C H A P T E R 3

O P E R A T I N G R O O M
Operating Room and Central Processing Division
The operating room functions to provide a controlled environment for the
performance of surgical procedures. Surgical wound infections are the second
most common nosocomial infection and may involve either the incision or
adjacent structures. Most surgical wound infections result from microbial
contamination (endogenous or exogenous source) of the wound during surgery.
Operating room procedures are designed to provide the maximum reduction of
exogenous microorganisms that could contaminate the surgical wound.
ersonnel and their compliance with surgically aseptic procedures are a
critical component in the prevention of surgical wound infections.
Infection Control Practices!
Employee Health
"areful attention to employee health# safety# and personal hygiene will
minimi$e the potential for ac%uiring or transmitting disease.
ersonnel wor&ing in the O' shall be free from active infection.
(ill &eep vaccinations current as vaccinations provide bac&up
protection when there has been a failure in wor& practices.
)ndividuals exhibiting signs and symptoms of an infection must report
immediately to their supervisor. The supervisor will refer them to
Occupational *ealth for evaluation and wor& duty status.
+ll personnel suspected of having communicable infections shall be
excluded from wor&ing in the O' until they have been cleared by
Occupational *ealth.
+n employee who feels he,she has been exposed to a communicable
disease or occupational exposure (i.e.# needle stic& or sharps injury)
must report immediately to his,her supervisor who will send the
employee to Occupational *ealth. )f the exposure occurred on Ms#
nights# or wee&ends# the individual will be evaluated in the
-mergency 'oom# but must report to Occupational *ealth the next
wor&ing day.
(ill become familiar with and adhere to policies set forth in the
)nfection "ontrol Manual.
(ill use protective barriers to reduce the ris& of s&in and mucous
membrane exposure to potentially infectious materials.
(ill follow hospital policy on .Standard recautions/ for protection
against blood borne pathogens and demonstrate competence in the
prevention of transmissible infections.
(ill use contact# droplet# or airborne precautions as appropriate when
providing care for patients who are &nown or suspected to be infected
or coloni$ed with microorganisms.
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(ill report promptly any suspected communicable diseases#
occupational injury# or infectious exposures to Occupational *ealth for
evaluation# treatment# and follow0up.
(ill adhere to good hygiene practices. *air# body and nails should be
clean at all times.
1either nail polish nor arti2cial nails shall be worn. 3ingernails
should be &ept short and clean and should not extend beyond the
2ngertips.
(ill practice fre%uent and thorough handwashing with appropriate
soap before and after each patient contact.
(ill utili$e wor& practices designed to minimi$e ris& of exposure to
pathogens.
(or& practice controls include prohibition of eating# drin&ing#
smo&ing# applying cosmetics or lip balm# and handling of contact
lenses in wor& areas where there is reasonable li&elihood of
occupational exposure to bloodborne pathogens. +ctivities involving
hand0to0nose# hand0to0mouth# or hand0to0eye action can contribute to
indirect transmission.
(ill report suspected trends or problems related to infection control
to the )nfection revention and "ontrol 4epartment.
Surgical Attire
Scrub clothing is worn to promote a high level of cleanliness and hygiene
within the surgical environment because the human body is a major
source of microbial contamination. Surgical attire helps contain bacterial
shedding and promotes environmental control. The rationale behind this
practice is to prevent the spread of infection from sta5 to patient. roper
operating room attire includes clean scrub suit (with shirt tuc&ed into
pants to prevent shedding of body scurf) donned in a designated dressing
area prior to entering the semi restricted or restricted areas of the
facility.
+ppropriate# clean attire minimi$es the introduction of
microorganisms and lint from personnel to surgical patients and to
the environment. "ontrolled laundering of garments contaminated by
blood or body 6uids reduces the ris& of transferring pathogenic
microorganisms from the health care facility to home and family.
Other garments should be contained completely within or covered by
the surgical attire. "lothing that cannot be covered by the surgical
attire should not be worn.
