Blue 725 Operating Theatre List

Royal United Hospital Bath NHS Trust
Operating Theatre List
OPERATING THEATRE LIST POLICY
Reference Number: 725 2007
Author / Manager Responsible: Heather Cooper

Charlotte Hamilton
Deadline for ratification:

(Policy must be ratified within 6 October 2010
months of review date)
Review Date: April 2009
Ratified by: Theatre Users Group
Date Ratified: April 2007
Related Policies Patient Access Policy
Author : Heather Cooper Date: April 2007

Job title: Theatre Manager Version: 1
Page 1 of 29 Review date: April 2009
INDEX
Section Page
Consultation and ratification schedule - - - - 3
Policy - - - - - - - - - 4
Introduction - - - - - - - - 4
Aims, Objectives and Area of Policy - - - - 4
Scope of Policy - - - - - - - 5
1. List Compilation, Notification & Submission - - 6
2. Responsibilities - - - - - - 7
3. Procedure for Changing Patient Details on Operating Lists 9
4. Surgical Booking Process Flow Chart - - - 11
5. Procedure for Notification of Change to Theatre Timetable 13
5.1 Procedure for Change of Surgeon on Operating Lists 14
5.2 Procedure for Cancellation of Operating Lists 14
5.3 Reallocation of Cancelled Sessions 16
6. Record Keeping & Data Requests - - - 18
APPENDIX 1 Minimum Standards for Elective Surgery 19
APPENDIX 2 Theatre List Scheduling Guidance - 20
APPENDIX 3 List Submission Timetable - - - 21
APPENDIX 4 Notification of Change to Theatre Timetable 23
APPENDIX 5 Loan Equipment Request Sheet - - 25
APPENDIX 6 Reasons for Cancellation - - - 28
Consultation checklist - - - - - - 29

CONSULTATION AND RATIFICATION SCHEDULE
Name and Title of Individual Date Consulted
Date policy e-mailed to policy co ordinator
Name of Committee Date of Committee

POLICY
INTRODUCTION
The Trust is committed to developing systems and processes that seek to match
demand and capacity for elective and emergency surgery. Effective planning and
management is essential to improve services to patients and ensure optimum use of
operating theatre capacity. More efficient use of the operating theatres and effective
scheduling will reduce waiting times for patients and avoid cancellations. Early
notification of operating lists can allow sessions to be fully utilised by surgeons and
enable the Theatre Manager to ensure any specialist equipment and staff are available.
AIMS OF THE POLICY
¾ To ensure that the ‘Minimum Standards for Elective Surgery’, as agreed by the
Surgical Division, are adhered to.
¾ To establish an agreed set of procedures for formulation and submission of

elective, emergency and trauma operating lists;
¾ To ensure, wherever possible, full utilisation of available operating sessions;
¾ Identify responsibilities of key staff involved in the compilation and submission of

elective and emergency operating lists;
¾ To establish an agreed set of procedures for identifying and listing PTL, cancer
and private patients;
¾ To establish methods of identifying lists where specialist equipment or staff is

required, allowing time for the necessary arrangements to be made; and
¾ To identify teaching lists and facilitate case mix adjustment where necessary.
AREA OF POLICY
Surgical and Anaesthetic Directorates under the management of the Surgical Division.
OBJECTIVE
To facilitate forward planning of the operating lists for the theatre departments, Main
Theatres and Day Surgery Theatres ensuring maximum utilisation of available
resources whilst meeting the activity and performance targets of the Trust.

SCOPE OF THE POLICY
The policy covers:
¾ The timetable for the notification of elective, emergency and trauma operating
lists to the theatre department;
¾ Responsibilities for compilation, notification and submission of all operating lists;
¾ Distribution flow for operating lists;
¾ Identification of PTL, cancer and private patients;
¾ Identification of teaching and training lists;
¾ Procedure for cancellation of operating sessions;
¾ Guidelines for the re-allocation of operating sessions;
¾ Timescale of notification of surgeon and anaesthetist leave;
¾ Identification of specialist requirements, staff and equipment; and
¾ Procedure for changing operating lists after submission to the Theatre

Department.

