uncapped into puncture-resistant
sharp containers. Be careful to avoid injury. Sharps used during a surgical
procedure are placed on a needle pad at the back table and discarded at the end of
the procedure in appropriate sharp containers.
4.6.14 EMPLOYEE’S HEALTH
4.6.14 1. Personnel working in the Operating Room shall be free from active infections.
4.6.14 2. Individuals exhibiting signs and symptoms of an infection must report immediately to
their Supervisor. The Supervisor will refer them to the Occupational Health for
evaluation and work duty status.
4.6.14 3. All personnel suspected of having communicable infections shall be excluded from
working in the Operating Room until they have been cleared by Occupational Health.
4.6.14 4. An employee who feels he/ she has been exposed to a communicable disease or
occupational exposure (i.e. needle stick or sharps injury) must report immediately to his/
her Supervisor who will send the employee to the Infection Control Committee. If the
exposure occurred in the afternoon, nights or weekends and holidays, the individual will
be evaluated in the Emergency Room, by the Nurse Supervisor on Duty, but must report
to the Infection control Nurse the next working day.
5.0 Definitions Of Terms
5.1 Scheduling
5.1.1 Elective surgery
5.1.1.1 Patients who require surgery within an elective time frame.
5.1.2. Emergency / Stat surgery:

5.1.2.1. Patients who require surgery within 2 hours or less.
5.1.2.2. Cases before 730am and after 4pm, Monday to Saturday and anytime
during Sundays and Holidays.
5.1.3. OR Emergency
5.1.3.1 Level 1: Emergency: Life-threatening condition. Done in next available room.
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5.1.3.2. Level 2: Emergency: Priority Status. Patient’s condition will deteriorate

significantly if not done urgently.
5.1.3.3 Level 3: Emergency: Cases that cannot wait until the next day’s elective
schedule.
5.1.4. Classification of Cases:
5.1.4.1. CLEAN: Elective, primarily closed and undrained non traumatic, uninfected, No
inflammation encountered, No break in asepsis, Respiratory, Alimentary,
Genitourinary or Oropharyngeal not entered.
5.1.4.2. DIRTY CASES: Traumatic wound and retained devitalized tissue, foreign body
fecal contamination, delayed treatment or from a dirty source Perforated visus
encountered Acute bacterial inflammation with pus encountered during
operation.
(Source: Principles of Surgery by Seymonn Schwantz, Table 5-4, p. 152)
5.2 Patient Safety
5.2.1 WHO Safety Checklist

5 2.1.1 “Sign in” - the period before induction of anaesthesia
5.2.1.2. “Time Out” - “surgical pause”; the period after induction and
before surgical incision
5.2.1.3. “Sign Out” - the period during or immediately after wound closure
but before removing the patient from the operating room.
5.2.2 PERI-OPERATIVE CARE

5.2.2.1 Pre-operative phase -begins when the patient is scheduled for surgery and
ends at the time of induction of anesthesia
5.2.2.2. Intra-operative Phase – begins during induction of anesthesia
and ends upon closure of the skin.
5.2.2.3.Post operative Phase – begins after closure of skin/extubation and ends at
the time the patient is transferred back to room/ward.
5.2.2.4 Types of Anesthesia:

5.2.2.4.1 General- reversible, unconscious state, analgesia, depression of
reflexes, muscle relaxation, and manipulation of physiological
systems and functions.
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5.2.2.4.2 Regional- a local anesthetic is used to block or anesthetize a

nerve or nerve fibers
5.2.2.4.3 Spinal- medication injected into column through a needle then
withdrawn. One time dose only. Lasts for several hours. Keep
head level after spinal to prevent headache.
5.2.2.4.4 Epidural - the space is the area between the dura and the
ligamentum flavum, a space occupied by fat and veins. A
catheter is inserted for periodic or continuous injection. No
spinal headache because the column is not entered.
5.3 Infection Control (based on Infection Control Policy)
5.3.1 Standard Precautions – are designed to reduce the risk of transmission of micro-
organism from both recognized and unrecognized sources of infection in the
Operating room. It applies to all patients regardless of their diagnosis.
5.3.2 Transmission Based Precautions – These precautions apply to selected patients, based on a
suspected or confirmed clinical syndrome, a specific diagnosis, or colonization or infection with
epidemiologically important organisms. These precautions are to be implemented in conjunction
with standard precautions. Three types of transmission –based precautions have been
developed ; Airborne, Droplet, and Contact. Few diseases (e.g. Varicella, Influenza) may require
more than one isolation category.
5.3.2.1 AIRBORNE Precautions – Desigend to prevent the transmission of disease by

