THE MODERN CONCEPTION OF AN OPERATING THEATRE SUITE M. TOWERS. M.B., CH.B., D.A., Port Elizabeth We have, of recent years, heard a great deal about the 'winds of change', and nowhere can this be more aptly applied than in the great changes in thought and practice that have developed in regard to the construction, and organization, of the modern operating theatre suite. There have been so many commissions and investigat- ing bodies, appointed in different parts of the world. to probe into the many aspects of this fascinating subject, that the reports and literature that have accumulated, have assumed formidable proportions. Since extensive new hospital building and reconstruc- tion is contemplated all over South Africa. it is essential that these new ideas of what should constitute the ideal operating theatre suite, should be widely disseminated, and more fully understood. We are on the brink of an era of what I shall describe as 'spare part' surgery. I refer to organ transplants. So it seems that surgery is going to become more complicated, more exacting and time-consuming, and will require the combination of more teams. Yes, the 'winds of change', are blowing lustily here, too. Gone are the days of the urgical virtuoso-to be replaced by surgical teams or units. Gone too, are the days when the operating theatre taff would accept, without protest, adverse, unhealthy, and trying working conditions. Gone also, are the days when all the anaesthetist was expected to do, was to keep the patient asleep and immobile, when he was de- fined as 'a man half asleep, looking after another man half awake'. Today his job is not only to keep the patient asleep, but he plays the major role in keeping the patient alive. This, inter alia, involves a host of monitoring equipment, laboratory facilities and others, for special investigations, plus the immediate availability of everything required for any resuscitative measures. All the skills of modern surgical units and all the new scientific developments will be of little value unless the operating theatre suite is properly planned and works efficiently. The operating theatre suite must be so well designed and so attractively set out, that not only will the work done there be of the highest order, but the personnel en- gaged therein, will find it a real pleasure to work in such ideal surroundings. Fatigue will be minimal, boredom non- existent, efficiency at its highest peak, and pride of achieve- ment the driving force. Yet, despite all this turmoil, we as a profession, cling tenaciously to our conservative concepts. We are just natur- ally opposed to any radical changes, and in fact, seem to be allergic to them. Simply the mention of them will always evoke a reaction. Most of the operating theatres in this country are com- pletely outdated-they open directly from a main corridor, in such a way as to be constantly exposed to gross con- tamination; a steam sterilizing room, with its high humi- dity, steam and heat, often leads directly off the theatre; and often there is no provision for ventilation, except by opening windows, and doors; the windows are facing directly into the sun, and even the direction of the pre- vailing winds have not been taken into consideration. In many of our hospitals, where air-conditioning, and plenum ventilation, have been installed, these have proved unsatisfactory. The reason for this is either because the initial specifications have been inadequate, or the com- pleted job has been accepted without proper tests having been carried out to ascertain whether everything is work- ing efficiently, and conforms to certain minimal standards. Too often the services of a competent bacteriologist are not consulted. In many instances it is obvious that the basic principles of plenum ventilation are not fully understood. The idea is to introduce filtered air-conditioned air at a temperature of 70F and a humidity of 50%, through apertures near the ceiling in the theatre. This air must be under pressure, and there must be _ 20 changes of air in the theatre per hour. This air is forced down to the floor taking any organisms with it, and gets out of the theatre suite under the doors. In many instances, particularly. where ventilation and air-conditioning have been installed into previously built theatres, we see rather a conflicting et-up. The air is cor- rectly introduced into the theatre, which unfortunately has a sterilizing room, directly communicating with it. In this room, there is invariably a canopy over the sterilizer, with an extraction fan high up. So the air from the theatre, plus any contaminated elements, gets into the sterilizing room, where the extraction fan high up sucks up the air from the floor leveL and in the process, ucceeds in dis- seminating. very effectively, any organisms which might be present. Gordon, in his article on the post-anaesthetic recovery room. describes the initial opposition encountered from the