1470 MAY 26, 1962

140A 2,192
PLANNING OPERATING-THEATRE SUITES
PLNIN OEATN-TETR
BRff
MEDICAL JOURNAL
changes in operating-theatre planning, and Hospital
PLANNING OPERATING-THEATRE Building Bulletin No. 1 (Ministry of Health, 1958)
SUITES confirmed the general pattern which had been estab-
lished. Most recent plans were based on the concept of
BY twin theatres sharing sterilizing- and sink rooms.
MICHAEL ESSEX-LOPRESTI, M.R.C.S., D.A. Sometimes the sterilizing-room was located on the
Assistant Senior Medical Officer outside in an attempt to reduce the effect of wild heat
AND from the sterilizers on the theatre temperature and
DAVID HUBERT, A.R.I.B.A. ventilation system. This meant that the only access to
Principal. ssistant Architect the sterilizing-room for both staff and sterile supplies
was through the sink room or through a theatre. If, on
North-West Metropolitan Regional Hospital Board the other hand, the sink room were beyond the
sterilizing room (Fig. 1), staff and material for disposal
Although the design of operating-theatre suites has been
influenced by the needs of modern surgical and
anaesthetic practice, the planning of theatres has been
more dominated by tradition than most other parts of
a hospital. Improvements in equipment and an
increased appreciation of the methods by which infec-
tion spreads make it timely to consider whether the plan
of a conventional operating-theatre suite meets present- I I
day requirements or whether modifications in accepted THEATRE STERILISING THEATRE
plan relationships could contribute to asepsis and ease
of working. L
It is only in comparatively recent times that hospitals -:SCR71 UB LP
have set aside special rooms for surgical operations. At
first operating-rooms were designed for demonstration ANA ES-
THETIC
and had tiered standings from which the students had TROLLEYS
an unobstructed view of the surgeon at work.
Appropriately enough, they were called theatres and the
name has been r,tained in this country. An adjoining
anteroom in which patients were prepared was in
evidence by the middle of the eighteenth century
(Russell, 1957), and this basic plan remained for some
150 years (Tomes, 1873; Osborn, 1876).
Lister's (1867) paper "On Anti-Septic Principles in the
Practice of Surgery" led to a growing understanding of
bacteriological principles, and Burdett (1893) was able to
cite existing operating-theatres which were isolated from FIG. l.-Twin theatres sharing sterilizing and sink rooms.
the wards to avoid infection, which were provided with must pass through a cleaner area unless it were possible
ventilators at high and low levels, and in which all to provide an outside door. This could be done if the
finishes were smooth and impervious so that the whole suite were at ground level, but such a door would allow
room and its contents could be washed and disinfected.
unfiltered air, and even unauthorized persons, to enter
Sinks, slop-hoppers, and sterilizers were provided and the operating-theatre.
the way was opened for the practice of aseptic surgical
techniques. Thus the theatre became an easily cleaned Williams et al. (1960) have emphasized the potential
multipurpose room in which the staff scrubbed-up, and danger of cross-infection between theatres sharing
the bowls, instruments, and materials were prepared and ancillary rooms and recommend that an independent
sterilized before an operation and were subsequently sterilizing and sink room should be provided for each.
washed and stored. Such theatres built at the turn of This would necessitate the installation of autoclaves
the century are still in use to-day. (which should be duplicated in case of breakdown), an
ultrasonic washer and other disposal equipment for
Between the wars surgeons came to recognize the each theatre, and an increase in the number of trained
advantages of removing subsidiary functions from the staff to supervise the preparation of the instrument
theatres to ancillary rooms to avoid the discomfort trolleys. There were other disadvantages of siting this
caused by steam from the boiling-water sterilizers and equipment immediately adjacent to the operating-
to reduce the noise as instruments were washed and theatre. Heat from the autoclaves, despite insulation
trolleys prepared. A report was published (Ministry and separate ventilation, raised the temperature and
of Health, 1937) recommending that an operating-theatre disturbed the planned air movement designed to carry
suite should form an enclosed cul-de-sac off the main infection away from the clean areas. Further, the
hospital corridor, that an anaesthetic room should lead automatic control mechanism was frequently not
into each theatre, and that a sterilizing-room, a sink
" flame-proof " and should not be fitted in an area where
room, and a scrub-up room should be directly accessible, inflammable anaesthetics and surgical spirit were used.
without doors, from the theatre. It was pointed out that The washing of bowls and instruments remained a noisy
economy in staff and equipment could be achieved by procedure even with the introduction of mechanical
sharing these ancillary rooms between a pair of theatres. appliances, and it was impossible to subdue the sound
The research undertaken by the Nuffield Provincial with the hard surface finishes which theatre hygiene
Hospitals Trust (1955) did not lead to far-reaching demanded.
 MAY 2 5, 1962 PLANNING OPERAT'4G-THEATRE SUITES BRITISH
MEDICAL JOURNAL
1471

