Transcript
SAFE ENVIRONMENT & OT
INFECTION PREVENTION
Dr.Sabah Javed
Consultant Microbiologist
RKCH Raipur
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OT
Theaters have been divided into two distinct
groups:
Superspeciality OT: Superspeciality OT
means
operations of Neurosciences, Orthopedics
(Joint
Replacement), Cardiothoracic and Transplant
Surgery (Renal, Liver etc).
General OT: This includes Ophthalmology
and all other basic surgical disciplines. 4
THEATRE DESIGN
Theatre Design Consideration:
The prevention of wound infection.
The safety of patients and staff.
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Design Features
Designing a safe environment incorporates features that prevent or control the risk of infection, fire, explosion, and chemical and electrical hazards.
Well-devised traffic patterns, material-handling systems, disposal systems, positive-pressure and well-dispersed clean ventilation, and high-flow, unidirectional ventilation systems for special applications all contribute to a safe surgical environment.
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DESIGN FEATURES
OT Size: Standard OT size of 20’ x 20’ x 10’
(Ht.
below the false ceiling level is considered).
Occupancy: Standard occupancy of 5-8
persons at any given point of time inside the
OT is considered.
Equipment Load: Standard equipment load
of 5-7 kW considered per OT.
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SUPERSPECIALITY & GENERAL OT
Appropriate ventilation systems aid in the control of infection by minimizing microbial contamination.
Air Changes Per Hour:
Minimum total air changes should be 30(superspOT) &25(GOT)based on international guidelines
The same will vary with biological load and the location.
The fresh air component of the air change is required to be minimum 5 air changes out of total minimum 30 air changes 30(supersp OT)& minimum 4 air changes out of total minimum 25 air changes(GOT).
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SUPER-SPECIALTY OT& GOT
Air Velocity: The vertical down flow of air coming out of the diffusers should be able to carry bacteria carrying particle load away from the operating table.
The airflow needs to be unidirectional and downwards on the OT table.
The air velocity recommended as per the international and national guidelines is 90-120 FPM at the Grille/Diffuser level.
Positive Pressure: There is a requirement to maintain positive pressure differential between OT and adjoining areas to prevent outside air entry into OT.
The minimum positive pressure recommended is 15 Pascal (0.05 inches of water) as per ISO 14644 Clean Room Standard.
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SUPER-SPECIALTY OT& GOT
Air handling in the OT including air Quality:
Air is supplied through Terminal HEPA filters in the ceiling. The minimum size of the filtration area should be 8’ x 6’ to cover the entire OT table and surgical team.
The minimum supply air volume to the OT (in CFM) should be compliant with the desired minimum air change.
The return air should be picked up/ taken out from the exhaust grille located near the floor level (appx6 inches above the floor level).
The air quality at the supply i.e. at grille level should be Class 100/ ISO Class 5 (at rest condition). Class 100 means a cubic foot of must have no more than 100 particles measuring 0.5 microns or larger. 10
SUPER-SPECIALTY OT& GOT
Temperature and Humidity: The temperature should be maintained at 21 +/- 3 Deg C (68° and 73°F) inside the OT
Relative humidity between 40 to 60% though the ideal Rh is considered to be 55% to reduce bacterial growth and suppress static electricity.
Appropriate devices to monitor and display these conditions inside the OT may be installed.
Temperatures in that range allow for comfort of the surgical team and are tolerated by most patients.
Each operating room should have individual temperature controls to accommodate patient safety, as when increased warmth is required for patients at high risk for inadvertent hypothermia during operative procedures.
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CONTD…
Air Filtration: The AHU must be an air purification unit and air filtration unit.
There must be two sets of washable flange type pre filters of capacity 10 microns and 5 microns with aluminum/ SS 304 frame within the AHU.
HEPA filters of efficiency 99.97% down to o.3 microns or higher efficiency are to be provided in the OT and not in the AHU.
The AHU of each OT should be dedicated one and should not be linked to air conditioning of any other area
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CONTD….