medical and nursing staff to the establishment of a re- covery room. TOW that it has been in existence for 10 years, they wonder how they ever managed without one. Yet now that, as a natural outcome to the existence of a recovery ward, an intensive therapy unit is about to be established. opposition is being encountered from the same sources. This unit should be near, but not part of the operating theatre suite. Before embarking on a description of the modem operating theatre suite, I should like to enumerate some basic aphorisms, which have evolved from the massive assault on this subject, by the various investigating bodies. I. Do not consider economy when planning an operat- ing theatre suite and certainly not at the expense of effi- ciency. Remember that good operating conditions can never be cheap, or acquired at bargain rates. 2. Plan for the future-and plan on a very liberal scale. The extra expense now will pay handsome dividends later. 3. Don't consider an operating theatre as a factory, and try to get the maximum return for the initial investment. Always ask, not how many operations can be done, but rather, how many should be done. Ideally, each theatre 182 S.A. TYDSKRIF VIR GE 'EESKU 'DE 25 Februarie 1967 should be given a completely free day. in the mid-week -besides the weekends-pIu a two-hour break between 'slates'. The greater the number of operations done in a theatre, the higher the possible incidence of sepsis. 4. It is not good economics to try and convert old theatres. They are never completely satisfactory, and eventually new theatres must be built. 5. The modern idea is veering towards progressive pa- tient care, and building a surgical block completely separate from the rest of the hospital. Progressive patient care is the systematic grouping of patients, according to their degree of illness, and depend- ency on the nurse. rather than by classification of disease and sex. It is a method of planning the hospital facilities, both staff and equipment, to meet the individual require- ments of the patient, and in practice, does not infer the construction of new hospitals, but a reorganization of the existing one. Thus there would be (a) intensive care units for critically ill patients, regardless of diagnosis or sex, who need highly specialized and constant nursing care; (b) self-care units for convalescent patients, or those requiring investigation; (c) intermediate care units-not in either of the above categories and which would constitute of all patients in hospital; and (d) beds attached to outpatient departments-for I-day patients like those hav- ing minor operations, electroconvulsive therapy, etc. 6. Much faulty planning in the past was due to an approach which concentrated on the operating theatre, without taking into account the equally important ancillary services and rooms. This conception of a recovery ward attached to the theatre suite is not only accepted every- where as a must, but many overseas hospitals have had this unit for 10 years or longer and could not envisage working without one. BASIC PRINCIPLES IN PLANNING AN OPERATING THEATRE SUITE (OTS) The sire. Ideally. it should be a separate building wi'h its own corridor of approach to ensure that it is literally a cul-de-sac, its lay-out should not be influenced by the ward block plan, it should have maximum protection from the prevailing winds, solar irradiation, or sources of heat, and it should not be exposed to any source of direct con- tamination. It should be on the first floor, with the central sterile supply depot (CSSD) situated immediately below it. In the rare case where the free availability of land permits the OTS to be sited on the ground floor, it is advisable to protect it, by building on an extra floor above it. Today, with the modern idea of a large reception room and a recovery ward forming part of the OTS, the question of the distance this unit is away from the wards is not an important one. The rooms of the suite should be so arranged that there is a continuous progression from the entrance to the suite. through zones that increasingly approach sterility, to the operating and sterilizing rooms. People working within the suite should be able to move from one clean zone to another, without having to pas through unprotected traffic areas. Thus. the surgeon, after he has changed into his operating clothes. should be able to move to the scrub room, without having to pass through the entrance lobby. Tt should be possible to remove dirty materials from the suite, without passing through the clean area. The direerion of the air flow within the operating suite should be from clean to less clean zones. The heating and ventilating systems should ensure, safe, comfortable climatic conditions for the patients, surgeons and staff. The ratio of surgical beds and number of operating theatres required is difficult to assess with any fixed rules. Much depends on the type of work done. the number and nature of the industries in the area, and the number of surgeons, urgical firms, and operations done. Too many operations in a theatre encourages sepsis. Each theatre should be used only 4 days a week, long 'slates' should be avoided, there should be adequate time allowed between 'slates' for theatre to be properly cleaned, and finally, there should be separate theatres for septic cases, plaster removals, neurosurgery; Stewart and Douglas recommend one operating theatre for every 30 beds. It is better to keep the lay-out of each theatre more or less the same. Building theatres as mirror images of each other is not good policy. The size of the operating theatre should be 22 x 22 ft.