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Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Traffic Control in Perioperative Areas (2.3.35)

Traffic Control in Perioperative Areas (2.3.35) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.35


UW HEALTH CLINICAL POLICY 1
Policy Title: Traffic Control in Perioperative Areas
Policy Number: 2.3.35
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 28, 2017

I. PURPOSE

To provide a plan to control movement within the Surgical Suite for infection control, patient and employee
safety, and efficient use of personnel and time.

II. DEFINITION

Perioperative: the time period describing the duration of a surgical procedure and/or non-surgical procedure,
that includes the three phases of surgery-preoperative, preoperative, and postoperative.

III. POLICY ELEMENTS

A. The Surgical Suite is divided into three designated areas:
i. Unrestricted – street attire is permitted
ii. Semi-restricted – requires scrub attire and hats
iii. Restricted – requires scrub attire, hat and mask
B. At University Hospital, personnel may enter the Inpatient Operating Room (OR) suite through G7/3 male
locker room [330A or 330B] or H6/3 female locker room [301 or 341], E6/301, or D5/301. Outpatient access
is through the automatic doors at each end of the hallway. American Family Children’s Hospital (AFCH)
access is through secure doors off staff elevator on 3
rd
floor (3290) or secure door by control station (3203)
between pre/post-op and OR. The American Center (TAC) OR access is through secure doors by control
station (room 1325), OR conference room (room 1323) and through secure doors adjacent to the Pre/Post-
op unit in the Universal Care Center.
i. Unrestricted – includes all areas not directly adjacent to the OR suites (Inpatient OR: front desk,
lounge, FDS, locker rooms; Outpatient OR: locker rooms and lounge).
ii. Semi-restricted – areas directly adjacent to the operating rooms and central supply storage. Areas
are marked with red flooring.
iii. Restricted – operating rooms while a sterile case is in progress.
C. Keep doors to the operating rooms closed except during movement of personnel and equipment.
i. This will decrease the mixing of air in the OR with air in the corridor and interstitial space above the
ceiling that may contain higher counts of bacteria. Open doors create a vacuum that draws non-
filtered air in the OR.
ii. AFCH, TAC and Inpatient access is restricted to authorized personnel by ID proximity badge. For
those without ID badge access, “intercoms” by the male and female inpatient locker rooms may be
used for those authorized for admission.
a. Male Locker Room (G7/330A)
b. Female Locker Room (H6/301)
D. Movement of clean and sterile supplies is separated as much as possible from soiled equipment and waste.
i. Supplies prepared in Central Supply are transported via the elevator to the clean supply core.
ii. External shipping cartons are removed before transfer into OR storage areas.
iii. In the Inpatient OR soiled supplies, instruments, equipment for reprocessing, trash, and soiled linen
should be contained and transported through the staff corridor to the soiled room (E5/317). In the
Outpatient OR, soiled supplies will be transported to the soiled room (E6/205a) via the main hall
through the back double doors.
iv. In AFCH OR, soiled supplies will be transported to the soiled room (3294) via the back door near
staff lockers (3290).
v. In TAC OR, soiled supplies, equipment, and instruments will be transported to soiled holding room
(room 1374) via the main OR staff and patient corridor.
E. In the Inpatient OR, patients shall arrive in the Operating Room through D5/301, or via FDS. In the
Outpatient OR, patients will be transported directly from OSC-Ambulatory to the OSC-OR via the back
hallway and entering through the back double doors. In AFCH OR, patients will be transported directly from
PICU via transport by Anesthesia, or from AFCH pre/post op to the OR via hallway 3130 or hallway outside
of control station. (3203). In TAC OR, patients will be transported directly from the Pre/Post op unit in the
Universal Care Center, ED or the Inpatient unit through secure doors to the OR.



UW HEALTH CLINICAL POLICY 2
Policy Title: Traffic Control in Perioperative Areas
Policy Number: 2.3.35

F. In the Inpatient OR, the first patients of the day go to FDS then to each OR; later scheduled patients are
transported to FDS and remain there until the operating rooms are prepared; patients in beds, or those
arriving directly from emergency room, are usually transported through the automatic doors. For AFCH OR,
all pediatric patients are taken to AFCH Pre/post op until the surgical team is ready or those arriving directly
from ED are transported through the automatic doors.
G. Following surgery in the Inpatient OR, patients are transported via the staff corridor to the Post Anesthesia
Care Unit, or via E6/301 directly back to their unit. Patients going directly to B4/5 will use the E-West
elevator by Radiology. . The circulating nurse will page the service NA during the day or on duty NA for PMs
or nights to summon an elevator for transporting to nursing unit. In the OSC, patients are transported directly
to the OSC-PACU or to OSC-AMB via the back corridor. In AFCH OR, patients are transported directly to
AFCH PACU via back hallway near staff elevators (3290), or directly back to their unit (PICU) via staff
elevators (3290). In TAC OR, patients will be transported to the PACU via the patient and staff corridor.
Patients who are able to bypass the PACU will be transported directly back to their Post-op room in the
Universal Care Center.
H. In both the Inpatient OR and AFCH OR, the elevator key is strapped to the Anesthesia Code Box to utilize
when responding to codes.

IV. COORDINATION

Author: Directors, Surgical Services Department
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: Clinical Operations Manager; Manager of TAC Operating Room
Approval committees: Surgical Services Policy and Procedure Committee; UW Health Clinical Policy
Committee
UW Health Clinical Policy Committee Approval: March 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REVIEW DETAILS

Version: Original
Last Full Review: December 28, 2017
Next Revision Due: March 2020
Formerly Known as: Surgical Services departmental policy #1.30