OT

1. Infection control in operation theatre Dr Priyadarshini Patro Microbiologist VY Hospital

2. Aim Provide a sterile field for a safe surgery Prevention of All HAIs ( not only SSI) Prevention of occupational hazards

3. Sterile Environment reduces Surgical site infections SSI are the second most common cause of hospital acquired ( Nosocomial ) infections. Leads to considerable morbidity and, when these occur deep at the site of the procedure, can lead to mortality as high as 77%. The source of SSIs may be:- Endogenous (normal flora of the patient’s skin, mucous membranes, or hollow viscera) Exogenous (surgical personnel , the operating room environment, and tools, instruments, and materials brought to the sterile field during an operation

4. Layout of OT Outer Zone: ( Main Access corridor, transfer area, supervisor office or control station, documentation area, preoperative patient holding area(s ), the changing facilities, toilet). Clean/ Semi restricted zone: ( Clean corridor, sterile equipment store, anesthesia and recovery room, rest areas) Restricted/ sterile zone: (scrub sinks, operation room)

5. Policy For Theatre Staff (Including Doctors) All staff working in OT complex and associated with patient care should have had a clean bath before arrival in the hospital. Staff must change into theatre clothes and shoes before entering the clean/ semi restricted area. Staff is expected to spend at least 1 minute at the scrub area washing their hands & thoroughly dried . The operating theatre ( restricted zone) should be restricted to just the personnel involved in the actual operation.

6. Dress code: A fresh mask for each operation. Disposable/linen caps for all staff. Surgical suits worn by patient caretakers comprising of surgical team, scrubbed nurse, anaesthetist should be clean and sterile (sterilized by autoclaving). Linen should be changed after attending an infected case in OT. footwear – needs to be cleaned off blood and body fluid after every case. They should be totally dry prior to use. Wristwatches and jewellery of any kind must not be worn.

7. Protective EYE WEAR should be preferably worn for all cases. Wear sterile gloves after wearing the sterile gown without touching the outer surface of the glove. For short visits to OT (photographer, physician, maintenance staff etc), the person is required to change into theatre dress with facemask and head cap. For urgent immediate attention to a sick patient / crash situtation , the staff need not change, but should put on disposable gowns or proper OT dress as soon as conveniently possible. Theatre personnel who collect patients for OT, collect blood, deliver urgent pathology specimen etc should wear a clean apron/gown & outside shoes before leaving OT complex for other areas.

8. Sterile field Do not allow sterile personnel to reach across unsterile areas or to touch unsterile items, or vice versa

9. Infection prevention and control Standard Precautions: Hand hygiene PPE Aseptic technique- Prevention of needle stick injury Environmental Cleaning Instruments reprocessing Waste management Universal precautions: Blood spillage management/ blood and body fluid post exposure management

10. General instructions Efforts should be made to minimize personnel traffic during operations. No one should leave the O. T. wearing O. T. clothes and slippers. 20 – 25 degree centigrade temperature to be maintained inside the O. T. & humidity should be 50-60%. Infected cases should be preferably scheduled at the end of the list. Surgical suits (staff dress) should be changed after attending such infected cases.

11. Appropriate device handling Handle used patient care equipment soiled with blood and body substances in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments. Reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed. Single use items are properly discarded after use.

12. Appropriate handling of laundry Clean and used linen should be transported and stored separately. Used linen should be put in trolly at the point of generation. Linen trolly should not be overfilled. Overfilling will prevent closure and increase the risk of rupture in transit. Staff should ensure sharps and other objects are not discarded into linen trolly . Linen soiled with blood or body substances should be packed and transported to laundry .

13. What is wrong with our Practices Disinfectants used indiscrimately , Used unnecessarily Not used when needed. Concentration not adequate Economic consideration, Business promotions.

14. Basic Principles Cleaning more Important than Disinfection and Sterilization ? However Cleaning Removes contaminants, Dust, organic matter, Disinfection Reduces number of microbes

15. Basic care of Operation Theatres Reduction of Microbial counts is important . Very rarely the Microbes reach the operation site . Paying great attention to Floors using unnecessary, too many chemicals is not necessary. Keep the floor Clean and Dry - Bacteria are reduced. Most Important component of Bacteria is water & dry areas causes natural death except spores.

16. Frequent cleaning of Walls and Roof of Operation Theatre is not needed Frequent cleaning has little effect . Do not disturb these areas unnecessarily . Do not use ceiling fans they cause aerosol spread . Clean only when remodeling or accumulated good amount of dust.

