OT

In spite of brief stay of patients in the operation theatre (in majority of circumstances), the environment of operation theatre plays a great role in the onset and spread of infection because of a multifactor causation of infection. It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances as in most developing countries, work in isolation and few facilities to make any epidemiological surveys Many believe that routine Microbiological monitoring is most essential but in reality it is not practicable. But every hospital should pay good attention in proper maintenance of air conditioning plants, ventilator systems, and to have greater control on mechanisms and personnel involved in disinfection and sterilization of materials used in the theatres in operative procedures.     

Operation theatres should be built with implementation of good civil Engineering standards.

OPERATION THEATRE – DISCIPLINE

1. Only people absolutely needed for an assigned work should be present.

2. People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres, which will greatly reduce bacterial count.

3. Air borne contamination is usually affected by type of surgery, quality of air which in fact depends on rate of air exchange.

All the persons including the least cadre of employers are partners in infection control and should be aware to comply with infection control regulations

4 Prompt disposal of Theatre waste out of the theatre is of top priority. Any spillage of Body fluids including Blood on the floors is highly hazardous and prompts the rapid multiplication of Nosocomial pathogens in particular Pseudomonas spp

SURVEILLANCE OF OPERATION THEATRE

Role of Microbiological Surveillance

The environments in the operation theatre are dynamic and subject to continuous change. Good infrastructures do not mean a safe environment as human make a greater difference in making the environment unsafe.

Microbiologists should be aware of organisms, sites and populations as surveillance cultures should be chosen carefully to allow meaningful interpretation of results.

Microbiologists should be familiar with the clinical techniques as those normally used for culturing clinical specimens may not yield correct result when applied to environmental specimens.

Sites and cultured reports should not be chosen as etiological sources in the present infections. Culturing unnecessary surface areas causes confusion and meaningful interpretation is lost.

AIR IS THE IMPORTANT SOURCE OF INFECTION

Bacterial counts in operation theatres are influenced by the number of individuals present, ventilation and air flow, the results should be interpreted taking the above facts into consideration.

Surveillance for Air borne Pathogens:

In resource poor Hospitals settle plates with blood agar are used and can detect pathogens, commensals and saprophytic bacteria. Multiple plates are kept and results are based on overall assessment rather than on a single plate study in the room. Microbiologists will clarify the acceptable counts at the different physical locations in multispeciality hospitals.

There is a sea change in analysis of bacterial counts in recent past with advances in medical technologies like Joint replacement surgeries dealing with critical patients. Slit sampler and Air centrifuge equipment for bacterial counts are replacing settle plates, the safe level of colony counts can be calculated as per the standards created with peer reviewed studies by the manufacturers.

How frequently we can do the Surveillance for Air borne Microbes.

Yet there is no definite answer to this question

Doing too frequent surveys are expensive and will not correlate the existing infection rate in the Hospital.

But can indicate the circumstance we operate which can have bearing effect if the safety standards fall

Surveillance for Clostridia spores

The age old tradition of detection of anaerobic spores of C.tetani, and Gas gangrene producing organisms are losing ground with onset of more awareness on theatre sterilization. Routine testing for the Anaerobes is not essential except when there were suspected cases of Tetanus or Gas gangrene attributed to operating in a particular Operation theatre.

But it is ideal to survey the Operation theatres for anaerobes when newly constructed or any remodeling or structural alterations are done. In such situations which will have trust worthy safety of the theatre.

STERILISATION AND DISINFECTION OF OPERATION THEATRES AND CRITICAL CARE AREAS

GENERAL INSTRUCTIONS

1. Keep the floor dry when in use.

2. Use only vacuum cleaners (booming to be forbidden as it will dispense the infected material all around and on the equipments.

3. Chemical disinfection of an operation room floor is probably unnecessary. The bacteria carrying particles already on the floor are unlikely to reach an open wound in sufficient numbers to cause an infection

(Ayliffe et al 1967. Hombroeus et al 1978)

Cleaning alone followed by drying will considerably reduce bacterial population.