droplet nuclei (particles <5um) or dust particles containing the infectious agent. These aprticles
can reamin suspended in the air and travel long distances. Airborne precautions are indicated for
patients with documented or suspected tuberculosis (pulmonary or laryngeal), measles, varicella,
or disseminated zoster.
5.3.2.2 DROPLET Precautions- Designed to prevent the transmission of diseases by large

particle (droplet)(particles > 5um) or dust particles containing the infectious agent. Unlike
droplet nuclei, droplets are larger , do not remain suspendedin the air, and do not travel long
distances. They are produced when the infected patient talks, coughs, or sneezes, and during
some procedures(e.g. suctioning and bronchoscopy). A susceptible host may become infected if
the infectious droplets land on the mucosal surfaces of the nose, mouth, or eye. Diphtheria,
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pertussis, influenza viruses, meningococcal and other respiratory infections are transmitted by
Droplets.
5.3.2.3 CONTACT Precautions – used to prevent the transmission of epidemiologically

important organisms from an infected or colonized patient through direct (touching the patient)
or indirect (touching contaminated objects or surfaces in the patient’s environment) contact.
Multiple drug resistant organisms (MDROs), Methicillin Resistant Staphylococcus Aureus
(MRSA) are important pathogens transmitted by contact contamination.
5.3.2.4 Personal Protetive Equipment (PPE) – A variety of barriers used alone or in

combination to protect mucous membranes, skin and clothing from contact with infectious
agents. PPE includes gloves, masks, respirators, googles, face shields, and gowns.
5.3.2.5 MDROs : refers to multidrug resistant organisms, eg. MRSA (methicillin-resistant

Staph aureus), VRE (vancomycin-resistant Enterococci), and CRE (carbapenem-resistant
Enterocateriaceae, Carbapenem Resistant Acinetobacter baumanii, etc.)
5.3.2.6 Terminal Cleaning – is defined as:”a procedure required to ensure that an area has been
cleaned/decontaminated following discharge of patient with an infection in order to ensure a safe
environment for all.
6. Procedures
6.1 OR Complex Procedures
6.1.1 Surgical Counting in the Operating Room (WVSU-MC OR –PO1)
6.1.2 Procedure on Care of Surgical Specimen in the Operating Room (WVSU-MC-PO2)
6.1.3 Receiving of Admitted Patients for Operation in the Operating Room (WVSU-MC OR-PO3)
6.1.4 Disinfection of Operating Room after Operation (WVSU-MC OR –PO5)
6.1.5 Procedure on Transporting Post-Operative Patient to the Post Anesthetic Care Unit,
Ward/Floors and Surgical Intensive Care Unit (WVSU-MC OR –PO7)
6.1.6 Foley catheter insertion in the Operating room complex (WVSU-MC OR –PO8)
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6.1.7 Procedure on Blood Transfusion in the Operating Room (WVSU-MC OR –PO9)
6.1.8 Procedure on Preoperative Preparation for General, Ears, Nose, Throat and Neuro
Surgery (WVSU-MC OR –P10)
6.1.9 Procedure on Preoperative Preparation for Laparoscopic Surgery (WVSU-MC OR –P11)
6.1.10 Procedure on Care Medico-Legal Specimen in the Operating Room (WVSU-MC OR –P12)
6.1.11 Garbage Disposal and Waste Segregation of Used Articles in the Operating Room
(WVSU-MC OR –P13)
6.1.12 Preparation of Surgical Ariticles for Packing, Wrapping and Sterlization (WVSU-MC OR
PO14)
6.11.13 Receiving of OPD Patients in the OR (WVSU-MC OR-P15)
6.11.14 Leasing and Releasing OF Supplies at Central Supply and Sterilization