1. LIST COMPILATION, NOTIFICATION AND SUBMISSION
1.1. Every booking coordinator and medical secretary will have access to the
up-to-date theatre timetable on the Theatre Timetable web page. This will
be updated regularly to reflect any changes to the planned format. The
Theatre Timetable web page may be found at:
http://webserver.ruh-
bath.swest.nhs.uk/departments/main_theatres/home_menu.htm
1.2. The elective surgery operating list will be produced on the theatre ORSOS
system.
1.3. Emergency and trauma lists will be accepted in hand written form but
should be booked to ORSOS theatre system prior to the patient being
called to theatre.
1.4. All patient details must be recorded including:

1.4.1. Patient name
1.4.2. Date of birth
1.4.3. Hospital number
1.4.4. TDS episode number
1.4.5. Wait list priority, including patient status e.g. cancer, PTL, private
etc.
1.4.6. Surgeon name
1.4.7. Date of operation
1.4.8. Theatre procedure to be performed in
1.4.9. ORSOS Session ID
1.4.10.Full procedure name and code, including any sub-procedures
1.4.11. Site of procedure
1.4.12. Anaesthetic information, i.e. GA, LA etc.
1.4.13. Any specialist equipment required
1.4.14.Any special conditions relating to patient or procedure
1.4.15.Information regarding any previous complication or cancellation
1.5. All questions regarding the patient and their operation should be
accurately and comprehensively answered when booking patients to the
ORSOS theatre system.
1.6. Elective operating lists must be submitted by 10am, 3 working days before
planned surgery.
1.7. Emergency lists should, where possible, be formulated with as much

notice as possible. It is accepted that this will not always be possible due
to the nature of the surgery.
1.8. Theatre One staff will enter all emergency lists on the theatre ORSOS
system at the earliest opportunity.

1.9. The Trauma Coordinator will be responsible for ensuring that all trauma
lists are entered on the theatre ORSOS system at the earliest opportunity.
1.10. All emergency and trauma patients require a priority rating / NCEPOD
classification at the time of listing.
1.11. Booking coordinators will compile the list according to the guidelines set
out in Appendix 2.
1.12. All PTL, cancer and private patients must be identified on the theatre list
using the appropriate column.
1.13. PTL patients should, where possible, be listed first on the operating list.
1.14. Clinical priority will supersede PTL status in the list order.
1.15. Any specialist equipment required should be highlighted on the operating

list and a Loan Equipment Request Sheet (Appendix 5) completed.
1.16. Loan Equipment Request Sheets should be completed in full at the

earliest opportunity and submitted to the G Grade theatre nurse
responsible for that speciality or theatre department.
1.17. All lists must be agreed with the operating surgeon before submission.
1.18. Electronic / hardcopy lists for elective surgery must be made available to
all clinical, nursing and management staff within the agreed timescale.
2. RESPONSIBILITIES
2.1. Booking coordinators will ensure that elective theatre lists are compiled
and submitted according to the List Submission Timetable in Appendix 3,
and that sign off by the relevant surgeon is received prior to submission
date.
2.2. The Elective Admissions Manager is responsible for ensuring list

compilation and submission is maintained during booking coordinators’
leave.
2.3. The medical secretaries are responsible for providing their surgical teams
with access to up to date theatre lists.
2.4. The Theatre Information Team will monitor the receipt of lists within the
specified timescale.
2.5. The Theatre Information Team will inform the Elective Admissions
Manager of any missing or late list submissions via email.

2.6. The Theatre Manager, the Day Surgery Manager and Band 7 theatre
nurses will review the case mix of the operating lists on a daily basis,
highlighting any potential under utilisation or cancellations due to “list
overrun”.
2.7. The Theatre Manager and Day Surgery Manager will accept responsibility
for downward and outward dissemination of information pertaining to
forthcoming operating lists to all senior staff.
2.8. The surgical teams will accept responsibility for ensuring that a Loan
Equipment Request Sheet is completed and submitted for any specialist
equipment required.
2.9. Senior theatre staff / team leaders will be responsible for monitoring any
special requirements for forthcoming lists for the forthcoming week.
2.10. The Theatre One staff will enter the emergency lists onto the ORSOS
system at the earliest opportunity.
2.11. The Trauma Coordinator will ensure that the trauma lists are entered onto
the ORSOS system at the earliest opportunity.
2.12. The Theatre Information Team will retain primary responsibility for making
any changes to the operating lists after the submission date.
2.13. The Booking coordinators will immediately inform Theatre Reception via
Cancelled Ops Group email address if any changes are made to the
operating lists after the submission date. New lists will then be printed
and circulated by the Theatre Information Team.
2.14. The Theatre Information Team will ensure adequate copies of the daily
operating list are available for all staff.
2.15. Senior theatre staff will be informed immediately by the Theatre

Information Team of any changes to forthcoming lists.
2.16. At the end of each operating session one list will be returned to the
Theatre Information Team detailing any changes in list order and any
cancellations.
2.17. Theatre Reception / DSU Recovery must e-mail details of all cancelled
patients to the appropriate booking co-ordinator to facilitate re-booking via
the Cancelled Ops e-mail address.
2.18. Remaining lists should be disposed of in Recovery or the Theatre

Information Office using the shredders or the blue confidential bins
provided to protect patient confidentiality. No other means of disposal
should be used.