4. Wall and Ceilings- Wall and ceiling are rarely contaminated. The numbers of bacteria do not appear to increase even if walls are not cleaned. Frequent cleaning is not necessary and has little influence on bacterial counts. Routine disinfection is therefore unnecessary, but only cleaned when dirty.

ENVIRONMENTAL CLEANING OF OPERATION THEATRES

At the Beginning of the Day

1. Only remove the dust with cloth wetted with clean water. ( Mop theatre furniture lamps, sitting tables, trolley tops, operation tables, procedure tables, Boyle’s apparatus)

Note: Need not use chemicals/disinfectants unless contaminated with blood or body fluids

Between the procedures

Clean operation tables or contaminated surfaces with disinfectant solutions.

1. In case of spillages of blood/ body fluids decontaminate with bleaching solution/ chlorine solution (10% available chlorine)

2. All discard waste in plastic bags (do not accumulate around surgical sites)

3. Do not discard soiled linen and gowns in the operation theatre floor.

At the end of the day

1. Clean all the table tops, sinks, door handles with detergent followed by low level disinfectant.

2. Clean the floors with detergents mixed with warm water.

3. Finally mop with disinfectant like phenol in the concentration of 1 in 10 (low concentrations of phenol will not serve the purpose).

4. Keep the operation theatre dry for the next day’s work

Fumigation

1. Seal the room with adhesive tapes round the edges of the doors/windows and ventilators and apertures.

2 For Each 1000 cu.ft of space place 500ml formaldehyde (40% solution) and 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door.

3. Seal the room for 24 hrs

4. Then open the door and neutralize any residual formaldehyde with ammonia by exposing 250ml of S.G 880 ammonia/ 1Lt of formaldehyde used. (Ref – Mackie and McCartney Practical Medical Microbiology 13th Edition)

5. Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous

6 Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theatres can be curtailed with Fumigation.

THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED THE RATES OF INFECTION

1. Every Hospital must constitute Infection control committee to monitor the events in the Hospital, on all matters related to control of Infections.

2. The entry of unnecessary personnel to be restricted into operation theatres as every one contributes to Infection.

3. A thorough washing with warm water and good detergent and carbolisation can bring overall improvement than mere fumigation.

4. Frequent monitoring and training of medical and paramedical staff must carry high priority than mere mechanical and chemical methods.

5. Thorough washing and carbolisation if done everyday after the surgeries will greatly enhance the safety standards and economize the repeated expenditure on fumigation.

TRAINING OF PARAMEDICAL STAFF/ RESIDENTS

1. The short solution to control infection lies with trained staff.

2. The principal and control of infection to all new comers and junior staff should be a goal of any good Institution.

3. Formulate guidelines update as per the changing situation in control the infection.

4. Institute should formulate ideas on infection control to the need of circumstances, as there are no fixed guidelines or formulae to control to suit all occasional.

5. Simple repeated hygienic hand wash is most cost effective method to reduce several infections in Hospitals, in particular operation theatres

Note

The knowledge on Maintenance, Sterilization and control of Infections in Operation theatres a rapidly evolving Science

Wish to know more about Operation theatre Maintenance for control of Infection Read through

Principles, And Practice of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe.

All Institutes wish to develop to improve hygiene and sterilization standards, and start critical surgeries doing Cardiothoracic, Organ replacement and prosthetic surgeries should subscribe to the internationally accredited Journal

“The Operating Theatre journal” published from U K.

Dr.T.V.Rao MD and Dr.Chitra Valsan MD work as Microbiologists in Indian Medical College, writes articles of Interest to Medical and Para Medical Professionals to create awareness to reduce infections in the Developing World.