Department (WVSU-MC OR-P16)
6.11.15 Releasing of Cadaver from the Operating Room (WVSU-MC OR-P17)
6.2 Nursing
6.2.1 Preparing Patient for Operating Room (OR) Procedure (WVSU-MC NSO-PO1)
6.2.2 Care of Post –Operative Patient (WVSU-MC NSO-PO6)
6.2.3 Document (FDAR) (WVSU-MC NSO-P12)
6.2.4 Reporting Adverse Drug Reactions to Blood Transfusion (WVSU-MC NSO-P13)
6.2.5 Reporting of Adverse Drug Reaction (WVSU-MC NSO-P124)
6.2.6 Blood Transfusion (WVSU-MC NSO-P15)
6.3 OPD
6.3.1 Admision of Patients at the Out-Patient (WVSU-MC OPD-PO1)

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6.3.2 Minor Operations and Diagnostic Procedures of OPD Patients to be done at the Operating
Room Complex (WVSU-MC OPD-PO3)
6.4 INFECTION CONTROL COMMITTEE ( Based on Infection Control Policy)
6.4.1 Standard Precautions

6.4.1.1 Hand Hygeiene
6.4.1.2 Use of Personal Protective Equipment
6.4.1.3 Patient Placement
6.4.1.4 Equipmemt/Supplies
6.4.1.5 Visitor Policy for Infection Control
6.4.1.6 Cleaning
6.4.1.7 Linen
6.4.1.8 Waste Management
6.4.1.9 Management of Spills
6.4.1.10 Needles and Other Sharps
6.4.2 Transmission Based Precautions

6.4.2.1 Airborne Precautions
6.4.2.2Droplet Precautions
6.4.2.3 Contact Precautions
7. Monitoring
Measurable Monitoring/ Frequency of Responsibility Monitoring
Policy Audit method Monitoring for Performing reported to which
Objective the monitoring groups/committees,
inc responsibility
for reviewing
action plans
Compliance to Observation, monthly OR OR Complex
approved rounds and supervisor/OR Committee
policies and feedback, managers
procedures meeting OR staff Assistant Directors
and personnel
Medical Center
Chief
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OR Complex Feedback during Annual OR Complex OR Complex

Policy review OR committee Committee Committee
meeting
Assistant Directors
Medical Center
Chief
8. Statement of Relationship to Existing Policies

8.1This policy will work in consonance with other policies of WVSU Medical Center.
9. Dissemination
9.1 A copy of this policy will be submitted to Quality Assurance Committee for review
and approval. Once approved, copies of this policy will be distributed to the different
units and departments.
9.1.1 The heads of Units and Departments are responsible to ensure that this
policies are available at all times.
9.1.2 Orientation of the policy will be given to all units and departments personnel
involve in Operating Room complex services.
5. ROLES AND RESPONSIBILITIES
5.1 Membership of the OR Committee

5.1.1 Committee Chair
5.1.2 Representative of the Hospital Administration/Health Operations Division as Co-
Chair
5.1.3 Representatives of all cutting specialties in the hospital
5.1.4 Representative of the Department of Anesthesiology
5.1.5 Representative of the Perinatal Operating Room
5.1.6 Representative of the Out-Patient Surgery Center/Ambulatory OR
5.1.7 Representative of the Hospital Infection Prevention and Control Office
5.1.8 OR Nurse Supervisor
5.1.8 OR Coordinator/Manager
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5.2 Operating Room Committee
The Operating Room Committee (ORC) is a committee of the medical staff. It is an

