Standard Operating Procedure (SOP) for Procedure Room as per NABH Standards
The standard operating procedure for a procedure room according to NABH standards should include dedicated areas with controlled access, proper ventilation systems, comprehensive infection control protocols, and clear documentation of all processes. 1
Physical Setup Requirements
Room Specifications
- Procedure room should be in a dedicated area, preferably isolated from regular patient traffic
- Negative pressure ventilation is ideal for infection control; if not available, ensure high air exchange cycles (≥25 exchanges/hour) 2
- Clear signage should be posted outside the room indicating its purpose and any precautions required
- Room should have controlled access with minimal entry/exit during procedures
Equipment and Supplies
- Only essential equipment should be kept in the procedure room to minimize contamination risk 2
- Disposable materials should be preferred whenever possible 1
- Pre-prepared sterilizable steel wire baskets containing all required surgical materials should be available 2
- Alcohol-based hand disinfectant must be readily available in the room 2
- Appropriate waste disposal containers must be present, including separate containers for infectious and sharp disposable instruments 2
Infection Control Protocols
Personal Protective Equipment (PPE)
- All personnel must wear appropriate PPE before entering the procedure room:
- Double gloves
- Protective goggles or face shield
- Fluid-resistant gown
- Appropriate respiratory protection (N95/FFP2/FFP3 masks)
- Long leg covers/shoe covers
- Head cap 1
Cleaning and Disinfection
- Room must be thoroughly cleaned and disinfected before and after each procedure 2
- All surfaces and electromedical devices must be accurately cleaned and disinfected 2
- Sufficient time should be allowed between procedures to reduce air contamination 1
- Proper disinfection protocols for reusable equipment must be documented and followed
Procedural Workflow
Pre-procedure
- Patient should be transported to the procedure room via a planned route to minimize environmental contamination 1
- Medical records should remain outside the procedure room and consulted/updated after adequate doffing 2
- Time-out procedure must be performed before starting any procedure
During Procedure
- Door must remain closed throughout the procedure 2
- Personnel should not leave the room during the procedure 2
- Additional materials, if needed, should be provided by personnel outside the room 1
- Minimize the number of personnel present to only those essential for the procedure 2
Post-procedure
- Recovery phase should be conducted in the procedure room before transferring the patient 2
- PPE must be removed and disposed of in designated doffing areas outside the procedure room 2
- All disposable materials must be properly disposed of according to biomedical waste management protocols 2
Documentation Requirements
Mandatory Records
- Procedure room utilization log
- Equipment maintenance records
- Cleaning and disinfection logs
- Staff training records
- Incident reporting system
- Patient consent forms
- Procedure notes and outcomes
Quality Indicators
- Infection rates
- Procedural complications
- Patient satisfaction
- Adherence to protocols
- Equipment functionality
Staff Training and Competency
- All staff must be trained on infection control practices, proper use of PPE, and emergency protocols 2
- Regular drills should be conducted to ensure preparedness
- Documentation of staff training and competency assessments must be maintained 3
Common Pitfalls and How to Avoid Them
Inadequate ventilation: Ensure proper air exchange rates and regular maintenance of ventilation systems 2
Frequent door openings: This increases infection risk - establish protocols to minimize unnecessary entry/exit during procedures 4
Improper PPE usage: Conduct regular training and audits on proper donning and doffing techniques 2
Poor documentation: Implement standardized documentation systems and regular audits 3
Inadequate cleaning between cases: Establish clear protocols and sufficient time between procedures for proper disinfection 1
By following these comprehensive SOPs, procedure rooms will meet NABH standards and ensure patient and staff safety while optimizing procedural outcomes.