Incoming search terms for the article:

ot sterilisation SOPs for operation theater infection control O T sterilisation Principles And Practice of Disinfection Preservation and Sterilization by A D Russel W

B Hugo & G A J Ayliffe gaseous gangrene infection control in operating theatre role of microbiologist in operation theator SOP Operating Room sterilization carbolisation sop for sterilization and disinfection operation theatre sterilisation

n spite of brief stay of patients in the operation theatre (in majority of circumstances), the environment of operation theatre plays a great role in the onset and spread of infection because of a multifactor causation of infection. It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances as in most developing countries, work in isolation and few facilities to make any epidemiological surveys Many believe that routine Microbiological monitoring is most essential but in reality it is not practicable. But every hospital should pay good attention in proper maintenance of air conditioning plants,

ventilator systems, and to have greater control on mechanisms and personnel involved in disinfection and sterilization of materials used in the theatres in operative procedures.     

Operation theatres should be built with implementation of good civil Engineering standards.

OPERATION THEATRE – DISCIPLINE

1. Only people absolutely needed for an assigned work should be present.

2. People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres, which will greatly reduce bacterial count.

3. Air borne contamination is usually affected by type of surgery, quality of air which in fact depends on rate of air exchange.

All the persons including the least cadre of employers are partners in infection control and should be aware to comply with infection control regulations

4 Prompt disposal of Theatre waste out of the theatre is of top priority. Any spillage of Body fluids including Blood on the floors is highly hazardous and prompts the rapid multiplication of Nosocomial pathogens in particular Pseudomonas spp

SURVEILLANCE OF OPERATION THEATRE

Role of Microbiological Surveillance

The environments in the operation theatre are dynamic and subject to continuous change. Good infrastructures do not mean a safe environment as human make a greater difference in making the environment unsafe.

Microbiologists should be aware of organisms, sites and populations as surveillance cultures should be chosen carefully to allow meaningful interpretation of results.

Microbiologists should be familiar with the clinical techniques as those normally used for culturing clinical specimens may not yield correct result when applied to environmental specimens.

Sites and cultured reports should not be chosen as etiological sources in the present infections. Culturing unnecessary surface areas causes confusion and meaningful interpretation is lost.

AIR IS THE IMPORTANT SOURCE OF INFECTION

Bacterial counts in operation theatres are influenced by the number of individuals present, ventilation and air flow, the results should be interpreted taking the above facts into consideration.

Surveillance for Air borne Pathogens:

In resource poor Hospitals settle plates with blood agar are used and can detect pathogens, commensals and saprophytic bacteria. Multiple plates are kept and results are based on overall assessment rather than on a single plate study in the room. Microbiologists will clarify the acceptable counts at the different physical locations in multispeciality hospitals.

There is a sea change in analysis of bacterial counts in recent past with advances in medical technologies like Joint replacement surgeries dealing with critical patients. Slit sampler and Air centrifuge equipment for bacterial counts are replacing settle plates, the safe level of colony counts can be calculated as per the standards created with peer reviewed studies by the manufacturers.

How frequently we can do the Surveillance for Air borne Microbes.

Yet there is no definite answer to this question

Doing too frequent surveys are expensive and will not correlate the existing infection rate in the Hospital.

But can indicate the circumstance we operate which can have bearing effect if the safety standards fall

Surveillance for Clostridia spores

The age old tradition of detection of anaerobic spores of C.tetani, and Gas gangrene producing organisms are losing ground with onset of more awareness on theatre sterilization. Routine testing for the Anaerobes is not essential except when there were suspected cases of Tetanus or Gas gangrene attributed to operating in a particular Operation theatre.

But it is ideal to survey the Operation theatres for anaerobes when newly constructed or any remodeling or structural alterations are done. In such situations which will have trust worthy safety of the theatre.

STERILISATION AND DISINFECTION OF OPERATION THEATRES AND CRITICAL CARE AREAS

GENERAL INSTRUCTIONS

1. Keep the floor dry when in use.

2. Use only vacuum cleaners (booming to be forbidden as it will dispense the infected material all around and on the equipments.

3. Chemical disinfection of an operation room floor is probably unnecessary. The bacteria carrying particles already on the floor are unlikely to reach an open wound in sufficient numbers to cause an infection

(Ayliffe et al 1967. Hombroeus et al 1978)

Cleaning alone followed by drying will considerably reduce bacterial population.