- a little larger than that usually recommended. The increase in recent years of operations in which 2 teams operate synchronously-abdomina-perineal resection. open hearts. etc., calls for a large theatre, 25 x 25 ft. in every large general hospital, and not less than 2 operation rooms of this size in a teaching hospital. The height of many of the older theatres was deter- mined by the supposed need for large windows and for providing a large volume of air. Today, with efficient mechanized ventilation, and adequate lighting facitities, windows are not absolutely necessary, and the height of the ceiling need not be over 10 feet. However, the height is also often determined by the type of lighting used. Proper anti-static measures must be taken; all theatre walls must be screened with wire mesh to minimize outside electrical interference, and even the colour of the wall and ceilings must be carefully planned. There are five basic probems involved when planning an operating theatre suite (OTS) which directly influences its design, and general lay-out. I. The Method of Sterilization The present-favoured method is bv high-pressure steam. plus a pre-vacuum, in an autoclave. . There is, however, a great deal of research going on in this field, and it is quite possible, that in the neat future, a more efficient method like ? gamma irradiation may supersede the present one. Only a small 'flash' autoclave is needed in the preparation room adjacent to the theatre. This is for instruments that have become contaminated during the operation or for those re- qUired and not initially supplied. Sterilizing time for these is 4 - 5 minutes. The currently accepted idea is the establishment of a central sterile supply depot (CSSD). This should be sited on the ground floor, below the operating suite, and should commUnIcate With the sterile zone via an exclusive lift or hoist. The CSSD will provide sterile packs, and the bulk of the materials such as gowns, caps, masks. gloves. towels, tubing, catheters, syringes, sterile water and saline. etc. H was thought that the CSSD should not supplv the sets of instruments for each operation, as there was too much indivi- dual variation and this would necessitate much laroer stocks of instruments. This has. however, not been the ex- 25 February 1967 S.A. M-E-f).ICA-L lOUR 'Al 183 perience. In the centres where the CSSD performs this func- tion, the concensus of opinion is that it works very well, and that even allowing for the individual idiosyncrasies of sur- geons, most can manage with the packs provided. There are decided ad"antages in having one CSSD only, for, b e s i d e ~ the economy in staff and equipment, the teaching programme is more comprehensive. since nurses doing their theatre training can be taught about every branch of surgery. It is generally accepted today that sterile packs have almost completely superseded drums. In addition. because it has been found satisfactory to store sterile packs for relatively long periods of time, provision for the storage of these has had to be made in the OTS. The CSSD situated as it is on the ground floor, can be so planned that it proyides sterile materials for outlying small hospitals, clinics, maternity services, etc. In many of the larger hospitals, additional sterilization faci- lities ha"e been provided. A theatre sterile supply unit (TSS ) has been established within the theatre suite to serve all the theatres. Here, packs of instruments are made up according to the requirements of individual surgeons, and then sent to where they are needed together with the sterile packages ordered from the CSSD. After each operation, the instruments should be washed in the sink room, and returned in a con- tainer to the TSSU or CSSD, to be autoclaved and stored, be- fore being assembled for use again. In many hospitals, particularly in the SA, ethylene oxide is being used to sterilize the large equipment, like heart-lung machines. anaesthetic equipment, etc. This method is not en- tirely satisfactory. It is expensive, usually needs a separate room, and is potentially toxic and dangerous to the personnel. 