+ll personnel entering the restricted areas of the O' suite#
decontamination# preparation# sterili$ation and sterile storage areas
will be attired in operating room scrub attire provided by and donned
at 1M". *ome laundering will not be done. Ta&ing previously worn#
soiled# or contaminated surgical attire into the home can result in the
spread of contamination to the home environment. 1o one in street
Operating Room -- !
C H A P T E R 3
O P E R A T I N G R O O M
clothes will be permitted in the suite at any time. arents,visitors are
allowed in the restricted areas# with coveralls# mas&# cap# and shoe
covers.
)f indicated# a head cover and beard cover shall be worn to fully cover
hair on head and face. The head cover or hood should be designed to
minimi$e microbial dispersal. *air acts as a 2lter and collects
bacteria. + bald or shaved head is covered to prevent the shedding of
s%uamous cells. 4isposable bou5ant and hood0style covers are
preferred. *ead cover should be applied before the scrub suit so that
hair does not touch the scrub suit while it is being donned. Single use
headgear should be removed and discarded as soon as possible after
daily use.
Mas&s will be worn at all times in the operating rooms and sub0
steriles. + single surgical mas& will be worn in surgical environments
where open sterile supplies or scrubbed persons are located. + mas&
should fully cover both mouth and nose and be secured in a manner
that prevents venting. + surgical mas& is worn if sterile instruments
are exposed# or if an operation is about to begin or underway. Mas&s
will be changed after each case and not worn dangling around the
nec&. Mas&s should be removed carefully by handling only the ties
and discarded immediately to avoid cross0contamination.
Sterile gloves are worn for sterile procedures and medical# nonsterile
gloves are recommended for nonsterile activities.
rotective eyewear# mas&s or face shields must be worn when
splashing or spraying is li&ely.
"omfortable supportive shoes should be worn for personal safety.
"loth shoes should not be worn because they provide little protection
from spills or accidentally dropped items. Shoe covers are considered
part of - and should be worn when it can be reasonably anticipated
that splashes or spills may occur. 3oot attire has no proven
signi2cance in reducing the incidence of surgical site wound
infections7 the primary reason for its use is to facilitate sanitation.
Shoe covers must be discarded prior to leaving the surgical area.
+ surgical team wears sterile gowns after a hand surgical scrub is
performed. 8owns must be resistant to penetration by moisture.
8own fronts are considered sterile from shoulder to table level on the
front and on the front of the sleeve (axillary area is contaminated).
Sterile gloves are worn by the surgical team. 8own and gloves must
be changed when punctures# contamination# or stri&e through occurs.
Scrub suits must be changed when visibly soiled# contaminated#
and,or penetrated by blood or other potentially infectious materials.
+ll attire will be fresh each day and changed if it becomes wet or
soiled.
(hen leaving the O' suite# a clean cover gown worn bac&wards and
tied or buttoned lab coat is to be worn over the scrub suit. "aps#
Operating Room -- 3
C H A P T E R 3
O P E R A T I N G R O O M
beard covers# mas&s# and shoe covers are to be removed and replaced
with fresh ones when returning to the operating room suite.
+ll personnel entering the semi restricted and restricted areas of the
surgical suite should con2ne or remove all jewelry and watches. 'ings
should be removed because rings can harbor organisms that cannot
be removed during hand washing. Other jewelry such as watches#
earrings# bracelets# nec&laces# and piercings should be removed or
totally con2ned within the scrub attire due to the possibility jewelry
could fall onto the sterile 2eld or into a wound. 1ec&laces that are not
con2ned could contaminate the front of the sterile gown. 9ewelry must
meet the 1avy standard# which is : ring each hand# plus
wedding,engagement ring set. Only one watch and bracelet are
authori$ed. One nec&lace can be worn# but not visible. 1o jewelry is
authori$ed while a person is scrubbed in on a surgical case or while
prepping or positioning a patient.
3ingernails should be &ept short# clean# natural and healthy due to the
subungual regions harboring the majority of microorganisms found on
the hand. 1ail polish that is obviously chipped or worn longer than
four days is associated with the presence of greater numbers of
bacteria. +rti2cial 1ails should not be worn. Studies have shown that
arti2cial nails on healthy hands increased the ris& of surgical site
infection.