interdisciplinary committee tasked to coordinate and standardize the care of patients
undergoing surgical or other invasive procedures in the operating rooms of the
Medical Center. This Committee oversees clinical practice related to preoperative,
intraoperative and postoperative care of patients undergoing surgical procedures. It is
mandated to establish clinical procedures and policies within the Operating Rooms
and recommend policies related to those procedures outside of the Operating Room.
The committee works collaboratively with Quality Assurance and Patient Safety
Committee to monitor and improve care and ensure patient safety within the Medical
Center. The specific areas of care of the Committee include the Main Operating
Room (MOR), Post Anesthesia Care Unit (PACU), Perinatal Unit, and the Outpatient
Surgery Center/ Ambulatory OR (OPSC). Likewise, the Committee must work and
coordinate with the Chairpersons of the Clinical Departments and Hospital
Administration to ensure that personnel (Interns, Clinical Clerks, Student Nurses,
Nurses and support services team members) working in the surgical environment
(PACU, PU, MOR, and OPSC) are held accountable to the policies and procedures of
the surgical environment.
5.2.1 Responsibilities and Duties
The Operating Room Committee has the following duties and responsibilities:
5.2.1.1 Responsible for ensuring professional practice and administrative activities within
the Operating Room Complexes of the Medical Center.
5.2.1.2 Maintain continuing evaluation of the professional performance of all members of
the medical staff engaged in the Operating Rooms.
5.2.1.3 Serve as liaison/representatives between the medical staff and hospital
administration.
5.2.1.4 Formulate policies and procedures pertaining to utilization of facilities, schedule of
surgical procedures and maintenance of a safe environment. Policies and associated
directives formulated and approved by the committee serve as guides for governing
the actions of surgeons, anesthesiologists and the Operating Room nursing staff while
in the OR complex.
5.2.1.5 Utilizes evidence-based medicine to recommend changes in the clinical practice.
5.2.1.6 Recommends policy and procedures that are specific to the Operating Room.
5.2.1.7 Provides institutional oversight and direction for staff and faculty education related
to operative and invasive procedures and care of the surgical patient.
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5.2.1.8 Ensures an effective process for patient and family education related to surgical care
and informed consent.
5.2.1.9 Works collaboratively with the quality assurance office to monitor and improve care
and ensure patient safety.
5.2.1.10 Monitors adherence to policies and procedures established for patient safety,
infection control, and smooth and efficient functioning of the operating rooms.
5.2.1.11 Recommends corrective measures to the hospital administration for efficient
functioning within the OR complex.
5.2.1.12 Reviews budgets allocated to the Operating Room and make recommendations on
capital expenditure and personnel.
5.2.1.13 Oversees the equitable distribution of resources, including OR time, within the
operative areas to meet the needs of surgical patients with a focus on: patient safety,
quality of care, patient satisfaction and fiscal responsibility.
5.2.1.14 Monitors the Operating Room operational efficiency and costs associated with OR
operations and addresses problems affecting effectivity of delivery of service.
5.2.1.15 Oversees the operation of the Out-Patient Surgery Center, Perinatal Operating Room,
and Post-Anesthesia Care Unit (PACU).
5.2.1.16 Keeps written records of actions taken, and results of the related actions, and ensure
that they are available to committee members, the Assistant Hospital Director for
Health Operations, the Medical Center Chief, or the Vice-President for Medical and
Allied Sciences.
5.2.1.17 May establish clinical procedures within the Medical Center Operating Rooms, and
recommend policies related to these procedures outside the Operating Room.
5.2.1.18 Ensure that each member of the hospital staff shall conform to the policies
established by the OR Committee.
5.2.2 The Operating Room Management Team Chairman

5.2.2.1 Shall have a term of 2 years, and may be renewed for another term.
5.2.2.2 Responsible for monitoring the compliance to policies and procedures within the
surgical environment.
5.2.2.3 Work closely with the Department Chairpersons and Hospital Administration
to ensure that personnel working within the surgical environment are held
accountable to the policies and procedures of the surgical environment.
5.2.2.4 May create sub-committees and appoint its chairman.
5.2.3 The Operating Room Management Team Members

5.2.3.1 Shall have a term of 2 years, and maybe renewed for another term.
5.2.3.2 Shall work together with the Chairman in the formulation of policies and procedures
applicable to the units in the surgical environment.
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5.2.3.3 Shall assist the Chairman in monitoring the compliance to policies and procedures
within the surgical environment.
5.2.3.4 Shall head the sub-committees that maybe created.
5.2.4 The OR Supervisor

5.2.4.1 Shall act as the secretary and be responsible for keeping the records of meetings
and proceedings of the committee.
5.2.4.2 Shall work closely with the Chairman and members of the committee and
sub-committees.
5..2.5 The Operating Room Nurse Manager