4. Wall and Ceilings- Wall and ceiling are rarely contaminated. The numbers of bacteria do not appear to increase even if walls are not cleaned. Frequent cleaning is not necessary and has little influence on bacterial counts. Routine disinfection is therefore unnecessary, but only cleaned when dirty.

ENVIRONMENTAL CLEANING OF OPERATION THEATRES

At the Beginning of the Day

1. Only remove the dust with cloth wetted with clean water. ( Mop theatre furniture lamps, sitting tables, trolley tops, operation tables, procedure tables, Boyle’s apparatus)

Note: Need not use chemicals/disinfectants unless contaminated with blood or body fluids

Between the procedures

Clean operation tables or contaminated surfaces with disinfectant solutions.

1. In case of spillages of blood/ body fluids decontaminate with bleaching solution/ chlorine solution (10% available chlorine)

2. All discard waste in plastic bags (do not accumulate around surgical sites)

3. Do not discard soiled linen and gowns in the operation theatre floor.

At the end of the day

1. Clean all the table tops, sinks, door handles with detergent followed by low level disinfectant.

2. Clean the floors with detergents mixed with warm water.

3. Finally mop with disinfectant like phenol in the concentration of 1 in 10 (low concentrations of phenol will not serve the purpose).

4. Keep the operation theatre dry for the next day’s work

Fumigation

1. Seal the room with adhesive tapes round the edges of the doors/windows and ventilators and apertures.

2 For Each 1000 cu.ft of space place 500ml formaldehyde (40% solution) and 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door.

3. Seal the room for 24 hrs

4. Then open the door and neutralize any residual formaldehyde with ammonia by exposing 250ml of S.G 880 ammonia/ 1Lt of formaldehyde used. (Ref – Mackie and McCartney Practical Medical Microbiology 13th Edition)

5. Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous

6 Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theatres can be curtailed with Fumigation.

THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED THE RATES OF INFECTION

1. Every Hospital must constitute Infection control committee to monitor the events in the Hospital, on all matters related to control of Infections.

2. The entry of unnecessary personnel to be restricted into operation theatres as every one contributes to Infection.

3. A thorough washing with warm water and good detergent and carbolisation can bring overall improvement than mere fumigation.

4. Frequent monitoring and training of medical and paramedical staff must carry high priority than mere mechanical and chemical methods.

5. Thorough washing and carbolisation if done everyday after the surgeries will greatly enhance the safety standards and economize the repeated expenditure on fumigation.

TRAINING OF PARAMEDICAL STAFF/ RESIDENTS

1. The short solution to control infection lies with trained staff.

2. The principal and control of infection to all new comers and junior staff should be a goal of any good Institution.

3. Formulate guidelines update as per the changing situation in control the infection.

4. Institute should formulate ideas on infection control to the need of circumstances, as there are no fixed guidelines or formulae to control to suit all occasional.

5. Simple repeated hygienic hand wash is most cost effective method to reduce several infections in Hospitals, in particular operation theatres

Note

The knowledge on Maintenance, Sterilization and control of Infections in Operation theatres a rapidly evolving Science

Wish to know more about Operation theatre Maintenance for control of Infection Read through

Principles, And Practice of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe.

All Institutes wish to develop to improve hygiene and sterilization standards, and start critical surgeries doing Cardiothoracic, Organ replacement and prosthetic surgeries should subscribe to the internationally accredited Journal

“The Operating Theatre journal” published from U K.

Dr.T.V.Rao MD and Dr.Chitra Valsan MD work as Microbiologists in Indian Medical College, writes articles of Interest to Medical and Para Medical Professionals to create awareness to reduce infections in the Developing World.