3. PROCEDURE FOR CHANGING PATIENT DETAILS ON OPERATING LISTS
Changes to operating lists are inevitable and can be made at any time provided
the following procedure is followed.
3.1. List changes including all cancellations should be entered onto the
ORSOS system at the booking coordinators’ earliest opportunity.
3.2. The Theatre Information Team is responsible for making any last minute
(within three working days) changes to operating lists. Any last minute
changes required by the surgical or anaesthetic teams should be
requested by clinicians via Theatre Reception.
3.3. Should the Theatre Information Team or a booking coordinator make any
changes to an operating list after it has been submitted they will
immediately inform Theatre Reception via email who will print and
circulate new copies of the list.
3.4. The Theatre Information Team will inform the relevant manager and senior
nurses for Main Theatres and Day Surgery Unit of any changes to the
relevant department’s lists.
3.5. Ward clerks or senior ward staff should immediately inform Theatre
Reception / Day Case Unit of all hospital and patient initiated
cancellations. This information will immediately be passed on to the senior
theatre staff for the relevant area and the changes noted on the operating
lists.
3.6. Any changes in the order of the operating list must be highlighted to the
Theatre Team Leader, surgeon, anaesthetist, Patient Admissions Centre
and ward staff immediately.
3.7. Any changes regarding specialist equipment requirements should be

detailed on a Loan Equipment Request Sheet and submitted to the
appropriate Band 7 theatre nurse at the earliest opportunity.
3.8. Theatre Reception will ensure that all appropriate staff have an up to date
copy of the operating list incorporating any alterations.
3.9. All operating list changes must be documented on the master copy which
is returned to the Theatre Information Team at the end of the session.
3.10. All Booking coordinators and the Theatre Information Team must ensure
that all cancelled operations are immediately and accurately recorded on
ORSOS.
3.11. Cancelled operations must be recorded on ORSOS on the date which

they occur.

3.12. Cancelled operations must be accurately recorded. A list of reasons for
cancellation may be found in Appendix 6 and are displayed in each
theatre and booking office. Should guidance regarding the reason for
cancellation be required, please contact the Theatre Manager or Day
Surgery Unit Manager/Elective Admissions Manager.
3.13. No PTL patients may be cancelled without authorisation from the Elective
Admissions Manager. The Elective Admissions Manager must
immediately be informed of all PTL patients who potentially may be
cancelled by the hospital for non-clinical reasons. All PTL patients must
be offered a new treatment date, in accordance with the Trust Access
Policy, before they are discharged.
3.14. Wherever possible all patients cancelled by the hospital on the day of
surgery or after their admission should be offered a new treatment date
before they are discharged.
3.15. The Trust procedure for compliance with the NHS Plan 28 Day Guarantee
must be followed for all patients cancelled by the hospital at the last
minute for non-clinical reasons.
3.16. The Elective Admissions Manager and booking coordinators will ensure
that all 28 Day Guarantee patients are offered a new treatment date within
28 days.

4. SURGICAL BOOKING PROCESS FLOW CHART
Booking Surgeon / Surgical

Theatres
Co-ordinator Anaesthetist Secretary
Patient booked to theatre list in accordance with Trust Access Policy
TCI & operation date recorded on TDS
Patient booked to ORSOS

All booking questions to be answered & special conditions noted including all information
available on T-card/TDS
Theatre lists should be ordered according to the Theatre List Scheduling Guidance set out
in Appendix 2
Patient & operation details recorded in speciality/consultant diary