5.2.5.1 Shall be responsible for implementing the policy to ensure professional practice and
activities within the Operating Room Complexes of the Medical Center.
5.2.5.2 Responsible for continual evaluation of the professional performance of all members
of the medical staff engaged in the Operating Rooms.
5.2.5.3 Serve as liaison between the OR Management Team and OR staff.
5.2.5.4 Enforces policies and procedures pertaining to utilization of facilities, schedule of
surgical procedures and maintenance of a safe environment.
5.2.5.5 Administers policies and associated directives formulated and approved by the
committee as guides for governing the actions of surgeons, anesthesiologists and the
Operating Room nursing staff while in the OR complex.
5.2.5.6 Recommends policy creation and procedure modifications that would result in the
efficient service delivery of the Operating Room.
5.2.5.7 Responsible for monitoring the adherence to policies and procedures established for
patient safety, infection control, and smooth and efficient functioning of the operating
rooms
5.3 Surgeon
3.3.1 Surgeons are medical doctors with additional training to perform general or specialized
types of surgeries. While surgeons spend time preparing for procedures, reviewing files
and meeting with patients, their most critical role is to perform accurately and efficiently in
the operating room.

5.3.5 During a procedure, the surgeon carries out the steps outlined with the patient in
pre-surgery appointments. Specific actions vary based on the type of surgery, but
the surgeon typically uses standard equipment and tools to perform operations.
These include scalpels, scissors and clamps. The surgeon also relies on the team
to assist during the procedure. In this role, the surgeon communicates his/her
equipment and tool needs as well as adjustments to oxygen and IV levels
throughout the procedure. In addition, the surgeon is responsible for quickly
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identifying problems and working to correct them during the procedure.
5.4 Anesthesiologist
5.4.5 An anesthesiologist is a medical doctor who keeps a patient comfortable, safe

and pain-free during surgery by administering local or general anesthetic. Once
the patient enters the operating room, an anesthesiologist will be by their side
throughout the surgery, making sure they are stable right through to the post-
anesthesia care unit.
5.4.6 During the surgery, the anesthesiologist will monitor the patient's blood pressure,
heart rhythm, temperature, level of consciousness, and amount of oxygen in the
blood. For a general anesthetic, the anesthesiologist will monitor each breath.
This is done by measuring the volume of breath exhaled and the amount of
carbon dioxide in each breath. They may also measure the amount of blood the
heart is pumping and blood pressure inside the lung vessels.
5.4.7 Some of the anesthesiologist’s duties during surgery include: continuous

monitoring of vital signs; monitoring of the levels and depth of anesthesia;
making adjustments if necessary; recognition of any potentially life threatening
emergencies and timely intervention; ensuring the safety of the patient and
taking appropriate steps to avoid any injuries to the patient’s body during the
anesthetic period.
5.5 Residents
5.5.5 A Resident Physician is a medical school graduate who is participating and
training in a specialized area of medicine. Residents, as they are more commonly called, have
a dual role in the health care system in that they are simultaneously learners and medical care
providers.
5.5.6 Participating in a program of graduate medical education and training in a specialized

area of medicine; Acts as both a student and a health care provider; Works in concert with
other members of the health care team to provide direct medical care to patients; Diagnoses
patients’ medical problems and devises appropriate management and treatment plans;
Perform surgeries if appropriate to medical specialty and level of training; Typically first
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interacts with newly admitted patients either in the Emergency Department, on the ward, in a
special care unit, or in an operating room.
5.6 OR Supervisor
5.6.5 Supervises and coordinates activities of personnel in the operating room. Ensures
adherence to procedure and schedule. Supervises the procurement and maintenance of
equipment and supplies, staffing and training of employees, and budgeting. Oversees
pre- and post-operative care of patients.
5.6.6 Reports to the head of a Department/Top management. Supervises a group of primarily

para-professional level staffs. Makes day-to-day decisions within or for a group/small
department. Has some authority for personnel actions. Thorough knowledge of
department processes.
5.7 OR Headnurse /Manager
5.7.5 Directs nursing service activities for assigned patients in the operating room. Delegates
responsibilities to auxiliary and operating room staff nurses. Supervises preparation and
maintenance of patient clinical records and writes reports on operating room staff
performance and services rendered. Maintains pre-set inventory standards for solutions,
supplies, medicines, equipment and keeps track of anesthesia/narcotic drugs.
5.7.6 Reports to OR Supervisor or Head of a department. Manages subordinate staff in the