2. The A \'oidance of Cross-Infection This is one of the main considerations influencing theatre de- sign. This is why the OTS should be an entirely self-contained area; why proper provision must be made to control and moni- tor the air currents coming into the suite from outside; why the theatre areas can only be entered via the change rooms; why only proper theatre clothes can be worn; why nothing likely to contaminate the theatre area, like the patients' folders, X-ray films. ward clothes and blankets and even wrist-watches, should be permitted into the sterile zone; and why any excess movements, and talking in the theatre is to be discouraged. 3. The Provision of Suitable Climatic Conditions Admission into the sterile zones, of filtered, air-conditioned air, with a humidity of 50 - 60% and a temperature of be- tween 65 0 - 75F. Plenum ventilation under pressure and change of air every 3 minutes. To achieve a satisfactory condi- tion, one must make rigid specifications; the plant must be meticulously tested before acceptance and thereafter, regularly and thoroughly maintained, and there must be provision made for a humidifier, and a refrigeration plant. There is really no necessity for windows, except that there are many people with claustrophobia. Tindal, in his very radi- cal article on this subject, envisages the theatres of the future as large steel air-conditioned cylinders, under about two at- mospheres of pressure. The theatre clothes he recommends are skin-tight and gloves are replaced by thorough washing, plus the application of resin to the hands. The deyelopment of lighting facilities has lagged behind that of theatre design. The present overhead lighting seen in most of our theatres, is very unsatisfactory, and a source of constant annoyance to the surgeon. They have to be moved and refocused by someone in the theatre at frequent interv::.ls during the average operation, the results are seldom quite right. and all this unnecessary movement over the theatre table encourages wound infection. Blin. of Paris, has devised an ingenious lighting system, which has. i/ller alia, been installed in the Port of Spain Hos- pital, Trinidad, and seems to be working satisfactorily. His source of light is from outside the theatre which has, as its ceiling, a transparent dome. By a system of reflectors, which are moved by electric motors, the surgeon can focus the light onto 2 separate operating fields at the same time. The control lever has been conveniently placed within easy reach of the surgeon and is covered with a sterile towel or cover for each operation. It i possible that the electrical engineers might in the near future devise something even better than this. It is enough that we realize the shortcomings of our present lighting sY3tem. and campaign for something better. 4. The Imporlance of MonilOring Syslems and Provision of Teaching Facililies Since surgery is becoming progressively more complex, it has become necessary to use more sensitive, and more efficient monitoring equipment. If these were all housed in the theatre. they would occupy enough space to interfere with its efficiency. and also constitute an additional hazard towards wound sepsis. Fortunately. internal television, though expensive to instal. has solved a host of problems, and is, without any doubt. accepted as an essential part of the equipment in any teaching hospital today. Television allows a monitoring room to be outside the theatre, often in a room above. It permits the theatre super- visor to see what is going on in theatres, via a television screen, and obviates the necessity of having to build viewing domes, or galleries for the students or nurses, who can now. in the lecture theatre, obtain a perfect view of operative pro- cedures, on the television screen. 5. Adequate Provision for Ancillary Services A large reception room with amenities for staff, patients. and their relatives: a recovery ward, an anaesthetic suite. which includes study and research facilities, a laboratory. a blood transfusion unit. X-ray units, separate theatres for sep- tic cases, an endoscopy theatre, a separate neurosurgical theatre unit, a separate theatre for removal of plaster-of-paris casts. and generous facilities in the staff change rooms for both sexes, including rest rooms, bathrooms, a library, a common-room. a tea room, etc., should all be provided within the OTS. DESIGN OF THE OPERATING THEATRE SUITE Although the design of the modern OTS which I am about to describe, is one which has gained considerable popu- larity in numerous hospitals all over the world, it has not been accepted as the ultimate in theatre design. There is, for example, the modular SySlem in which the operating zone, is one large, unimpeded floor space, on which are erected prefabricated transparent theatre units. The ad- vantages claimed for this system is that the whole lay-out can, in a matter of hours, be dismantled, and any future changes in design can thus be economically incorporated into the reassembled units. It is precisely because there is, to date, no universally accepted