Information to include wait list date, urgency, date patient confirmed operation, any
previous cancellations & whether 28 day guarantee patient, ORSOS number & any special
conditions/additional information as appropriate
Any changes to the theatre list, including cancellations, should be recorded immediately
on TDS, ORSOS and in diary to ensure that PAS data is accurate at all times
Medical secretary / Anaesthesia Directorate Coordinator to provide surgical and

anaesthetic teams with access to up to date operating lists as required.
Surgeon & anaesthetist to review theatre list at least 3 working days prior to surgery to
ensure that lists are booked appropriately & information is accurate
Theatre Information Team / booking coordinator to be informed of any changes required
Theatre staff to review theatre list at least 3 working days prior to surgery to ensure that
theatre lists are booked appropriately & efficiently
Surgeon, anaesthetist & theatres to be informed of any changes to or cancellations from

the theatre list within 3 working days of surgery
Theatre Information Team to record all changes to theatre list & reasons for cancellation
within 3 working days of surgery. New copies of updated lists to be printed and
circulated.
Theatre list to be returned to Theatre Information Team on day of surgery to ensure that
PAS data is accurate at all times
Theatre Reception / Recovery to e-mail details of all cancelled patients to Cancelled

Operations Group to facilitate re-booking

Cancellation to be recorded on TDS & patient rescheduled to theatre list in accordance with
Trust Access Policy

5. PROCEDURE FOR NOTIFICATION OF CHANGE TO THEATRE TIMETABLE
The Notification of Change to Theatre Timetable Form (Appendix 4) must be used to

record ALL changes to the standard four week theatre timetable. The timetable must
be reviewed on receipt of surgical rotas and any changes reported as appropriate.
It is the responsibility of the booking coordinators and the Elective Admissions Team to
cover all theatre lists (with the exception of Theatre 1 and Theatre 2) on notification of
surgeon leave or unavailability.
It is the responsibility of the Orthopaedic Project Manager to cover all trauma lists
(Theatre 2) on notification of surgeon leave or unavailability.
It is the responsibility of the Theatre Manager / Assistant Divisional Manager for Surgery
to cover all emergency lists (Theatre 1) on notification of surgeon leave or unavailability.
Booking coordinator informed of surgeon leave or a change to theatre timetable

(at least 6 weeks notice)
Booking co-ordinator must attempt to cover the theatre list

within speciality by e-mailing all surgeons, including registrars
DAY 1
& staff grades to ask if anyone is available to cover that theatre
list.
È
If the booking co-ordinator has been unable to cover the
DAY 5 theatre list within 5 working days they must contact, by phone,
all surgeons who have not responded to their earlier email.
È
Booking coordinator to complete a Notification of Change to
Theatre Timetable Form and email it to the Changes to
DAY 6
Theatre Timetable Group. A copy of the email must be
retained by the booking co-ordinator for record.
È
Team Leader to print Notification of Change to Theatre
Timetable Form and action as appropriate. On notification of
DAY 7 a cancelled session Elective Admissions team leaders should
approach other specialties in an attempt to cover the theatre
list.
È
Appropriate team leader to seek authorisation from the Theatre
DAY 9 & Anaesthetic Departments and inform the Theatre Information
Team of all changes at the earliest opportunity.

5.1. PROCEDURE FOR CHANGE OF SURGEON ON OPERATING LISTS
5.1.1. Booking coordinators must complete a Notification of Change to

Theatre Timetable Form for any change in the operating surgeon
for a list.
5.1.2 The Elective Admissions Team Leader will inform the relevant
manager for Main Theatres or Day Surgery Unit and the
Anaesthesia Directorate Coordinator of all changes at the weekly
Theatre Meeting.
5.1.3 The relevant theatre manager and Anaesthesia Directorate

Coordinator must authorise a Notification of Change to Theatre
Timetable Form for all agreed changes.
5.1.4. Once an authorised form has been received, the Theatre

Information Team will update ORSOS and the Theatre Timetable
Web Page with the details of the change of surgeon.
5.2. PROCEDURE FOR CANCELLATION OF OPERATING LISTS
5.2.1 Cancellation by Surgeon

At least six weeks notice must be given for the cancellation of
theatre sessions for reasons of annual leave or study leave. If
cancellation is unavoidable the consultant surgeon, with the
appropriate manager, is responsible for arranging cover, or an
additional theatre session to replace the lost one, within an
acceptable time scale if this is possible.
5.2.2 When a surgeon is unable to undertake a planned operating

session the speciality should make every effort to cover the list
internally (e.g. another consultant or junior surgeon). If this process
is successful a Notification of a Change to Theatre Timetable Form
should be completed. The appropriate theatre manager and
Anaesthesia Directorate Coordinator should be informed of the
surgeon using the list and any issues relating to case complexity or
any specialist equipment required.
5.2.3 It is the responsibility of the surgeon to inform their booking

coordinator of sessions cancelled in both Main Theatres and Day
Surgery Theatres.
5.2.4 Booking coordinators will complete a Notification of Change to

Theatre Timetable Form and confirm the cancellation with their
team leader.