Incoming search terms for the article:

ot sterilisation SOPs for operation theater infection control O T sterilisation Principles And Practice of Disinfection Preservation and Sterilization by A D Russel W

B Hugo & G A J Ayliffe gaseous gangrene infection control in operating theatre role of microbiologist in operation theator SOP Operating Room sterilization carbolisation sop for sterilization and disinfection operation theatre sterilisation

Theatre Infection Control Policy

Scope of policy: Applies to all operating theatres, including day procedures and recovery

INDEX

1. Skin decontamination & use of antiseptic agents:

Hand hygiene: surgical scrub

Skin preparation and use of antiseptic agents

2. Infection control policies in theatre areas:

Sharps use and disposal

Clinical waste

Blood spillage

3. Theatre wear and codes of practice:

Theatre wear

Visitors

Dress when leaving theatre areas

Movement in theatre

Order of patients on operating list (dirty/clean cases; patients with MRSA)

Patients with blood-borne viruses

4. Environmental cleaning and decontamination Cleaning between patients

Daily cleaning schedule

Annual cleaning & maintenance

General guidance: standards of cleanliness

5. Ultra Clean Ventilated (UCV) theatre (theatre 4)

Codes of practice Air quality monitoring

6. Governance: roles and responsibilities

Skin decontamination & use of antiseptic agents: preoperative hand hygiene

Hand decontamination is an important contributor to reducing infections. Hands must be decontaminated by an appropriate method.

How long the preoperative wash or ‘surgical scrub’ should be and what type of antiseptic should be used is not universally agreed. Hand washing should be for minimum of 2 minutes (studies show this duration is effective in reducing hand bacterial colony counts); the optimal duration for washing is not known. Alcohol gel hand rubs are an acceptable alternative to repeated hand washing.

Box 1: Recommended antiseptic agents for surgical scrub

Chlorhexidine gluconate 4% “Hibiscrub” Povidone iodine 7.5% “Betadine”

Recommendations for pre operative surgical scrub

Agents or methods of skin decontamination that cause skin abrasions should not be used.

Using a scrubbing brush on the skin is not recommended. The first wash of the day should include a thorough clean under the

fingernails; a brush or orange stick can be used. Nailbrushes should be single use disposable. An approved antiseptic agent (see box 1) should be used for hand

washing. ‘Surgical scrub’ hand wash should be for a minimum of 2 minutes,

however, There is no evidence that more than a two minute wash

(decontamination) Using aqueous disinfectants is required. In

between cases, use of alcohol gel hand rub, applied using correct technique, is considered adequate in the operating theatre where the surgeon’s hands are clean and have already been decontaminated by conventional methods.

If skin irritation, dermatitis or sensitivity to a particular hand cleaning product or antiseptic agent occurs seek advice from Occupational Health and Safety.

It is important to allow sufficient time for alcohol based skin preparations to dry thoroughly after application and before commencing the procedure to ensure that all combustible ingredients have evaporated. Antiseptic ‘cocktails’ should not be used because many antiseptics are mutually inactivating. (If several consecutive applications are made to the same body site, the same agent should be used).

Skin preparation & use of antiseptic agents:

Alcohol solutions are more effective than and preferable to aqueous solutions for skin preparation (see table 1). They should be allowed to dry thoroughly

Chlorhexidine gluconate 0.5% w/w in spirit 70%. Povidone iodine 7.5%.

Box 2: Recommended antiseptic agents for skin preparation

Recommendations for use of antiseptic agents

Gross contamination at the site of incision should be removed before the antiseptic skin preparation.

Apply the antiseptic skin preparation in concentric circles moving away from the proposed incision site to the periphery; allow sufficient prepared area to accommodate an extension to the incision or new incisions or drain sites to be made.

Allow the alcohol to dry after application and before the use of electrocautery.

The application of the skin preparation may need to be modified according to the condition of the skin (e.g. burns) and the location of the incision site (e.g. face or mucous membranes).

Ideally antiseptics should be supplied at ready-for-use dilution in small, single-use containers with dispensers attached where necessary. The 500ml bottles should normally be changed at least daily.

Multiple-use containers are liable to contamination each time they are opened.

Multi-use bottles of antiseptics - if use Label with date first opened Use within the ‘Use by Date’ or discard once ‘use by date’ reached Never refill or ‘top up’; discard container and dispenser after use or

when use by date has been reached.

Sharps use and disposal

Ensure removable blades can be easily detached using an appropriate device.