day-to-day performance of their jobs. Ensures that project/department milestones/goals
are met and adhering to approved budgets. Has full authority for personnel actions.
Extensive knowledge of department processes.
5.8 Charge Nurse
5.8.5 The charge nurse is responsible for the day-to-day smooth running of OR
activities. She/he must coordinate activities in conjunction with the trauma
resuscitation unit, general hospital units, and the post anesthesia care unit.
Besides managing the personnel under his/her supervision, some of his/her other
activities included staff education, competency testing, scheduling, and other
administrative duties such as budgeting.
5.8.6 The charge nurse coordinates patient flow from other hospital units into the
operating room. This includes ensuring that the patient is ready for surgery,
surgeon is available to perform the surgery and the operating room is cleaned,
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and prepared with the appropriate equipment for the planned surgery, and a
competent operating room staff is assigned.
5.9 Circulating Nurse

5.9.5 Before a surgical procedure gets under way, the circulating nurse is responsible for
ensuring that the OR is set up correctly. This includes checking its inventory of
disposables, such as pads and sponges, and sterile instruments. The circulating nurse
also checks all equipment needed before the procedure to verify that it is functional.
When the patient arrives, the circulating nurse verifies the patient's identity and
necessary consent forms and then reviews the site and nature of the procedure with the
surgeon.
5.9.6 The circulating nurse and other members of the surgical team position the patient
correctly on the operating table. The circulating nurse hooks up any necessary suction
and cauterization equipment and assists the anesthesiologist during anesthesia
procedure. During the operation, the circulating nurse provides the surgical team with
sterile fluids and medications as needed and also replenishes the surgical team's supplies
if they need additional disposables or instruments. Each member of the surgical team
has specific personal responsibilities, and maintaining big-picture oversight of the
patient's condition is the circulating nurse's responsibility.
5.10 Scrub Nurse

5.10.5 Works directly with the surgeon within the sterile field by passing instruments, sponges,
and other items needed during the surgical procedure.
5.10.6 During surgery, the scrub nurse assists the surgeon by passing instruments -- such as
scalpels and retractors -- or supplies -- such as pads and sponges -- to the surgeon. This
is more demanding than it sounds. The nurse must be knowledgeable enough to follow
the progress of the procedure and anticipate the surgeon's needs, having the correct
items available immediately when requested. The scrub nurse also maintains a count of
pads and sponges used in the procedure, and verifies that the correct number are also
removed from the patient. When necessary, the scrub nurse requests additional
instruments or supplies from the circulating team members.
5.11 Floor Nurse

3.11.1 They perform a variety of duties and prepares
the client before the scheduled operation.
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3.11.2 Ward nurses are responsible for the basic care of patients. This includes setting up IVs,
giving pre-op medication, informing the patient of his condition and diagnosis, and
providing emotional support through conversation and patient interaction. Nurses also
maintain and update patient medical records.
5.12 Nursing Aide
3.12.1 Nursing Aides cleans & makes the operating table, removes clean & clinical waste
products - used linen, suction canisters & general waste- and mops the floor as required.
Terminal weekly and monthly environmental cleaning is completed as per schedule.
Assists with linen ordering & restocking. Maintains positioning equipment & assists
with procedural equipment maintenance.
3.12.2 Nursing Aides role encompasses cleaning and maintenance of patent equipment and
aids; cleaning and removing clinical waste from operating theatre; daily, weekly, and
monthly environmental cleaning of the operating rooms.
5.13 Institutional Worker

3.13.1 They transport patients from the floor down to the operating room. They assist
the RNs and Surgeons with positioning and prepping the patient for surgery.
They assist in emergencies by getting blood from the blood bank for the
anesthesiologist to give.
3.13.2 They help turn over the room between surgeries. This mean they help clean the room
but more importantly they help configure the equipment needed for surgery.
Depending on what kind of surgery we are doing, special equipment needs to
be set up in the OR, and the operating room assistant helps with this.
3.15 Clinical Instructor
3.17.1 Clinical instructors (CIs) serve in health care settings such as hospitals and
clinics as well as in diagnostic labs and academic settings. The focus may be on
nursing skills, or even therapeutic recreation.
3.17.2 A key component of the clinical instructor role is providing instruction to

students based on a course syllabus. Typically students receive classroom
instruction from a different professor or instructor, while the CI handles only
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the clinical portion. The CI may also use textbooks or other written materials but
relies heavily on laboratory simulations and on-site rotations. The CI is responsible
for connecting the classroom material and its real-life application and for
accommodating the varied learning styles and paces of clinical students.
3.16 Nursing Students
3.18.1 A nursing student is a student in a post-secondary educational program that

leads to certification and licensing to practice nursing. A nursing student can be
enrolled in a program that leads to a diploma, a Bachelor of Science in nursing.
3.18.2 Take a complete health history, as indicated; Take a concise, pertinent history
and do focused exam for a specific complaint; Make appropriate judgments
about the diagnosis and management of common health problems.
3.17 Infection Control Nurse