5.2.5 The following information must be included in any correspondence
relating to the cancellation of an operating list – date of session to
be cancelled and reason why session is being cancelled (e.g.
annual leave, study leave, court appearance, etc.).
5.2.6 Information regarding the cancelled session must then be

authorised by the appropriate theatre manager and the Anaesthesia
Directorate Coordinator.
5.2.7 Once an authorised Notification of Change to Theatre Timetable

Form has been received the Theatre Information Team will update
ORSOS and the Theatre Timetable Web Page.
5.2.8 When reallocation within the speciality is not possible, the Elective
Admissions Team, subject to six weeks notice, will be offered the
opportunity to offer any available sessions to alternative
directorates or the Private and Overseas Patients Coordinator.
5.2.9 Should an alternative directorate or the Private and Overseas

Patient Coordinator wish to utilise an available session, the
appropriate booking coordinator will complete a Notification of
Change to Theatre Timetable Form. The form must detail the
intended operating surgeon and any issues relating to case
complexity or specialist equipment required.
5.2.10 All reinstated sessions must be authorised by the appropriate

theatre manager and the Anaesthesia Directorate Coordinator.

5.2.12 Cancellation by Anaesthesia Directorate, Main Theatre

Department or Day Surgery Unit
Every effort to find alternative cover for anaesthetic or theatre staff
should be sought prior to requesting that an operating session be
cancelled. The use of locum medical staff, bank or agency nursing
staff, or the payment of overtime or waitlist initiative rates must be
approved in advance by the Divisional Manager for Surgery.
5.2.13 The Elective Admissions Manager must be informed immediately of

all potential cancellations. No theatre sessions or patients may be
cancelled without the authorisation of the Elective Admissions
Manager, Assistant Divisional Manager for Surgery or Divisional
Manager for Surgery.
5.2.14 Should cancellations be required, the Elective Admissions Manager

will review all theatre lists, prior to any cancellations being made, to
ensure that the most appropriate session and / or patients are
cancelled.
5.2.15 The clinical urgency of patients on the list to be cancelled should be

considered and new dates or spaces on alternative lists sought by
the booking coordinator prior to any cancellations being made.
5.2.16 The contractual waiting times of patients on the list to be cancelled

must be reviewed and new slots identified as a priority for all PTL
patients prior to any cancellations being made.
5.2.17 If no alternative solution is available and a theatre session is to be

cancelled the surgeon for the list and the relative booking
coordinator must be informed immediately.
5.2.18 Steps 5.2.4 to 5.2.7 of the Procedure for Cancellation of Operating

Lists should be followed.
5.3 REALLOCATION OF CANCELLED SESSIONS
5.3.1 The appropriate theatre manager and Anaesthesia Directorate

Coordinator will be responsible for the reinstatement and
reallocation of cancelled theatre sessions.
5.3.2 The Theatre Information Team will ensure the Theatre Timetable
Web Page displays up to date information regarding available
operating lists, and inform members of the Elective Admissions
Team of available sessions.
5.3.3 All surgical directorates and the Private and Overseas Patient
Coordinator will be invited to take up any of the cancelled sessions,
subject to adequate notice.
5.3.4 Medical staff wishing to use a vacant session should inform their
booking coordinator who will apply for allocation of the session.
5.3.5 Booking coordinators should complete a Notification of Change to

Theatre Timetable Form and inform their team leader of any
application for a session and subsequent allocation.
5.3.6 Booking coordinators will be responsible for ensuring that

anaesthetic cover is available for the session. If no anaesthetic
cover is available the possibility of a Local Anaesthetic only list will
be investigated.
5.3.7 The Elective Admissions team leader will be responsible for ensuring that
there is bed availability before they request additional theatre sessions.
5.2.19 All reinstated sessions must be authorised by the appropriate

theatre manager and the Anaesthesia Directorate Coordinator.

5.3.9 A weekly meeting will be held on Thursday mornings to discuss

vacant sessions and to facilitate the optimum utilisation of theatre
resources.
5.3.10 In general, no “to be confirmed” sessions will be re-allocated after

11am on the Wednesday three weeks prior to the vacant session.
However, it is recognised that the Trust needs to ensure that
theatre resources are optimally utilised. Therefore, in exceptional
circumstances, all requests to fill these lists after the deadline
should be directed to the appropriate theatre manager and
Anaesthesia Directorate Coordinator who will assess the feasibility
of filling the session by liaising with all relevant parties.