17. Cleaning the Floor Floors get contaminated quickly, depend on Number of persons present in the Theatre / Movements they make , has direct relation to increase of bacterial counts. Floor should be decontaminated with Vacuum cleaner and Wet cleaning techniques . A simple detergent reduces flora by 80 % Addition of disinfectant reduces to 95 % In busy Hospitals counts raise in 2 hours

18. Cleaning in Operation theatres - Frequency of cleaning : Operation rooms – daily Entire theatre complex – once a week Schedule for cleaning of the OTs – Before first case i.e. beginning of the day During a Surgery Between Surgeries End of the day Weekly/ Monthly

19. Prior to First Case: Wipe all furniture, equipment, lights, suction points, OT table, slabs, etc with a detergent/soap and water Complete at least one hour before start of Surgery . During surgery: Spills/ Blood Splashes in the vicinity of the sterile field - absorbed with a cloth & covered with freshly prepared sodium hypocholorite for at least 30 mins Clean the area with soap and water.

20. In Between Surgeries: Gather all soiled linens in the receptacles and place them in trolleys to be taken for sorting. The dirty linen is then sent to the laundry. Use gloves while handling dirty linen. Used instruments – Disinfect – Wash in adjacent room by scrubbing with brush, liquid soap and vim – Send for sterilisation. In septic theatres – autoclave first – then clean manually – pack and reautoclave . Furniture, Operating Lights, Suction Cannisters and other equipment used - Wiped with a detergent. Patient transport vehicles are wiped. Floor – mop 3-4 feet area of the floor around the table

21. Days End: Repeat Same procedure as earlier. Wipe over head lights, cabinets, waste receptacles, equipment, furniture with soap/detergent and water. Wash floor with soap and water followed by disinfectant solution (0.1% hypochlorite solution/ 1% Bacillocid solution/ 7% Lysol). Disinfect the operating room, scrub utility, corridor, furnishings and equipment.

22. Weekly (Deep cleaning ) Staff undertaking cleaning must wear appropriate Personal Protective Equipment (PPE). The patient(s) must be vacated from the area to be cleaned. Pre cleaning culture swabs must be taken by ICN. Disposable/opened items must be discarded; the area is cleared of all personal effects, equipment (once cleaned), linen and biomedical waste. Remove the curtains prior to cleaning and send for laundering. Housekeeping services are responsible for cleaning the entire environment including en-suite facilities/patient lockers/tables/underside of bed frame with Bacillocid 1% .

23. Clean the wall and ceiling with Bacillocid 1 %. AC ducts/vents should be cleaned. Mop the beds and mattress with Bacillocid 1 %. Mopping should be done for air beds unless contraindicated by manufacturer‘s instructions . Floor should be scrubbed with water and detergent (R2) and then mopped with Bacillocid 1% from inside to outside . Suction jars and Humidifiers should be cleaned with soap and water, Korsolex and dipped in Sodium Hypochlorite 1 % for 45 minutes or send for ETO. All equipments clinical and nonclinical are mopped with disinfectant. Biomedical staff is responsible for cleaning of all electronic equipment with Bacillol 25.

24. All equipment in the area must be decontaminated prior to transferring to a clean area. Post cleaning culture swabs to be taken by ICN. The ward/area can resume its normal activities after taking the culture swabs.

25. 3 bucket system For mopping of floors 3 bucket system should be preferred. 1st Bucket with water : Dirty mop is rinsed 2nd Bucket with fresh water for rinsing: Mop rinsed again in this water 3rd Bucket with low level disinfectant : Mop is immersed in the solution and the floor mopped liberally. Wash the used mop with disinfectant after use and dry thoroughly before reuse .

26. Fogging in patient care areas 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 Facilities that state that the CDC does not support disinfectant fogging.

27. Fogging is indicated in following situations: 1. If there is a case of anthrax, gas gangrene, tetanus or an open septic wound with laboratory evidence of Clostridium tetani in any area where surgical procedures are carried out. 2. Before functioning of a newly constructed or renovated or repaired operation room/ intensive care unit. 3. When routine environmental surveillance reveals C.tetani or any pathogenic spore former. 4. As a part of terminal cleaning once in a week. 5. Daily in operation theatres where surgeries are performed with window ACs.