Use an appropriate size and type of ‘sharps’ bin/box for the area and anticipated volume of usage

Do not place ‘sharps’ bins/boxes in areas where there may be an obstacle to environmental cleaning.

Avoid overfilling: the sharps containers must be closed securely when three-quarters full.

Used needles must not be resheathed.

Clinical waste As per Waste disposal policy.

Surface contamination by blood or body fluids should be dealt with promptly and removed as soon as possible

Chlorine solution may damage equipment and some metal surfaces so it is important to rinse surfaces well after cleaning splashes or blood spillage.

Blood spillage

Larger spills: sprinkle with chlorine releasing granules (NaDCC as ‘PreSept’ or approved brand) until the fluid is absorbed.

Small blood splashes or drops: wipe up using fresh hypochlorite solution 10,000 ppm available chlorine (as per manufacturer’s instructions on container: ‘PreSept’ or approved brand); apply solution using disposable paper towels.

Leave the granules to solidify or paper towels with hypochlorite solution for a contact time of 2-5 minutes

Clear up using scoop (granules) or with disposable paper towels and dispose of as clinical waste. Wipe the area clean using hypochlorite solution.

Rinse well using detergent and hot water (hypochlorite is corrosive). Dry using paper towels.

Report any sharps inoculation injury promptly according to Trust policy.

Theatre wear and codes of practice

Theatre wear

Gloves have a dual role: as a barrier for personal protection from patients’ blood and exudates to protect bacteria from the surgeons hands entering the surgical site. Surgical gloves must conform to BS EN 455-2

Gloves

Wearing double gloves at surgical procedures helps to reduce hand contamination and protect the wearer from viral transmission. However double gloving may be uncomfortable and reduce manual dexterity and tactile sensitivity. Puncture of a glove is not necessarily an indication to change gloves (there is no evidence that perforated gloves increase the incidence of infection). It may be preferable to don a second pair of gloves to protect the operating surgeon or individual undertaking the procedure.

If glove punctured: change gloves or put a second pair over the first pair.

Face Masks

There is insignificant evidence to support the continued wearing of masks to prevent wound infection Risk assessment should be undertaken and if necessary masks should be worn for the protection of the wearer.

The use of masks to reduce post-operative wound infections is questionable; studies have shown no increase in infection rate when masks were not worn for general surgery.

Masks do however provide a barrier for airborne organisms and also protection for the wearer against blood and body fluid splashes.

Staff needs to be protected from inhalation of surgical smoke and laser plumes

Scrub team members should wear sterile surgical gloves donned after the sterile gown.

A fresh pair of sterile gloves should be worn for each procedure. A mask (with a filter size <1.1 microns) may be worn over the mouth

and nose by all members of the ‘scrub’ team; a visor or goggles should also be worn for added protection where risk of aerosol.

If worn, a fresh mask should be worn for each operation. The mask should be changed if deemed to have become

contaminated or saturated. Although there is no evidence on which to base the recommendation

it would seem reasonable that surgeons with beards should wear a facemask.

Masks should not be worn outside theatre area or left tied around the neck. After surgery, the mask should be removed and disposed of.

In vertical laminar flow theatres a mask should be worn during prosthetic implant surgery.

Disposable headgear is worn by all theatre staff in most UK operating departments; different colours are frequently used to indicate seniority or identify students.

Theatre Caps

Scrubbed staff should wear disposable headgear because of their proximity to the operating field, particularly in a laminar flow field.

Hats must be worn in laminar flow theatre during prosthetic implant operations.After use dispose of headgear and do not wear outside theatre.

In terms of infection risk, non-scrubbed staff members of the operating team do not need to wear disposable headgear, since effective theatre ventilation probably counteracts any possible increase in bacterial shedding. However it is Trust policy for headgear to be worn in theatre by all staff likely to be near the operation field and this includes non-scrubbed staff; common sense also dictates that hair should be kept clean and out of the way.

Theatre footwear

Theatre footwear should be cleaned regularly.