6. RECORD KEEPING AND DATA REQUESTS
6.1. The Theatre Information Team will monitor and record all cancelled operating
sessions.
6.2. The Theatre Information Team will, on a weekly basis, inform the appropriate
theatre manager and Elective Admissions Manager of the number of theatre
sessions utilised and cancelled in each theatre department according to
speciality. This information will be reported to the PTL Meeting, on a weekly
basis, and to the Surgical Division and Theatre Management Group, on a
monthly basis, highlighting the amount of potential operating hours not utilised
by the Trust.
6.3. The Theatre Information Team will ensure that an accurate record of the start
and finish time of each procedure and theatre session is maintained, including
any reasons for delay.
6.4. The Elective Admissions Manager and Main Theatres Manager will monitor and
analyse the start and finish times of each operating session. This information
will be reported to the Surgical Division and Theatre Management Group, on a
monthly basis, highlighting the amount of potential operating hours not utilised
by the Trust.
6.5. The Theatre Information Team will ensure that an accurate database of
cancelled operations is maintained.
6.6. The Elective Admissions Manager and Main Theatres Manager will monitor and
analyse all cancelled operations. This information will be reported to the PTL
Meeting, on a weekly basis, and to the Surgical Division and Theatre
Management Group, on a monthly basis. Cancelled operations data will also be
made available to all Trust employees as part of the monthly Performance Pack.
6.7. All requests for electronic operating logs or theatre data should be addressed to
the Theatre Information Team with reasonable notice. Requests should detail
the specific information required.
6.8. Patient information may not be emailed to a non-RUH email address. A

computer disc or CD-Rom should be provided in conjunction with any data
request. Theatre data information will only be printed in hard copy by the
Theatre Information Team in exceptional circumstances.

APPENDIX 1 – MINIMUM STANDARDS FOR ELECTIVE SURGERY
The following minimum standards will be applied to all elective surgical lists from 1
November 2003. Where these standards are not met the list will not be able to start and
postponements of cases are likely to result. It is the responsibility of all members of the
team to ensure these standards are met.
1. Operation lists must be available by 10:00 three working days before the date of
surgery (as per operational practice).
2. No subsequent list changes may be made without discussion with the relevant
theatre team leader, senior anaesthetist, senior surgeon and ward staff.
3. Patients must be in hospital before the list start time and must arrive in sufficient
time to allow the preparation required before anaesthetic assessment.
4. Provision must be made for patients to be seen in an appropriate clinical area. This
area should provide privacy and a site for examination.
5. All hospital notes and x-rays must be available.
6. Baseline results must be available in the notes (where indicated this includes ECG,
FBC and U&E).
7. Pre-medication and routine drugs must be given by the ward staff, as prescribed. If
they are not given the anaesthetist must be contacted directly before the patient is
transferred to theatre.
8. A recent set of observations must be available before the patient leaves for theatre.
The anaesthetist should be informed of any abnormalities noted.
9. An appropriate bed must be available and irreversibly allocated before the patient is
transferred to theatre.
10. The patient must have been seen and marked appropriately by the operating
surgeon before induction of anaesthesia.
11. If appropriate post-operative care (both in terms of site and nursing) is not available
anaesthesia and surgery cannot proceed.
Guidelines:
These are strongly encouraged but do not form a minimum standard.
1. Patients will receive written information about their anaesthetic before admission.
2. Any patient about whom there is reason for concern should be discussed with an
anaesthetist (for example but not only: any patient with disease that limits exercise
tolerance, BP systolic > 180, diastolic >100, predicted difficult airway, gross obesity).
3. The guidelines on anaesthesia monitoring and PACU as published by the AAGBI are
adopted.

APPENDIX 2 - THEATRE LIST SCHEDULING GUIDANCE
1st ON THEATRE LIST
LATEX ALLERGY PATIENTS

Always first on a morning list to facilitate theatre preparation
Ð
PAEDIATRIC PATIENTS
With the exception of latex allergy patients paediatric cases should always be listed
first
Ð
DIABETIC PATIENTS
Listed first if neither of the above cases are scheduled
Ð
PTL / URGENT PATIENTS
To be listed immediately after patients with clinical requirements. To be listed first if
none of the above cases are scheduled
Ð
DAY CASE PATIENTS ON IN-PATIENT LISTS

To be listed as early as possible to facilitate prompt discharge
Ð
LOCAL ANAESTHETIC CASES
To be placed at the end of a general anaesthetic list should none of the cases below be
scheduled
Ð
“DIRTY CASES” (INFECTIONS, DEBRIBEMENTS, ABSCESSES ETC.)