3.19.1 Monitors compliance and correct implementation of the policies and procedures;
provides assistance with regards to implementation; educates employees and folks
regarding the practice of isolation precautions
4 General Principles/Ethical Principles
4.1 This Policy Document is aligned with the provision of the law in accordance to the Data
Privacy Act of 2012
10. Bibliography/References
10.1 WVSU-MC OR Complex SOP
10.2 WVSU-MC Infection Control Committee Policies and Procedures
10.3 WVSU-MC OPD Policies and Procedures
10.4 WVSU-MC NSO Policies and Procedures
10.5 REPUBLIC ACT NO. 4226 – HOSPITAL LICENSURE ACT
10.6 REPUBLIC ACT NO. 8504 – HIV PREVENTION AND CONTROL ACT 1988
10.7 DOH ADMINISTRTATIVE: AO NO. 2008-0023- NATIONAL POLICY ON
PATIENT SAFETY
10.8 AO NO. 2008-0009 – REVISED LIST OF NOTIFIABLE DISEASES,
SYNDROMES, HEALTH RELATED EVENTS AND CONDITIONS
10.9 WORLD HEALTH ORGANIZATION – WORLD ALLIANCE FOR PATIENT
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SAFETY 2008
10.10 CDC/HICPAC 2007 Guidelines for Isolation Precautions: preventing
Transmission of Infectious Agents in healthcare Settings
10.11 WHO SEARO, Practical Guidelines in Infection Control for Healthcare Facilities,
2004
10.12 Ministry of Health, MalaysiaFRB/HIS/OTMS/2004/version 1.1
http://nursingcrib.com/perioperative-nursing/operating-room-committee/
Ht tps://www.medicalcenter.virginia.edu/clinicalstaff/csec/orc.html
http://work.chron.com/duties-responsibilities-surgeon-operating-room-24301.html
http://work.chron.com/functions-scrub-nurse-12322.html
http://work.chron.com/scrub-nurse-11046.html
http://work.chron.com/responsibilities-circulating-nurses-15643.html
https://www.nursesource.org/perioperative.html
https://www.sokanu.com/careers/anesthesiologist/#what-does-an-anesthesiologist-do
http://swz.salary.com/salarywizard/Head-Nurse-Operating-Room-Job-Description.aspx
http://swz.salary.com/salarywizard/Operating-Room-Supervisor-Job-Description.aspx
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419423/
https://careertrend.com/facts-6777206-job-description-floor-nurse.html
http://nswhealth.erecruit.com.au/ViewPosition.aspx?id=37499
http://allnurses.com/cna-ma-nursing/cnas-in-the-881606.html
11. Attachment
11.1SURGICAL SAFETY CHECKLIST
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11.2ANESTHESIA RECORD
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11.3 ANESTHESIA PREOPERATIVE CHECKLIST (FRONT)
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11.4 ANESTHESIA PREOPERATIVE CHECKLIST (BACK)
11.5 ANESTHESIA SAFETY CHECKLIST

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11.6 OPERATIVE RECORD

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11.7 SPONGES, NEEDLES AND INSTRUMENTS COUNT SHEET (FRONT)
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11.8 SPONGES, NEEDLES AND INSTRUMENTS COUNT SHEET (BACK)
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11.9 SPECIMEN MONITORING FORM
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REVIEWED
BY:
Policy
Development MS. VIRGINIA J. DR. JOSE SENOI G. GULMATICO MS. FE V. ROBLES
Committee GUBATANGA Health Operations Admin & Finance
Nursing Service Office
ORIGINATED BY: RECOMMENDED BY:
Miguel Angelo G.
Labyen, RN
NUR
DR. ARETHA SE III, OR COMPLEX
ANN G. LIWAG
Chairman, Quality Rog DR. GIOVANNI A. DELOS R
Assurance elio F. Navigar, RN DR. RAMON S. GUERRA VP for Medical and Allied Sc
Committee NURS JR.
E III, OR COMPLEX Medical Center Chief II
Author
APPROVED BY:
LUIS M. SOROLLA, JR., Ph.D.,CSEE