Special well-fitting footwear with impervious soles should be worn in the operating department.

Footwear should be regularly cleaned to remove splashes of blood and body fluid.

All footwear should be cleaned after every use, and procedures should be in place to ensure that this is undertaken at the end of every session.

Jewellery and accessories

Necklaces, ear-rings and rings with stones should be removed;

•

Wedding rings may continue to be worn by ‘scrub’ and non-scrub’ staff although surgeons may be advised to remove these, particularly if working with metal prostheses.

Staff in the operating theatre should not wear false fingernails.

Visitor

Visitors attending the anaesthetic room do not need to wear special protective wear or footwear and may wear ordinary outdoor clothes. If a visitor is to enter any of the main operating theatres, then they should change into theatre suits

Dress when leaving theatre

There is little or no research-based evidence to show that wearing surgical ‘greens’ outside theatre without changing into clean theatre suits increases surgical wound infection rates. However, wearing greens outside theatre and in public areas can give the impression that discipline is lax. Although there is insufficient evidence to support the wearing of cover gowns over surgical attire to prevent infection when theatre staff leaves the theatre area temporarily, the practice is desirable aesthetically

Masks and hats should not be worn outside theatre & recovery areas.

Recommendations:

Theatre staff should wear a clean white coat over theatre suit, if leaving the department and especially in public areas.

Surgical masks must be removed before leaving theatre; masks should never be left tied around neck.

Hats must be removed when leaving theatre.

Theatre: codes of practice

Operating room doors need to be kept closed during procedures to optimise the efficacy of the ventilation system

A conventionally ventilated theatre should have an air change rate of around 20 air changes/hr (1 air change every 3 minutes)

. Each air change will, assuming perfect mixing, reduce airborne contamination to 37% of its former level.

Movement in Theatre

The main routes of microbial entry into an open clean surgical wound are from the patient’s skin, from the surgeon’s hand or by airborne microbes setting into the wound or onto instruments that will be used in the wound. Most microbes in theatre air are from staff and few from the patient; microbial dispersion increases with movement.

Control of movement in, and entry into, the theatre environment is important in reducing the airborne contamination routes.

Recommendations:

Keep operating room doors closed in order to optimize the efficiency of the ventilating system.

Keep ‘traffic’ in and out of the operating room to a minimum during surgical procedures.

The two most probable routes of infection transmission between successive or sequential surgical patients are via air or from environmental surfaces. If theatre ventilation is effective, air should not be a source of infection transmission between sequential patients. This means that surface contamination is more likely to pose infection risk.

Order of patients on operating list: dirty/clean cases

Most microbes in theatre air are from staff and few from the patient. If theatre ventilation is effective air should not be a source of infection transmission between patients, regardless of whether the procedure is “dirty” or clean.

Surface contamination is more likely to pose risk of transmission of infection than air surfaces such as operating tables and other furniture, and instruments that make direct contact with more than one patient have potential for transmission of infection between ‘dirty’ and subsequent cases. The only practical way of reduction of microbes is by cleaning and disinfection of the relevant environmental surfaces.

Surfaces and equipment in direct contact with the patient should be cleaned carefully before the next patient. What is important is that this should is carried out effectively after the procedure, not whether or not the patient is last on the list.

Traditionally “dirty” cases are put last on the list; however it is not always necessary to put the “dirty” case last on list provided the cleaning of relevant surfaces can be done adequately before the next patient. If it is judged that these processes can be carried out adequately during a list, there should be no extra hazard. If “dirty” cases (i.e. patients likely to disperse microbes of particular risk to other patients) are placed last on a list, this may facilitate the process of adequate cleaning/ decontamination of the relevant surfaces.

It is unlikely that operating department staff will always be aware of whether a patient has MRSA hence care should be applied to routine cleaning of surfaces in direct contact with patients

(Patients with MRSA

Provided there are routine high standards of cleaning between patients, it is not necessary to put patients with MRSA last on list unless they meet the specific risk criteria below:

Recommendations:

The operating table, surfaces & items of equipment in direct contact with the patient should be cleaned* between patients.