design for an OTS that I have concentrated on basic principles. A simple plan setting out this OTS design is shown below. The modern OTS besides complying, wherever possible. with the principle of isolationism, is divided into four zones: (I) an outer protective zone-leading into (2) a clean zone; (3) a sterile zone; and (4) a disposal zone. 1. DUler Protective Zone This zone will occupy the major portion of the floor area of the OTS because it is here where provision mu t be made for housing the many ancillary services. It is in this zone that the architect must be given a free hand to plan for every conceivable contingency. and provide all the comforts_ and safeguard the health of everyone connected with the operating theatre suite. I shall enumerate, briefly, the many components of this zone, with short explanations where necessary. (a) A reception room should be generous in size, as it must fulfil a number of functions, and the decor should 184 S.A. TVDSKRIF VIR GENEESKUNDE 25 Februarie 1967 PLAN OF OPERATING THEATRE SUITE DESIGN OlR1Y CORRIDOR - DISPOSAL f---r--------,rl -l lfl lfl C O.T. 1 J oPE.Rf\1lNG THEATRE CLEAN ZONE OUTER PROTECTIVE ZONE O.T OT OPE RATING be bright and pleasant. It aelS as an auembly site; the pa- tients for the day's operating list are wheeled in on special trolley beds, during the course of the morning. The pre- sence of this room helps to reduce the amount of infection brought into the clean and sterile zones of the OTS. As the prospective operating cases are wheeled in they are a sembled in one section of this room. Before their opera- tion. everything on the patient, and on the trolley belong- SUITE CORRJDOR ing to the ward is stripped, and clean sterile sheets, operat- ing clothes, pillows. etc.. are donned. and the trolley pushed on to the clean side of the reception room. When the patient is ready to be wheeled into theatre, the trolley top. plus the patient, is transferred onto a clean trolley base, that operates only in the clean zone, and from this zone is wheeled into the anaesthetic room, which leads directly into the theatre. 5 S.A. MEDICAL JOURNAL 25 February 1967 In the reception room the patients can be given their pre- medication, drips can be put up, and the anaesthetist can once more assess their suitability for operation. Patients' relatives can be interviewed, and facilities should exist where the relatives can be with the patient before opera- tion. At night, patients from casualty can be admitted for observation, without disturbing patients in the wards. Office accommodation should be provided for a recep- tionist or secretary-typist, a theatre supervisor, the duty sister and staff, and medical staff. There should be a place for the patient's relatives, and one where these people can be interviewed, when necessary, by members of the medi- cal staff. At the entrance there should be a cloak-room, where overcoats. hats, umbrellas, etc., can be deposited. A scrub-up room, a small preparation room, a small steri- lizer, a cupboard for keeping dangerous drugs, and a store- room for sterile packs and equipment, must all be provi- ded. Lastly, adequate wash-up and toilet facilities for staff and visitors of both sexes, plus amenities like a tea room, and even music and television, must be incorporated into the scheme. (b) A recovery ward. The necessity for this ward as an integral part of the OTS has been universally conceded. In every hospital where this has been installed it has proved so successful and worth while that they wonder how they ever managed without it. Every patient is taken from the theatre to this recovery ward on specially constructed trolley beds which are used in this ward. These trolley beds have large castors. and a quick and efficient tipping mechanism, operable from either end. The head end is under separate control, so that the patient can be sat up. The width is 2 ft. 6 in., they have a 4 in. rubber mattress, and the ends and sides are quickly removable in case of emergency. Intravenous transfusion stands are incorporated, plus a bracket for an oxygen cylinder. To be on the safe side, plan to have 2 beds for every theatre, even though one could probably do with less. Tn many hospitals, this ward has been used as a com- bined unit, for constant care of patients with respiratory deficiencies. Another use to which this ward has been put, is the reception of night admissions. This keeps the other wards quiet, and groups together patients requiring more urgent attention during the night. The length of stay of patients in the recovery ward varies from 30 minutes to 2 days. The average time is 2 hours. 