Window & split A/c should not be used in any type of OT because they are pure re circulating units and have convenient pockets for microbial growth which cannot be sealed.
The flooring, walls and ceiling should be nonporous, smooth, seamless without corners and should be easily cleanable repeatedly. The material should be chosen accordingly.
periodic preventive maintenance be carried out in terms of cleaning of pre filters at the interval of 15 days.
Preventive maintenance of all the parts is carried out as per manufacturer recommendations.
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TRAFFIC FLOW
Traffic Patterns in the Surgical Suite, a
three-zone designation of areas within
the surgical suite facilitates appropriate
movement of patients and personnel.
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TRAFFIC FLOW
1. Unrestricted areas are those in which personnel may wear street clothes, and traffic is not limited.
2. In semi-restricted areas, such as processing and storage areas for instruments and supplies, as well as corridors leading to the restricted areas of the surgical suite, personnel must wear surgical attire and patients must wear gowns and hair coverings.
3. Restricted areas include operating rooms and clean core and scrub sink areas. Surgical attire and masks are required in these areas when there are open sterile supplies or scrubbed persons in the area.
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TRAFFIC FLOW
The flow of supplies should be from the clean
core area through the operating rooms to the
peripheral corridor.
Soiled materials should not re-enter the clean
core area. Soiled linen and trash collection
areas should be separated from personnel and
patient traffic areas for infection control
purposes.
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EMERGENCY SIGNALS
Every surgical suite should have an emergency signal system that can be activated inside each operating room.
A light should appear outside the door of the room involved, and a buzzer or bell should sound in a central nursing or anaesthesia area.
The signals should remain on until the alarm is turned off at the source.
All personnel should be familiar with the system and should know both how to send a signal and how to respond to it.
Such a system, restricted to use in life-threatening emergencies, saves invaluable time in bringing additional personnel and resources for assistance.
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OPERATING DEPARTMENT COMPRISES:
Rest rooms
Changing rooms
Teaching rooms
Storage
Reception areas
An operating suite
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AN OPERATING SUITE
Is one functioning unit of a department:
An anesthetic room
Clean preparation room
Scrub-up area
Operating theatre
Sluice room
Exit bay
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CLEAN AND DIRTY”
All journeys within the department
are made from clean to dirty
areas, never the other way round
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PATIENTS
Will enter the department from the hospital corridor via a transfer bay. Here they are usually lifted on to a theatre trolley, leaving the ward bed outside.
Next they enter either a holding bay area or else move directly to the anesthetic room.
Finally they enter the theatre itself where surgery is to be performed
The journey has been one through progressively cleaner areas, arriving finally at the cleanest of all.
Once the wound has been closed and covered with dressing, it is safe for the patient to return to the ward via progressively more dirty areas: through the exit bay, recovery and the hospital corridor.
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INSTRUMENT AND EQUIPMENT Are brought from outside the department into clean
store rooms.
Instruments are often supplied in pre-packed sterilized trays by the Theatre Sterile Supplies Unit (TSSU).
Finally, they enter the theatre ready for use on the scrub nurse’s trolley.
At the end of an operation, dirty instruments, linen and rubbish are removed to the sluice room, and when correctly packaged for disposal, to agreed collection points.
Porters then take them via a dirty corridor to their several destinations: the TSSU, laundry or hospital incinerator.
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THEATRE PERSONNEL
Enter the department via a changing room
where outdoor clothing is left.
Once attired in correct theatre dress they
can proceed to a suite along a clean
corridor.
Here they enter via the clean preparation
room or the scrub-area, and like the
patient, leave through the exit bay.
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THE ANESTHETIC ROOM
The anesthetic machine
Suction apparatus
The drug cupboar
The Operating Theatre The operating table – centre piece of the
room, a very versatile piece of equipment.
It has to be in order to accommodate the great variety of different operating positions.
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THE OPERATING LIGHTS
There are usually two operating lights in a theatre attached to the ceiling.
The lights are easily maneuvered, necessary to accommodate the needs of surgery.