mechanical washer and bags of soiled linen and

Central Sterile Supply Department material for disposal left for collection in a lobby open-
Accordingly a strong case could be made in favour ing from the sink room to outside the clean area. The
of removing sterilizing-rooms and sink rooms from the trolley is disinfected and the cleaned instruments and
vicinity of the theatres. It could be achieved by relying utensils are returned on it to the preparation room.
entirely upon a central sterile supply department to The centralized sterilizing unit should be situated as
provide every sterile pack required, but it was generally close to the operating-theatres as possible, its position
agreed that while the central supply of sterile linen, being influenced by the need to have access from the
dressings, syringes, and so on was acceptable, the selec- hospital to the stores adjoining the preparation room
tion of instruments for a particular case must be under and from the disposal bay to the hospital circulation.
the supervision of the theatre staff, as only they knew These communications could be horizontal or vertical.
the individual preferences of each surgeon. Moreover, To obtain a smoothly flowing circulation of sterile goods
the difference between theatre instruments and those from the sterilizing-room to the theatre supply rooms.
supplied to the wards and other departments would and of soiled articles back to the sink room, it is
probably make it more convenient for them to be dealt expedient to provide separate corridors (Fig. 2). One
with separately in the central sterile supply department, route could be along the theatre corridor and the other
thus establishing a sub-unit. We believe that there is a could be by a separate passage reserved for the move-
case for such a unit, but that it should be divorced from ment of trolleys in one direction only. This passage
the central department and sited in the clean zone of could possibly be used for sterile goods to avoid the
the theatre suite supplying the sterile needs of the risk of contamination and shorten the journey to the
theatres on the production-flow principle (Fig. 2). theatre. Soiled articles would be returned to the sink
I - - 0 - -
T I-
I I Il

I W 0
-
SUPPLY SUPPLY SUPPLY SUPPLY
-
to
,,V

w-z~~~~~~
+I
INSTRUMENT
TROLLEYS
a I

m e SIN K
bi_-- -- - - - - - . - - -
,

FIG. 2. Plan showing sterilizing and sink rooms removed from vicinity of theatres.
In this system a preparation room would hold the room by the theatre corridor; they should be covered
stock of theatre instruments and bowls and have direct to prevent the airborne transfer of infection while in
access to stores of linen and presterilized packs which transit and to conceal anything which might distress a
could be replenished from the "hospital" side. Lists patient on the way to an anaesthetic room. A sink
of the day's cases in each theatre would be displayed must be provided near the exit from each theatre with
and the instruments, bowls, linen, and dressings for each storage space for materials for cleaning the operating-
case collected on to a trolley. The preparation of the table and floor between cases.
trolleys for all the theatres would thus be easily super-
vised. The trays or packs of instruments and bowls Avoidance of Cross-infection
would be autoclaved and then taken on the trolley As there is a risk of cross-infection between
together with the presterilized packs of linen and theatres when sterilizing and sink rooms are shared,
dressings to the sterile supply room attached to each the circulation through the centralized sterilizing unit
theatre. must be examined closely to ensure that this risk is
Each sterile supply room would contain a stock of not repeated. Cross-infection could occur if articles
sutures, sterile fluids, and a number of spare wrapped from one theatre were to move through the sterilizing
instruments, previously sterilized, to replace a dropped unit and enter a different theatre without being properly
or forgotten instrument without the delay necessary for cleansed. Instruments and utensils would always be
resterilization. A telephone communicating with the autoclaved, but dressing trolleys are difficult to dis-
preparation room would allow a theatre nurse to request infect and we suggest that each trolley should have a
other instruments should the case on the table require label or identifying colour so that it could be reserved
an unexpected surgical procedure, or should an for a particular theatre. This would have the additional
emergency be introduced into the list. advantage that the arrival of a trolley in the preparation
At the end of a case the soiled articles are taken on room during a list would indicate to the staff the theatre
the trolley from the theatre to the sink room. The from which it came and they would then prepare the
instruments and bowls are cleaned in an ultrasonic or instruments for the next case in that theatre. Again,
 1472 MAY 26, 1962 PLANNING OPERATING-THEATRE SUITES B^msH
MEDICAL JOURNAL

