Hospital Infection Control
KEIT DAY HOSPITAL
Operating theatre ventilation and AHU management protocol
Official Manual of Clinical, Care and Organizational Protocols
| Document Code | KEIT-SOP-06 | Version | 2.0 |
|---|---|---|---|
| Revision | 02 | Status | Official |
| Issue Date | 28/03/2026 | Next Review | 28/03/2027 |
| Prepared by | Medical Directorate / Quality | Approved by | |
| Signature and Date | Distribution | Controlled - Internal Use |
Purpose of the document. To officially define the scope, responsibilities, operating procedure, KEIT standards, records and protocol review criteria.
1. Document Control Information
| Application | All clinical, nursing, technical and organizational personnel involved in the described process. |
|---|---|
| Archiving | KEIT internal document management system and controlled copy in the relevant areas. |
| Review | At least annually or earlier in the event of regulatory, organizational or technological updates. |
2. Scope of Application
Applicable to operating theatres, airlock areas and technical areas connected to the operating suite.
3. Responsibilities
- Medical Directorate and Technical Manager: definition of environmental requirements and verification of system performance.
- Maintenance Service: implementation of the inspection plan, filter replacement and recordkeeping.
- Operating Room Coordinator: immediate reporting of alarms or deviations in environmental parameters.
4. Operating Procedure
- Check the operating status of ventilation systems and environmental alarms daily.
- Maintain positive pressure in the operating theatre relative to adjacent areas, in accordance with the system design.
- Verify proper airflow and the continuous operation of the dedicated AHU.
- Perform scheduled preventive maintenance and replace filters according to the internal technical plan.
- Suspend or restrict surgical activity in the event of failures that compromise essential environmental requirements until safe conditions are restored.
- Retain maintenance reports, commissioning records and functional verification reports.
5. KEIT Operational Standards
- KEIT uses an operating theatre AHU with advanced filtration, positive pressure and controlled airflow over the surgical area.
- The system’s HEPA filters are replaced according to the internal maintenance plan; AHU filters are managed at a documented high frequency.
- Every maintenance activity is recorded and made available for audit and internal verification purposes.
6. Records and Documentation
- Daily inspection register.
- AHU and filter maintenance register.
- Commissioning reports and technical intervention records.
- Failure reports and corrective actions.
7. Review and Updates
Joint review by the Medical Directorate and Technical Department at least annually.
Implementation Note
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.
8. Related Attachments and Forms
- Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
- Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.
9. Final Approval
| Position | Name and Signature | Date |
|---|---|---|
| Medical Directorate |
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