0 patient is permitted to leave this ward until cardiovascular function and respiration are stable, the re- flexes all recovered, and full consciousness present. A full-time member of the medical staff, preferably an anaesthetist, is usually appointed to supervise the running of this ward, but the patient's own surgeon and physician still manage the care of the patient. The nursing staff is usually chosen for its higher stan- dard of intelligence, and for its greater interest and apti- tude for this type of work. The nurses undergo an inten- sive and highly specialized training in respiratory physi- ology, surgical shock. and the various aspects of all the monitoring equipment. There should be adequate bed space, and there should be 2 points for suction, 2 for piped oxygen, 1 for compressed air, a sterile container with a catheter, and 2 angled-spot- lights for each bed. l85 Adequate equipment for monitoring, plus whatever may be required for dealing with any postoperative emergency, will include laryngoscopes, intratracheal tubes and connec- tions, bronchoscopes, ventilators, ECG and EEG machine, various drugs, intravenous fluids, blood, etc. Since this ward is in continuous use, all amenities must be provided. This will include a kitchenette, a nursing station and sister's office, a doctors' room, plus lavatorie and ablution facilities and rest rooms for both sexes, with similar facilities for the nursing staff. An efficient call system with a link at each bed, so that the nurse can sum- mon help without any delay, is essential. A preparation room, a sterilizing room, storage rooms for dressing packs and equipment, drug cupboards. sluice room, scrub-up room, washing facilities, etc., are all part of this recovery ward. (c) Change roonU". It is important to remember that in the approved theatre de ign, the theatre zone can only be entered via the change rooms. These too should be on the generous scale, and cater not only for both sexes of the medical and nursing staff, but for different people like the cleaners, electricians, engineers, maintenance staff, techni- cians, etc. Besides showers, baths, change rooms, and locker rooms, there could be rest rooms, a library, and a tea room. It is a good idea to instal a glass partition looking into the theatre corridor, so that there could be communication be- tween, say, a chief, and his registrar. without having to enter the theatre area. (d) AnaestheTic deparrmenT. This would consist of an office suite for the head of the department, a duty room, a common room, a reading room, a technical work room, a research laboratory, a lecture room, a sterilizing room and a secretary's office. (e) A laborarory for doing emergency work like frozen sections, Astrup readings, blood chemistry, electrolytes, etc. (/) A blood transfusion unit with all the facilities it needs. (g) An X-ray deparrmenT for coping with all theatre X- ray services. (h) Special neurosurgical Thearres, with their own X-ray units for doing all their investigatory work. (i) A plaster room in which all plaster-of-paris casts are removed. a procedure which is notorious for spreading organisms. (j) A septic thearre for doing all cases known to be septic. (k) An emergency TheaTre, for those cases like ruptured appendices, which come in as emergencies, and are known to be potentially septic. (I) An endoscopy Theatre, in which only bronchoscopies, sigmoidoscopies, cystostomies, and oesophagoscopies are done. (m) Adequate store rooms for storing monitoring and other equipment, intravenous transfusions, and a host of surgical equipment and linens, etc., associated with a theatre suite. (n) A special room for doing the ethylene oxide steriliza- tion. (0) Spare rooms for which plenty of uses can always be found. I I I I I I I I I I I I I I I I I I I I I 186 S.A. TYDSKRIF VIR GENEESKUNDE 2S Februarie 1967 2. A Clean Zone This is really in the nature of a barrier zone, and consists mainly of a clean corridor, plus certain storage facilities. It is in this zone that clean trolley bases are housed. and where facilities exist for keeping them clean. 3. A Sterile Zone It is here that the theatres, anaesthetic rooms, sterilizing rooms, sterile store rooms, scrub rooms, and perhaps a TSSU is housed. Mention has already been made of the different patterns advocated for theatre designs, varying from Tindal's revo- lutionary idea of stainless steel theatres under 2 atmos- pheres pressure, the modular system, and the one I am about to describe very briefly, based on the operatmg theatre lay-out at the Royal Infirmary, Dundee. However the same basic principles already described apply, particu- larly as regards the ventilation, air-conditioning. suitable barriers to avoid infection, and the advisability of building each theatre unit alike, and not as a mirror image of each other. Each theatre unit consists of: (a) An anaesthetic room which should not be smaller than 190 sq.ft. and bigger if used for teaching purposes. The lighting in this room must be adequate, and it is essen- tial to have a special light, easily focused and adjustable for venepuncture work, epidurals, etc. In this room too, there must be piped oxygen and nitrous oxide, plus a spare pipe-line ready for any future anaesthetic gas. A sink, wash-basin, and