Good lighting is needed to carry out an operation, and lighting a wound from two converging angles is designed to eliminate shadows.
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ANESTHETIC SCAVENGING
A long length of corrugated plastic tubing
connected to the anesthetic circuit at one
end, while the other connects to a vent in the
ceiling or wall.
The system draws out of the theatre any anesthetic
gases or agents leaking from the circuit and which
pollute the atmosphere.
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THE SWAB RACK
This is a metal piece of furniture used for hanging up swabs during an operation for ease counting.
It comprises of several tiers have either hooks to hang the swabs, or else holes to poke them through.
The hooks and holes are grouped in numbers off fives, and each tiers can usually accommodate ten swabs.
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THE SWAB BOARD
This is for recording the amount of blood loss
during the operation especially major operation.
The nurses record this information for anesthetist's
benefit, who will instigate replacement therapy.
The board is usually marked in two columns; one
for blood loss from the swabs and one for loss from
the suction.
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WEIGHING SCALE: ESTIMATING BLOOD LOSS
You should find a list of known dry weights of each different type of swab.
To estimate blood loss, you weigh the blood-soaked swab, and from that weight subtract the known dry weight.
This leaves you with the weight of blood lost, which is the amount you record, adding it to the running total.
e.g.; Dry Large swab = 20g, Soaked in blood = 90g
: 90g – 20g =70g is the weight of the blood loss
(1g = 1ml) 32
X-ray Screens
This is vital as some operations are conducted with close
reference to a patient’s x-rays throughout.
e.g. orthopaedic surgery, tumour surgery and operations
such as cholecystectomy
RUBBISH BINS, SWAB BINS AND LINEN BINS
Every theatre has separate disposal containers for rubbish, swabs and linen.
During the operation the swabs must remain separate, to facilitate the swab counting procedure.
Leave the disposal bags in the theatre until the end of the operation, until the scrub nurse is entirely happy with the final count.
Fresh disposal bags are always brought in for every operation.
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RECOVERY AREA
Carried out in the corridor outside the
operating theatre.
Normally made up of several bed
spaces, each with necessary equipment to
facilitate recovery e.g. oxygen, suction
apparatus, pulse oximetry, emergency trolley
necessary to deal with cardiac arrests or
anesthetic emergencies etc.
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CHANGING TO THEATRE CLOTHING
To cut down on any bacteria brought from outside
Cotton uniform less static electricity Pride for nurses working in theatre Laundry purposes Reduce anxiety for patient
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WHAT IS WRONG WITH OUR INFECTION
CONTROL PRACTICES
Disinfectants used indiscrimately,
Used unnecessarily
Not used when needed.
Concentration not adequate
Economic consideration,
Business promotions.
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BASIC PRINCIPLES
Cleaning more Important
Disinfection and Sterilization ?
Cleaning
Removes contaminants,
Dust, organic matter,
Disinfection
Reduces number of microbes
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BASIC CARE OF OPERATION THEATRES.
Reduction of Microbial counts is important.
Very rarely the Microbes reach the operation site,
Paying attention to Floors
Using unnecessary, too many chemical not necessary
Keep Clean Dry - Bacteria are reduced,
Most Important component of Bacteria is water, dry areas causes natural death.
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WALLS AND ROOF OF
OPERATION THEATRE
Frequent cleaning has little effect.
Do not disturb these areas unnecessarily,
Floors get contaminated quickly, depend on
Number of persons present in the
Theatre / Movements they make,
On many people make unnecessary
movements than needed
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CARE OF FLOORS
Do remember only 1 % are pathogenic.
On many occasion S.aureus.
The counts depend on the number of persons,
Only people needed for procedures should enter the
theatres.
Unnecessary movements disturbs the bacterial flora
Floor should be decontaminated with
Don't broom
Use Vacuum cleaner.
Wet cleaning techniques
Wet Mop / Keep the mops dry
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CARE OF ROOF
Do not disturb unnecessarily,
Do not use ceiling fans they cause aerosol
spread
Clean only when remodeling or accumulated
,good amount of dust.