SUC President IV
WVSUMC-QA-F06-00

OR POLICY - NEW TEMPLATE (Revised)

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WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER

E. Lopez Street, Jaro, Iloilo City

SERVICE POLICY OF THE

Author: Marcos D. Bito-onon, M.D., MPG, FPSA, DPBPM

Co Authors: Miguel Angelo G. Labyen, RN.

Executive Lead: Dave Endel R. Gelito III, MD, MM

Status: Approval Date:

DATE PAGES COMMENTS APPROVED BY

Members of the Operating Room Committee:

2.3 MEETINGS & REPORTS

4. ACTIVITIES, PROCEDURES AND INTERVENTIONS

The West Visayas State University Medical Center manages a decentralized

The Operating Room Committee, is established to serve as the policy-making and

4.1.2. Students must present themselves to the OR

4.1.6. Informed Surgical Consent will be accomplished by the surgeon and

4.1.7. Informed consent will be signed by able patients who are

4.2.9 Charge nurse or designate receiving the notice of cancelled/postponed cases

4.3 Patient Safety

4.3.1 Peri-Operative Care

4.3.1.2 Identification of sedated patients should be confirmed through checking of ID

4.3.1.3 The nurse should be knowledgeable about the procedure to be performed in

4.3.2. Surgical Safety Checklist

4.3.2.2 Operating Room Complex WHO SURGICAL SAFETY CHECKLKIST should be

4.4.3. Sharps, Sponges and Instrument Count

4.4.3.5. Sponges packed in a wound

4.4.3.5.2. If a patient is to be packed with sponges that will be left in place, it is to

4.4 Handling and Care of Surgical Specimens

4.5.5.1.1 name and room number of patient

4.5.6 For Frozen section

4.5.6.1 The Circulating nurse should confirm with the surgeon

4.5.7 Non-routine specimen should be handled with extra care.

4.5.8 Intra-uterine Fetal Death – Neonatal Death:

4.5.9 Amputated Extremity:

retrieved, secured, and properly labeled.

4.5 Infection Control

4.6.2 Pre-Operative preparation for the patient

4.6.2.1.2. Done before shaving and giving pre-op medications

4.6.2.3 Skin Drapes

4.6.2.3.1 Sterile Cotton fabric drapes should be used as a general rule

4.6.2.4 Skin preparation with in the Operating Room Complex

4.6.2.4.2 Povidone Iodine, and/or chlorhexidine solutions are used as preparatory

4.6.2.5 Endotracheal Tubes and Anesthesia Conduits

4.6.2.6 Catheters and Tubes

4.6.2.7.1 Fingernails should be kept short and free of nail polish.

4.6.2.7.3 The number of OR personnel allowed in the personnel allowed in the OR

4.6.3 THE OPERATING ROOM PERSONNEL

4.6.4 FOR AFFILIATE MEDICAL AND NURSING STUDENTS AND VISITORS

4.6.4.1 Observation of surgical procedures for medical education purposes is an integral

4.6.5 OR PERSONNEL ATTIRE

4.6.6 HAND SCRUBBING

4.6.7 GOWNING AND GLOVING

4.6.8 OPERATIVE PROCEDURE

4.6.8.2 Strict observation of proper surgical technique (asepsis, homeostasis, avoidance of

4.6.8.4 Disposable surgical drapes are used for infectious cases.

4.6.8.5 Linens are received, inspected and processed.

4.6.9 OPERATING ROOM ENVIRONMENT

4.6.9.1.1 Perioperative Nurses and Surgical Technicians

4.6.9.2 Traffic control is aided by a three-zone concept:

4.6.9.4 Design and Traffic Patterns:

4.6.10 For Infectious Cases

4.6.10.1. Operating Room 2 is allotted for Infectious Cases such as:

4.6.11 PATIENT CLASSIFICATION

4.6.11.3.5. An N95 disposable respirator should be used by HCW when dealing