Putting patients last on the list may facilitate cleaning but is not always necessary if cleaning between patients is adequate.

A conventionally ventilated operating theatre does not need to lie fallow for more than 15 minutes before a clean procedure is performed following a dirty operation. Vertical laminar flow theatres need only 5 minutes to replace the full volume of air in the theatre.

Put last on list:

Patient has extensive eczema or other exfoliative skin disorder colonised with MRSA

Patient with MRSA is undergoing orthopaedic or joint replacement surgery

Patient has tissue infection with MRSA and/or where aerosol-dispersing power tools are used on infected tissue. Patients with blood-borne virus: Hepatitis B, C or HIV

Treat in the same way as any other patient, with universal blood precautions.

Take due care with sharps and ensure that all measures are in place to minimise risk of needlestick injury or contamination with blood: the operating/scrub team should be experienced and the procedure should be unhurried; the scrub team may wish to double-glove; risk assessment should determine whether water impermeable gowns should be worn.

Scrub team should know the correct procedure to follow in the event of an inoculation or ‘sharps’ incident if there has been exposure to HIV.

Environmental cleaning and decontamination

After the patient has left and before the next patient, surfaces such as the operating table and any equipment in direct contact with the patient should be cleaned with detergent. Surfaces that do not have direct patient contact (e.g. floor, wall and light) do not become more contaminated after dirty than after clean operations.

Cleaning between patients Surfaces such as the operating table and any equipment that has been in direct contact with the patient:

Clean carefully after the patient has left, using an approved detergent (e.g. ‘Hospec’) and hot water using a disposable cloth OR using a disposable detergent wipe. Wipe the area thoroughly and allow to dry.

It is not necessary to use disinfectants in addition, unless there has been contamination with blood/body fluid spillage or aerosol

After cleaning, the surface should be dry before the next patient; 15 minutes is sufficient for conventionally ventilated theatres (1-3) to lie fallow after “dirty” cases and before the next case; 5 minutes for theatre 4 (UCV).

Patients with other infections

Seek advice from Infection Control where necessary. If the patient has an infection that may be transmitted by respiratory droplet or secretion (e.g. TB or VZV/chickenpox): Seek advice from the Infection Control Nurse or Doctor (Refer also to Infection Control Isolation policy).

Environmental Cleaning

Cleaning at end of session: Daily schedule for recommendations

Operating theatre floors

Operating theatre floors should be cleaned using an approved detergent (e.g. ‘Hospec’) and hot water. Floor scrubbing machines, where used, should have detergent reservoirs that can be cleaned.

Use mops according to recommendations in table 3

The whole of the floor including corners and edges must be cleaned Horizontal surfaces and fixed equipment

Damp dust horizontal surfaces using a disposable cloth (lint free) for all operating theatre cleaning.

Clean all fixtures and any equipment in theatre by wiping with an approved detergent (e.g. ‘Hospec’), hot water and disposable cloth. Overhead lights and canopy

Damp dust lights and fittings using an approved detergent (e.g. ‘Hospec’), hot water & disposable cloth.

Check for splashes and contamination. Clean using an approved detergent (e.g. ‘Hospec’), hot water and disposable cloth. Where there may have been spillage or contamination with blood/body fluids wipe surface with dilute hypochlorite solution 1,000 ppm available chlorine (1 ‘PreSept’ NaDCC table/litre water), then rinse well (wipe with cloth and water); allow to dry. Anaesthetic room, prep room/other areas

Clean floor using an approved detergent (e.g. ‘Hospec’) and hot water. Follow recommendations in table 3; use different colour code mops to those used to clean operating room.

Ensure no visible dust/dirt on floor

Damp dust horizontal surfaces and fittings. Wipe clean ventilator grills.

Mops should be colour coded: each theatre area should have a separate colour code, with mops kept for one theatre. After use mops should be decontaminated by hot wash: return to laundry daily. Store mops in a designated area: store upright with mop heads in air and kept dry. Mop buckets should be emptied, cleaned and dried after each use. Store inverted