Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > Care in the operating theatre

Care in the operating theatre

The operating theatre team

4 Mr James Wisheart, consultant cardiac surgeon, explained:

`... the team in the operating theatre is made up of:

`(i) the anaesthetists, who normally include consultants, either senior registrars or registrars and the anaesthetic nurse;

`(ii) the surgeon, together with his senior registrar or registrar and senior house officer;

`(iii) the nurses who scrub to assist the surgeon and to be the "runner" [1] in the operating theatre (and the anaesthetic nurse);

`(iv) the perfusionists who operate the cardio-pulmonary bypass equipment.' [2]

5 Mr Janardan Dhasmana, consultant cardiac surgeon, identified the members of the operating theatre team as being the surgeons, anaesthetists, nurses, perfusionists, supporting laboratory staff and technicians. [3]

6 Mr Wisheart explained how a particular team would be brought together for an operation. He said that the patient was referred to a surgeon and placed on his waiting list and would then be scheduled for an operation on a day when it was known that a paediatric cardiac anaesthetist would be working:

`When the nursing team sees the operating programme it plans the allocation of its members to particular operations, and a nurse who is experienced in the work for children will be allocated to this paediatric procedure.

`Similarly an anaesthetic nurse who has experience with children will be allocated to assist the anaesthetist.

`The perfusionists will similarly allocate one of their members to carry out this perfusion and one to assist them. The assistant may be either more junior or more senior than the person who is actually undertaking the perfusion.' [4]

7 Mr Wisheart explained the involvement of the various teams in the various phases of an operation in the form of a table: [5]

8 Mr Dhasmana commented on Mr Wisheart's table:

`I have nothing more to add, except for supporting his statement that every team was an integral part of the whole service and communication and co-ordination between different teams was essential in order to achieve successful outcomes.' [6]

9 Mr Wisheart also set out those factors that he thought affected the performance of the team in the operating theatre. These included:

`Mundane issues such as the absolute necessity for punctuality, openness and honesty ... Each individual member of the Team must have prepared for the operation and should anticipate the problems and needs that could arise.' [7]

10 Mr Wisheart commented on the hours of work. He said:

`The theatre nurses contracts provided for a stated number of hours per week. In cardiac surgery the nurses also provided on call cover at nights and weekends. If they worked extra hours attempts were made to "give back" those hours.

`Perfusionists worked in a similar way, but were paid for overtime hours.

`Junior doctors contractual arrangements evolved during the period 1984-1995. Initially there was no specified number of hours of work; later it was limited to 80 hours a week and still further on to 56 hours a week as a target. In cardiac surgery vigorous efforts were made to comply with these regulations but we did not always succeed.

`Consultants contracts do not specify any particular number of hours per week. [8]

`There were occasions when personnel were tired but I believe their performance in the operating theatre remained at a high level.' [9]

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Footnotes

[1] Or `circulating nurse'

[2] WIT 0120 0165 Mr Wisheart

[3] WIT 0084 0070 Mr Dhasmana

[4] WIT 0120 0166 Mr Wisheart

[5] WIT 0120 0168 Mr Wisheart. The table does not refer to the actual conduct of the surgery

[6] WIT 0084 0070 Mr Dhasmana

[7] WIT 0120 0171 Mr Wisheart

[8] This may convey a misleading impression. The Inquiry has received advice that from 1984 until 1st April 1991, the National Health Service (Remuneration and Conditions of Service) Regulations 1974 provided for the remuneration and conditions of service of officers employed by a Health Authority or Special Health Authority. These `officers' included doctors. Forty-four hours were contracted for (11 sessions of four hours' notional duration). With effect from 1st April 1991, the National Health Service (Remuneration and Conditions of Service) Regulations 1991 were made, which, amended only in respect of the definition of authority, to take account of changes made by the Health Authorities Act 1995, and in respect of the power of Authorities to determine remuneration where there was no recognised negotiating body, continue to the present. Where a full-time consultant or Associate Specialist appointment is made, it may be held on one of two bases: whole time or `maximum part-time'. Both are `... expected to devote substantially the whole of their professional time to their duties in the NHS'. A maximum part-time practitioner is paid ten-elevenths of the whole time salary, and has a minimum work commitment equivalent to ten notional half-days. It appears to follow that a consultant contracts for 11 sessions per week, each session being of a notional four hours' duration. `Employing authorities' (i.e. Trusts) may offer part-time appointments to be held by consultants and associate specialists. A staff grade of hospital practitioner contracts for a minimum average work commitment of 10 sessions a week, each session being equivalent to four hours' work plus a liability to deputise for absent colleagues who are on annual and study leave, or for no more than two weeks where other forms of leave have been taken or a vacancy has been unfilled. In addition, the staff grade practitioner commits to undertake `such exceptional irregular commitments outside normally rostered duties as are essential for continuity of patient care; and ... exceptionally, duty in occasional emergencies and unforeseen circumstances.' Junior doctors (SR, R, SHO and HO grades) contract for 40 standard hours per week, plus `such further hours ... as are agreed with the employing authority' subject to certain controls. Those controls in the 1995 edition introduced a provision that `as soon as practicable the maximum average contracted hours of duty for practitioners working on on-call rotas' should not exceed 83 per week, including handovers at the start and finish of duty periods. There are other provisions restraining the average contracted hours `in hard-pressed posts', and preventing any period of continuous duty being longer than 32 hours during the week and 56 at weekends, and for a minimum period of time off every three weeks.

[9] WIT 0120 0173 Mr Wisheart