when the trolley left the sterilizing unit there would be supply room. Since theatre 2 will have the larger
no doubt about the theatre to which it should be taken. number of cases, it adjoins the sterilizing unit, while
Another precaution is to restrict the movement of theatre 1 is reached by a short corridor reserved for
staff through the sterilizing unit, which could be sterile supplies only.
achieved by fitting stable doors at the entrance and After each operation soiled articles would be covered
exit of the sink room, the lower halves normally being and wheeled down the main corridor to the wash-up
open to allow trolleys to be pushed into and out of the room. The disposal lobby, linen store, piped oxygen
room. Indeed, it would be possible to regard the sink store, and autoclave chamber, all open into the
room as being outside the clean zone and to staff it by hospital corridor outside the clean area. The staff rest
an orderly or porter who entered and left through the rooms have a pleasing outlook on to the garden and
disposal lobby. At night, when a small staff is on are sited near to the tea kitchen. The surgeons' rest
duty, it is likely that one theatre only would be in room can be used as an overnight room by a doctor
use and the routine could be modified. Air movement who wishes to remain near to a serious case in the
between theatres is unlikely to occur through this unit. adjoining recovery room. The recovery room will
One practical application of these proposals is a suite mainly serve theatre 1, but it is planned to be easily
of two theatres (Fig. 3) intended mainly for thoracic reached also from the angiocardiography room of the
x-ray department and
10 5 0 10 -o 30 40 50
to have an outlet to
the approach corridor.

A Suite of Five
Theatres

RSTEKI Li SNAwc UTOCL,2 Another application

SUFFL 00g (Fig. 4) shows five
theatres clustered
WOPJRA O 0
round the sterilizing
ro<> m~ unit. As before, the
sc-Ku ilr approach corridor
UP WA5 H- UrP leads to the changing-
rooms and a patients'
l 9gOtransfer
[I F bay adjacent
;$l5+73 X to the theatre superin-
tendent's office. The
']1J)wcc O D
entrances to each
AL :_ENU5ES theatre are arranged
LNaUItf so a
that the patient
_STOKE_ _ S enters on one side of
the table and the
)B BY sterile trolley and
scrubbed-up staff on
the other. Patients
may be retained in
the lobby outside a
theatre for a short
period after operation,
and windows have
F. A. C. M A,UNDER F J.6A.T.Fi. been provided in the
A CHITECT anaesthetic rooms to
FIG. 3.-Plan of two-theatre suiite. facilitate supervision.
In the preparation
surgery. Theatre 1 is here enlarged to accommodate the room there is a wall-mounted instrument cupboard
special equipment required for this work and theatre 2 along one side with space for trolleys beneath, and at
is primarily an endoscopy room. The approach corridor the end is a store for sterile packs of linen and gloves.
from the hospital leads through swing doors to the From time to time this storage unit may be lowered for
changing-rooms, patients' entrance, and the exit from restocking into the central sterile supply department on
the recovery room, so planned that the clean corridor the floor below. Three autoclaves are provided, having
can be reached only through the changing-area. In the service access from below.
lobby adjacent to the sister's office the patients' ward It is estimated that four instrument trolleys should be
blankets are changed for blankets reserved for theatre available for each theatre and these should be labelled
use, and ward nurses and porters put on gowns and shoe so that they are not interchangeable. While one trolley
covers before entering the clean corridor and proceed- was being used in the theatre, another would be
ing to the anaesthetic rooms. In practice the patient prepared and left waiting in the supply room, a third
enters the theatre on one side of the operating-table might be in the sink room with the soiled articles from
while the sterile trolleys arrive on the opposite side to the previous case, and a fourth should be available if
reduce the risk of contamination. Surgical instruments, an additional set of instruments was required at short
utensils, and linen are prepared in the sterilizing unit notice for the case on the table or to allow an adequate
and wheeled on covered trolleys to the appropriate turn-round for a series of quick cases. Stable doors are
 MAY 26, 1962 PLANNING OPERATING-THEATRE SUITES BRJUH 1473
0 V so .30 40 o0