28. Procedure: 1. Measure the area of room to be fogged in cubic feets . 2. Seal the room including windows and ventilators air tight. Use adhesive tapes to close the gaps. 3. Switch off the fans and ACs. 4. For each 1000 cu.ft .(28.3 cu.mt.) space, use one litre of 0.5% Baciliocid extra solution/ 20% Ecoshield solution 5. Pour this solution to fogging machine 6. Switch on the machine 7. Keep it for 60 minutes

29. Microbiological surveillance after Fogging Recommended only in case of fogging done after new construction/ renovation/ repair work or after procedures done on septic cases. Not indicated in case of fogging being done as a part of terminal cleaning. In such case the area/room can be used immediately after fogging. Surveillance cultures in the form of air sampling by open plate cultures (settle plates) and swabs for isolation of aerobic and anaerobic bacteria should be taken by infection control nurse. Information regarding the same should be provided to infection control team prior to fogging. The area/room where fogging was performed should not be used until the microbiological surveillance cultures are reported as negative.

30. Action plan in case of positive microbiological surveillance report: The area/site should be cleaned and scrubbed thoroughly with soap/detergent and water followed by cleaning with disinfectant ( phenolic agents/ hypochlorites ). This should be followed by repeat fogging and repeat microbiological testing. OT/room/area can be used only after microbiological surveillance cultures are reported as negative.

31. CDC recommendation for prevention of SSI Category IA : Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies. Category IB :Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale. Category II : Suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale. No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

32. Preoperative Preparation of patient Hand antisepsis for surgical team members Management of infected or colonized surgical personnel Antimicrobial prophylaxis

33. Preparation of the patient Identify and treat all infections remote to surgical site before elective operations (IA). Do not remove hair preoperatively unless it will interfere with the operation( IA). If needed, remove hair immediately before the operation preferably with electric clippers instead of razor (IA) 4 % chlorhexidine showers/bath is mandatory for all elective surgical patients after shaving is complete. If this is not feasible (e.g. sick bedridden patients), chlorhexidine , 4% povidone iodine lotion is to be sponged on to the patient in bed. Patient scalp hair needs to be capped by a disposable cap before shifting to OT.

34. Hand/forearm antisepsis for surgical team Keep nails short and do not wear artificial nails IB Perform preoperative surgical scrub for at least 2 to 5 minutes using an appropriate antiseptic IB Dry hands with sterile towels and don a sterile gowns and gloves IB

35. Antimicrobial prophylaxis Administer a prophylactic antimicrobial agent only when indicated IA Administer by the IV route the initial dose not more 1 hour before incision IA

36. Intraoperative Ventilation system Cleaning and disinfection of environmental surfaces Microbiological sampling Sterilization of surgical instruments Surgical attire and drapes Asepsis and surgical technique

37. Ventilation Maintain positive pressure ventilation in the operating room IB Maintain a minimum of 15 air changes per hour with at least 3 fresh air IB Do not use UV radiation in the operating room to prevent SSI IB Keep operating room doors closed except as needed for passage of equipment personnel and the patient IB General traffic in & out of the OT should be reduced as far as possible.

38. Asepsis and surgical technique Alcoholic solutions preferred over aqueous solutions for skin preparation. Single use sachets of solutions ; not multi-use bottles. Wounds should not be drained unless absolutely necessary. If drainage is used , use a closed suction drain, insert it through a separate incision distant from the operative incision and remove it as soon as possible IB

39. Evaluation of infection control practices Checklists Surveillance

40. Evaluation of infection control practices Checklists Used to evaluate everyday performance and compliance to infection control practices Provide feedback to OT staff to rapid intervention.

41. Evaluation of infection control practices Surveillance IB Use CDC case definitions to identify SSIs and all other HAIs either during hospital stay or after patient discharge. Provides incidence rate of infection Stratifies risk factors HAIs that need strong intervention.

42. Sampling of OT air and floor swabs OT air will be sampled by using culture plates circulated through the OT atmosphere manually and kept in OT for 1 hour . OT door should remain closed during the sampling hour. Swabs will be taken from OT floor, table, Walls, Boyle‘s Apparatus, A.C. duct and light source in all OTs. The sampling will be done once a month.

43. Operation Theatre Saftey is Responsibility Of

44. Everyone

45. Remember we are More important than many

46. Sterilization and Disinfection policies Create you own Infection control team which suits your Hospital. Infection control team decides the policies . Educate the staff on Methods and policies in Hospital safety and Hygiene. Educate the staff on few useful option, many theoretical ideas confuse . To many Chemicals – Costly, need not be effective .

47. Importance of Staff Education Speicify the staff for duties and responsibilities. Education is a matter of continuity Train under the seniors observation. Train the staff with scientific goals