To be listed last to prevent the spread of bacteria & infections
LAST ON THEATRE LIST
Where possible DSU request that similar operations be listed together e.g. Tonsillectomy
Hysteroscopy
EMEAs
STOPs
Vein surgery etc.
APPENDIX 3 - LIST SUBMISSION TIMETABLE
In order to gather useful, accurate and timely information for bed, duty, theatre and
waiting list management purposes, the following points have been suggested and
agreed:
¾ Operating Theatre Lists will be submitted at least 3 working days prior to the list
date
¾ Changes to the Operating Theatre List must be entered onto the ORSOS system
¾ Any changes to the lists after submission must be e-mailed to the Theatre
Information Manager after updating the ORSOS system
The table below has been produced as an aide memoir:
Day of Surgery List to be Submitted by:
Monday Wednesday - 10 am
Tuesday Thursday - 10 am
Wednesday Friday - 10 am
Thursday Monday - 10 am
Friday Tuesday - 10 am
Saturday Wednesday - 10 am

Name of Policy and Procedure
APPENDIX 4 - NOTIFICATION OF A CHANGE TO THEATRE TIMETABLE

Change requested by:
Date:
CHANGE OF CANCELLED REINSTATED

SURGEON SESSION SESSION
Date: Theatre:
Main
am pm All day PAW DSU
Theatres
Session
start time:
Scheduled Replacement
Surgeon: Surgeon:
Specialty: Specialty:
Reason for Change:
Please complete the following information, as applicable:

No. of patients booked to session
LA
In-patient
GA
Day case
Mixed
Mixed
Paediatrics
Authorisation & notification:

Team Leader
Signature & date
Theatre / DSU Manager
Signature & date
Author : Heather Cooper Date: October 2007

Page 23 of 29 Review date: October 2012
Anaesthetic Department
Signature & date
Please note that changes to the theatre timetable will only be made once this form has been
authorised and returned to the Theatre Information Team
Theatre Information Team
Signature & date

APPENDIX 5 - LOAN EQUIPMENT REQUEST SHEET

Patient number
Patient name
Surgeon
Operation date
(if known)
Equipment required
Please return form to Band 7 Theatre nurse for appropriate specialty or department
Supplier:
Order number:
Date ordered:
Signature:
Delivery date:
Collection date:

Checking In of Loan Kits
Date received into

department:
Checked in by:
Signature:
Signature:
Name:
Date & time sent to

DSDU: Date:
Time:
Tray labeled as:
Received from DSDU

to theatres: Date:
Signature

Prosthesis Used
Date:
Patient number:
Prosthesis Stickers

APPENDIX 6 - REASONS FOR CANCELLATION

The ORSOS system code for each reason for cancellation is listed accordingly.
HOSPITAL CANCELLATION: CLINICAL

68 Pre existing medical condition (hospital cx)
69 Unfit due to acute illness (hospital cx)
70 Pre-operative guidance not followed
80 Patient not starved
79 Latex allergy
25 Operation not necessary (hospital cx)
3 Further tests required
10 Procedure done on ward/outpatients
65 Procedure done in X-ray department
21 Patient transferred to another hospital
12 Unsuitable for day surgery
56 Patient requires GA
HOSPITAL CANCELLATION: NON-CLINICAL

6 ICU/HDU beds unavailable
35 Ward beds unavailable
44 Emergencies / trauma
4 List overrun
22 Surgeon unavailable
26 Anaesthetist unavailable
72 Theatre staff unavailable
34 Anaesthetic assistant unavailable
18 Equipment failure/unavailable
20 DSDU Problem
42 Administrative error
73 Operation date brought forward
7 Other (PTL/Cancer) cases took priority - Elective only
PATIENT CANCELLATION
66 Appointment inconvenient (patient cx)
2 Unfit for surgery (patient cx)
5 Operation not required (patient cx)
77 Patient had operation privately
78 Patient treated by Alternative Provider (APO)
16 Patient died prior to theatre
17 Patient refused operation
76 Unable to contact patient
1 DNA
CHANGES TO ORSOS
36 Patient transferred to another theatre
41 Clerical error (not a cx)
CONSULTATION CHECKLIST
Author; please attach this to each copy of the policy being sent to a meeting for
comments.
Dear Chairman, please would you review this policy at your committee and return any
amendments / comments to ____________________________ by _____ / _____ / _____
Title of meeting ______________________________________
Date of meeting ______________________________________
Name of policy ______________________________________
Name of author ______________________________________
Yes No N/A
Are there any elements of this policy which present
operational issues that require further discussion? If yes,
please provide a contact name for the author.
___________________________________
Is the policy referenced?