SCALE OF FEET

CLEAN CORRIDOR -SUGEONS' ALENUES NUSS'

J EO REST E'IT REST
ANAESTHETIC L ANAETHETIC
DARR NRE
u% S'
CRU CRU
| 1Al DAR SU EONS'CHANCINC ' ' NGING
STOE OPERATING UO UP t OPERATING ROOM lANCING
UP EN
THEATRE THEATRE STOkE SURGEONS

0 SISTEK5S PLASTER
TKOLLEY AUTOCLAVES NCN
WAk-L UP
bpY OPELATING c I w

5.CRU~ U MALE c
AND STERILIZINC TROLLEY TH E AT RE UP 'RSES co
0 ANEStTIETI T
DISPOSAL STEKILE SUPPLY esy Z NG

o ~qDERLIES
r--~
<SUPFLY S5UPPLYI NETI I
71 |OPEKATINC L- \1 POPERATING CLEANER RECOVERY
THEATRE FCRU RU THEATRE LINWN WARD
LR~ 11uUP 1-} 1-1 UP 11EQIUEENNDE L
F9AESTHETICI THEATKE<vm
CLEAN UP ><| nS~~~~~~TOIkE
I _ ANAESTHETIC|| U ESuIpNlTN
L
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URGEON F
CLEAN
[3_
CORRIDOR
TRANSFER E LUICE

F. A.C. MAUNDER P.br.A.ff A.M.T.E,L

ARCH ITECT
Fio. 4.-Plan of suggested five-theatre suite.
provided at the entrances and exit to the sink and clinicians, and nursing staff who have helped us to for-
disposal room, and a hoist and stairs communicate with mulate our ideas.
the floor below. The theatres are lighted naturally by
means of clerestory windows having double glass with REFERENCES
blinds between. The plaster room is sited in a bank of Burdett, H. C. (1893). Hospitals and Asylums of the World-
Their Origin, History. Construction, Management, and Legis-
rooms remote from the clean corridor to reduce the risk lation. Churchill, London.
of contamination from old infected plasters; the Lister, J. (1867). Lancet, 2, 353.
recovery room adjoins and may be used for the inten- Ministry of Health and Department of Health for Scotland
(1937). Report of Departmental Committee on Cost of
sive care of cases of respiratory acidosis from the wards Hospitals and Other Public Buildings. H.M.S O., London.
as well as for post-anaesthetic cases. - (1958). Hospital Building Bulletin, No. 1. H.M.S.O.,
London.
Nuffield Provincial Hospitals Trust and the University of Bristol
(1955). Studies in the Functions and Design of Hospitals.
Summary Oxford Univ. Press. London.
The plans of conventional operating-theatres are Osborn, S. (1876). Brit. med. J., 1. 13.
Russell, R. (1957). Guy's Hosp. Rep., 106, 133.
examined in relation to economy of working and the Tomes, C. S. (1873). Brit. med. J., t, 297.
prevention of cross-infection and certain deficiencies are Williams R. E. O., Blowers, R., Garrod, L. P., and Shooter,
R. A ( 960). Hospital Infection, Causes and Prevention,
noted. It is proposed that a centralized sink room and p. 164. Lloyd-Luke, London.
sterilizing unit should be provided in the theatre suite
to serve all the theatres, and the organization and the
circulation of staff and goods are considered in detail. The National Marriage Guidance Council has published
a booklet, Making Ends Meet. with the aim of helping
We thank Dr. F. J. Fowler. senior administrative medical young couples to plan their finances. " It is very surprising,"
officer, and Mr. F. A. C. Maunder. regional architect. North- says the booklet, " how a financial tiff can turn into a
west Metropolitan Regional Hospital Board, for their domestic crisis." The booklet is obtainable from the Book-
-encouragement and helpful criticism, and our colleagues, room, 58 Queen Anne Street, London W.1, price 3s. post free.