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CLEANING THE FLOOR
A simple detergent reduces flora by 80
%
Addition of disinfectant reduces to 95 %
In busy Hospitals counts raise in 2
hours
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ENVIRONMENTAL CLEANING OF HOSPITAL.
Disinfectant Purpose
Sodium hypochlorite (1%) Contaminated with
Blood and body fluids
Alcohol 70% /Bacillol Metal surfaces
trolleys
Bacillocid Extra(1%)
forOTDisinfection44
BETWEEN PROCEDURES IN THE
OPERATION THEATRES.
Clean operation tables, theatre equipment with disinfectant solution with detergent,
In case of spillage of blood / body fluids decontaminate with hypochlorite solution ( 1 % available chlorine ).
Always discard wastes in prescribed plastic bags –Don’t accumulate biohazard waste in the operation theatres.
Don’t discard discarded soiled gowns in the operation theatre.
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AT THE END OF THE DAY
IN OPERATION THEATRE.
Clean all the table tops sinks, door handles with
detergent / low level of disinfectant.
Clean the floors with detergents mixed with warm
water,
Finally mop with disinfectant like Bacillol/Bacillocid.
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FUMIGATION OF OT
Environmental Fogging Clarification Statement
CDC and HICPAC have recommendations in both 2003 Guidelines for Environmental Infection Control in Health-Care Facilities and the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilitiesthat state that the CDC does not support disinfectant fogging. Specifically, the 2003 and 2008 Guidelines state:
2003: “Do not perform disinfectant fogging for routine purposes in patient-care areas. Category IB”
2008: “Do not perform disinfectant fogging in patient-care areas. Category II”
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CONTD….
These recommendations refer to the spraying or fogging of chemicals (e.g., formaldehyde, phenol-based agents, or quaternary ammonium compounds) as a way to decontaminate environmental surfaces or disinfect the air in patient rooms.
The recommendation against fogging was based on studies in the 1970’s that reported a lack of microbicidalefficacy (e.g., use of quaternary ammonium compounds in mist applications) but
also adverse effects on healthcare workers and others in facilities where these methods were utilized.
Furthermore, some of these chemicals are not EPA-registered for use in fogging-type applications.
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SURVEILLANCE OF OPERATION THEATRE
EXAMINATION OF AIR
Estimations are done for detection of
bacteria carrying particles in Air.
Factors influence
Number of persons present.
Body movements,
Disturbances of clothing.
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METHODS OF AIR SURVEILLANCE
1 Settle plate method.
2 Slit sampler method (from given volume)
Counts vary from one to many
Settle plates method
Record position – Time - Duration
Plates with media as Blood agar/N.Agar exposed for specified period and incubated in the
incubator for 24 hours at 37º c
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HOW MANY BACTERIA ARE PATHOGENIC
Counts vary On number of personal present in the given area.
Behavior of the persons.
Depend on nature of procedures, type of operations.
Varying ranges
But remember only 1 % are pathogenic
Presence of S. aureus makes difference
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DO WE NEED SURVEILLANCE REGULARLY
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Bacteriological surveillance testing at regular internals is not warranted,
But warranted when modification of operation theaters are done,
In any unforeseen increase of incidence of infection form any particular operation theatre.
IMPORTANCE OF HAND WASHING
Soap
Water
and
Common
Sense
Yet the best Antiseptic
William Osler
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GOOD HAND WASHING PRACTICES
SAVE MANY LIVES
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OPERATION THEATRE SAFTEY
IS RESPONSIBILITY OF?
CHEERFUL / DEDICATED STAFF MAKE A GREAT
SUCCESS.
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OUR FUTURE VISION - CREATE
CLEAN,TECHINICALLY ADVANCED
OPERATION THEATRES WHICH CAN
CHANGE THE SAFETY OF OUR
CHERISHED PATIENT.
Thank You All
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PRAYING THE BEST FROM OF DIVINITY
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CLEAN HANDS - THE SAFE HANDS FOR
EVERYTHING WE DO IN HOSPITALS.
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The End
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