Does the policy include a training plan?
If you are the appropriate forum, have the necessary
resources been agreed to implement this policy?
Is there a plan for policy implementation?
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
Other comments
from meeting.
Policy accepted without further comment. (Please circle) Yes / No

Policy needs further amendment. (Please circle) Yes / No
Name of Chair __________________________

Signature ______________________________ Date _____ / _____ / _____
For Human Resources Policies only
Name of Staff Side ______________________
Signature ______________________________ Date _____ / _____ / _____


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Royal United Hospital Bath NHS Trust

Operating Theatre List

OPERATING THEATRE LIST POLICY

Reference Number: 725 2007

Author / Manager Responsible: Heather Cooper

Deadline for ratification:

Review Date: April 2009

Ratified by: Theatre Users Group

Date Ratified: April 2007

Related Policies Patient Access Policy

Author : Heather Cooper Date: April 2007

Consultation and ratification schedule - - - - 3

Aims, Objectives and Area of Policy - - - - 4

1. List Compilation, Notification & Submission - - 6

3. Procedure for Changing Patient Details on Operating Lists 9

4. Surgical Booking Process Flow Chart - - - 11

5. Procedure for Notification of Change to Theatre Timetable 13

5.1 Procedure for Change of Surgeon on Operating Lists 14

5.2 Procedure for Cancellation of Operating Lists 14

5.3 Reallocation of Cancelled Sessions 16

6. Record Keeping & Data Requests - - - 18

APPENDIX 1 Minimum Standards for Elective Surgery 19

APPENDIX 2 Theatre List Scheduling Guidance - 20

APPENDIX 3 List Submission Timetable - - - 21

APPENDIX 4 Notification of Change to Theatre Timetable 23

APPENDIX 5 Loan Equipment Request Sheet - - 25

APPENDIX 6 Reasons for Cancellation - - - 28

Author : Heather Cooper Date: April 2007

CONSULTATION AND RATIFICATION SCHEDULE

Name and Title of Individual Date Consulted

Date policy e-mailed to policy co ordinator

Name of Committee Date of Committee

Author : Heather Cooper Date: April 2007

AIMS OF THE POLICY

¾ To establish an agreed set of procedures for formulation and submission of

¾ To ensure, wherever possible, full utilisation of available operating sessions;

¾ Identify responsibilities of key staff involved in the compilation and submission of

¾ To establish methods of identifying lists where specialist equipment or staff is

Author : Heather Cooper Date: April 2007

The policy covers:

¾ Responsibilities for compilation, notification and submission of all operating lists;

¾ Distribution flow for operating lists;

¾ Identification of PTL, cancer and private patients;

¾ Identification of teaching and training lists;

¾ Procedure for cancellation of operating sessions;

¾ Guidelines for the re-allocation of operating sessions;

¾ Timescale of notification of surgeon and anaesthetist leave;

¾ Identification of specialist requirements, staff and equipment; and

¾ Procedure for changing operating lists after submission to the Theatre

Author : Heather Cooper Date: April 2007

1. LIST COMPILATION, NOTIFICATION AND SUBMISSION

1.4. All patient details must be recorded including:

1.7. Emergency lists should, where possible, be formulated with as much

Author : Heather Cooper Date: April 2007

1.15. Any specialist equipment required should be highlighted on the operating

1.16. Loan Equipment Request Sheets should be completed in full at the

2.2. The Elective Admissions Manager is responsible for ensuring list

Author : Heather Cooper Date: April 2007

2.15. Senior theatre staff will be informed immediately by the Theatre

2.18. Remaining lists should be disposed of in Recovery or the Theatre

Author : Heather Cooper Date: April 2007

3.7. Any changes regarding specialist equipment requirements should be

3.11. Cancelled operations must be recorded on ORSOS on the date which