What are the standard operating theatre protocols for surgical cases, including patient verification, time‑out, infection control, equipment checks, antibiotic prophylaxis, and postoperative handover?

Standard Operating Theatre Protocols for Surgical Cases

Operating theatre protocols must prioritize a systematic approach encompassing pre-operative verification, surgical time-out, infection control measures, equipment safety checks, and structured postoperative handover to reduce morbidity and mortality.

Pre-Operative Patient Verification and Assessment

Patient Identification and Allergy Screening

• Conduct thorough pre-operative assessment including occupational history and specific allergy screening 1
• Ask specifically about reactions to balloons, condoms, or latex gloves (itching, rash, angioedema)
• Document latex allergy in case notes and on patient wrist bracelet if positive
• For patients with positive/equivocal latex history, refer for testing (latex-specific IgE or skin prick testing with 75-90% sensitivity) before non-emergency surgery 1

Equipment Checks

All anaesthetic equipment must be checked at the beginning of each theatre session using standardized checklists 2. This includes:

• Power supply and electrical connections (direct mains connection, no extension leads)
• Gas supply pipelines and machine configuration
• Breathing systems, filters, connectors, and airway devices
• Ventilators, suction, and monitoring equipment
• Alternative means of ventilation (self-inflating bag) must be immediately available
• Record that checks have been completed and maintain service records

A "first user" check after servicing is especially critical and must be documented 2.

Surgical Time-Out Protocol

The time-out procedure must be performed before first incision in 100% of cases 3. The process should:

• Include an announcement to indicate start of time-out (completed in <1 minute typically)
• Verify patient identity, surgical site, and procedure
• Confirm prophylactic antibiotic administration timing - antibiotics must be infused within 60 minutes prior to incision 4
• Address any safety concerns immediately (stop procedure if needed)
• Minimize distractions - though 10% of time-outs involve at least one distracted team member, compliance remains critical 3

Piggybacking antibiotic verification onto the time-out protocol achieves >99% compliance compared to 65% baseline 4.

Infection Control Measures

Standard Precautions

• Strict hand hygiene before and after all patient contact
• Appropriate personal protective equipment (PPE) for all staff
• High operating room air exchange cycles (≥25 exchanges/hour recommended) 5
• Minimize staff traffic and limit personnel to those essential for the procedure 6, 7, 5

Latex Allergy Precautions (When Applicable)

If latex allergy diagnosed pre-operatively 1:

• Avoidance is mandatory
• Prepare theatre the night before; schedule patient first on list
• Place "Latex allergy" notices on anaesthetic room and theatre doors
• Use only synthetic gloves for all equipment preparation, anaesthesia, surgery, and post-operative care
• Remove non-essential equipment from patient vicinity
• Ensure all anaesthetic/surgical areas contain only latex-free products
• Use only latex-free dressings and tapes
• Limit staff traffic

COVID-19 Specific Protocols (When Applicable)

For suspected/confirmed COVID-19 patients 6, 7, 6, 5, 8, 5:

Operating Room Setup:

• Dedicate specific OR as close as possible to theatre block entrance
• Negative pressure preferred; if unavailable, ensure >25 air exchanges/hour 5
• Close all OR doors once patient enters; keep closed throughout procedure 6, 5
• Minimize equipment in room to essentials only
• Cover monitors, laptops, ultrasound surfaces with plastic wrap 7
• Use disposable supplies/instruments whenever possible 6, 8, 5

Personal Protective Equipment:

• Powered air-purifying respirators (PAPRs) for long operations, or
• Fitted N-95/FFP2 minimum (FFP3 for aerosol-generating procedures)
• Eye protection (goggles or full-face shields)
• Disposable AAMI level-III surgical gown or coveralls
• High-cuffed surgical gloves (consider double gloving)
• Fluid-resistant shoes
• Hand hygiene before/after donning/doffing 6, 8

Intraoperative Measures:

• Limit team size and record all participating staff for contact tracing 7, 5, 8
• Personnel should not leave OR during procedure 5
• Set electrocautery as low as possible to minimize surgical smoke 6
• Patient examination, induction, and recovery should occur in OR itself 7, 6
• Medical records remain outside OR 5

Antibiotic Prophylaxis

Prophylactic antibiotics must be administered within 60 minutes prior to incision 4. This timing is critical for reducing surgical site infections and should be verified during the time-out procedure.

Postoperative Management and Handover

Recovery Phases

First-stage recovery 9:

• Continue until patient awake with protective airway reflexes returned and pain controlled
• Occurs in recovery area with appropriate facilities and staffing
• Modern techniques may allow bypassing this stage for some patients (especially those with local/regional blocks)

Second-stage recovery 9:

• From stepping off trolley until ready for hospital discharge
• Takes place adjacent to day surgery theatre
• Equipped to handle common postoperative problems (PONV, pain) and emergencies
• Anaesthetist and surgeon must be contactable
• Nurse-led discharge using agreed protocols should be standard

Discharge Instructions

Provide verbal and written instructions including 9:

• Warning signs of possible complications and when to seek help
• No alcohol, machinery operation, or driving for 24 hours after general anaesthetic
• Procedure-specific driving recommendations
• Pain management instructions with timing for oral analgesics

COVID-19 Postoperative Considerations

For COVID-19 patients 6:

• Screen for hyper-inflammation markers (ferritin, platelet count, LDH, CRP)
• Differentiate postoperative complications from COVID-19 infection progression
• Consider telemedicine for postoperative follow-up to maintain social distancing
• Transport suspected cases to isolation ward immediately if respiratory symptoms develop

Post-Procedure Cleaning

For COVID-19 cases 6, 5:

• Dispose all contaminated materials in designated infectious waste containers
• Disinfect OR surfaces and equipment thoroughly
• OR should be closed for adequate time (30 minutes to 2 hours depending on air exchange)
• All staff should shower and change scrubs before resuming duties 7, 5
• Disinfect contaminated instruments separately with proper labeling

Common Pitfalls to Avoid

• Equipment checks: Never skip the "first user" check after servicing - errors during reassembly can be fatal 2
• Time-out distractions: Even brief time-outs (<1 minute) commonly have distracted team members; ensure all personnel actively participate 3
• Antibiotic timing: Simply adding verification without systematic process integration may not improve compliance if baseline is already good 10
• PPE doffing: Self-contamination during removal is a major risk - requires specific training and attention 6, 5
• Documentation: Keep medical records outside OR for COVID-19 cases to prevent contamination 5