work table are essential, and there should be at least 3 electrical points. In addition there should be a dangerous drug cupboard, and one for linen removed from the patient. It is wise to have conduits for monitoring cables from the central monitoring room, let into the anaes- thetic room. The general decor should be soothing, the walls should be covered with plastic to give a panelling effect and the ceilings should have a delicate, attractive pictorial design. In this room, anaesthetic induction will be done, moni- toring equipment adjusted, diathermy plates and tourni- quets applied, etc. This room should open directly into the theatre, and should have a separate entrance from the clean zone. (b) A scrub room, with the usual scrub-up facilities and leading directly into theatre. (c) An exit room, leading out directly from the theatre, and communicating with the anaesthetic room and having a separate exit into the aseptic corridor. It is in this room where the clean trolley bed is waiting to receive the patient who is then wheeled into the recovery ward. (d) The operating theatre which besides conforming to the already mentioned specifications with regards to size, ventilation, and lighting must have provision for piped oxygen and nitrous oxide, plus a spare line for a future gas, at least 2 suction points, conduits for monitoring cables, and for television and perhaps a built in X-ray unit. There must be the usual antistatic measures with spark- proof electric points and switches, and the X-ray screens should permit the films to be put in from outside the theatre. All excess equipment should be housed outside the theatre, which should contain the absolute minimum com- patible with efficiency. All unnecessary movements, talking, and walking about in theatre is discouraged, and articles like wrist-watches, patient's folders, etc., are not allowed to be brought into theatre. (e) A sterilizing room containing a small 'flash' sterilizer, for sterilizing any instrument which has fallen on the floor, or become contaminated, and instruments required for the operation and not already set out. It is also used for setting out the sterile packs, etc. (f) A STOre room for storing the sterile packs, instru- ments, etc., that might be required in the theatre. Besides the theatres, this zone houses offices for the theatre staff and surgeons, store rooms, and in many hos- pitals, a TSSU. If the latter is installed, it must be divisible into 2 self-contained parts to allow for maintenance and repair work. without the necessity of a complete shut- down. A dark room for processing X-ray films must also be incorporated in this suite. 4. A Disposal Zone Completely separate with no direct access into any of the other zones. The only communication with the theatre zone is via a 2-sided autoclave, and special hatches, which convey dirty linen and dressings put into containers down the special chutes, into the disposal zone. It is desirable t? have only one disposal zone to serve the whole OTS. ThIS not only enables better supervision of the cleansing and of the equipment, but the teaching of this part of the theatre work is thus centralized and non-nursing personnel can be used. No instrument trolley is allowed into the disposal zone. The instruments after they have been washed are passed via an autoclave, into the disposal zone, into the CSSD or autoclaved and passed into the TSSU. Thus the disposal of soiled and infected material is direct to the disposal zone, over barriers that prevent the passage of any personnel. There is no fear of an airborne spread of infection from the disposal zone to other zones, since the direction of the OTS ventilation is in the direction and under pressure. The disposal zone opens directly on to a 'dirty' corridor, completely separate from the OTS. There are also chutes leading from the disposal zone, to the non-sterile area of the CSSD and to the incinerator re- ceiving-room. co CLUSION It must be realized that an article such as this can only touch on the fringes of the detailed planning required when an OTS is actually built. If however I succeed in evoking a 'state of awareness' to the and imperfections of our existing theatres, and initiate a desire to 'do something about it', 1 shall be highly satisfied. BIBUOGRAPHY Douglas, D. M. (1962): Lancet, 2, 163. Gordon, R. A. (1963): Canad. Anaesth. Soc. J., 10, 140. Hospital Brief (1960): Architect Journal, 132, 7 July. Lidwell, O. M. and Blowers, R. (1962): Lancet, 2, 945. Lowenthal, l. (1962): Brit. Med. J., I, 1437. Ministry of Health (1957): Hospital Building BuUetin, No. 1. London: Her Majesty's Stationery Office. ... Nutlield Provincial Hospital Trust and the Umverstty of Bnstol (1955): Studies in the Functions and Design 0/ Hospitals, chapt. 3. London: Oxford University Press. Raven, R. W. (1962): Brit. Med. l., 1, 43. Smith, W. (1960): Planning the Surgical Suite. New York: Dodge. Tindal, A. (1962): Lancet, 2, 240.