Surgical Drapes
4raping is the process of covering with sterile barrier materials the
non0sterile area immediate to and surrounding the operative site.
4rapes are used as barriers to prevent microorganisms outside the
operative area from entering a wound.
4raping is done primarily for the protection of the patient# the
surgical site# and the sterile 2eld.
4raping creates an aseptic barrier between the surgical incision and
the patient;s non0prepared s&in# guarding the wound from bacteria.
Sterile drapes are used to establish a sterile 2eld around or close to a
surgical site.
4isposable surgical drapes are used.
4rapes should be resistant to the passage of blood and 6uids
(resistant to stri&e through)# impermeable to moist microbial
penetration# including viruses# resistant to tearing# puncture# or
abrasion# lint free# 6ame resistant,6ame retardant and antistatic# free
of toxic ingredients# porous enough to maintain an isothermic
environment appropriate to body temperature and easy to use.
The disposable drapes are obtained sterile from the factory in
protective wrappers. rior to use# the wrappers are chec&ed closely
for damage to ensure sterility.
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4rapes are handled as little as possible and should not be waved or
fanned in the air.
4rapes are held high enough to avoid touching non0sterile areas until
they are over the area to be draped.
Sterile gloved hands are protected from contact with the patient by
placing them under the drape (cu5ing) as each drape is placed.
4o not move or rearrange drapes once placed.
<inens are receivxed# inspected# and processed in accordance with
9oint "ommission re%uirements and +O'1 standards.
4isposable drapes that most closely conform to the needs of the
procedure are chosen. 4rapes are used in accordance with factory
recommendations.
++M);s Technical )nformation 'eport outlines four categories of
barrier (draping) materials!
<i%uid resistant (inhibits the penetration of li%uids)
<i%uid barrier (prevents the visible penetration of li%uids)
Microbial barrier (prevents the penetration of microorganisms)
<i%uid proof (prevents the penetration of li%uids and
microorganisms)
Surgical Environments
3loors# (alls and "eilings
The surface of all 6oors must not be porous but instead be suitably
hard# wear resistant# seamless# non0conductive# and easy to clean.
3loor drains should not be installed. 4rains in cystoscopy rooms
should contain a non0splash hori$ontal06ow 6ushing bowl beneath the
drain plate.
(alls should be one continuous surface# easy to clean# and free of
seams.
"eilings should be a minimum of := feet high# hard# nonporous# 2re
resistant# waterproof# stain proof# seamless# non0re6ective# and easy
to clean.
Temperature and Humidity
Temperature should be maintained between >?@3 to AB@3 (C=@" to
CB@") within the operating room suite and general wor& areas in
sterile processing.
4econtamination area temperature should be maintained between
>=@3 to >D@3 (:>@" to :?@")
'elative humidity should be maintained from B=E to >=E within the
perioperative suite# including operating rooms# instrument processing
areas# and sterili$ing areas. + relative humidity of below A=E should
be maintained in sterile storage areas.
Operating Room -- #
C H A P T E R 3
O P E R A T I N G R O O M
Airborne Contamination and Ventilation Systems
+irborne "ontamination! One of the major goals of the surgical team is to
reduce or minimi$e the counts of bacteria0carrying particles in the air.
Fentilation Systems! Should be designed so that air6ow patterns will
not allow air contaminants to enter clean areas. +ir should 6ow from
areas of positive pressure to areas of negative pressure.
The %uality of air entering the operating rooms should be carefully
monitored.
+ir should be 2ltered through two 2lters7 the 2rst 2lter should be
rated as B=E e5icient and the second at G=E e5icient.
Operating 'oom ventilation is maintained at positive pressure with
respect to the corridors and adjacent areas because positive pressure
prevents air6ow from less clean areas into more clean areas. +ll air
should be introduced from the ceiling and exhausted at the 6oor.
Operating 'oom doors should be &ept closed except as needed for
passage of e%uipment# personnel or the patient to reduce the
microbial level in the air.
+ minimum of C=E of the incoming air (three air changes per hour)
should be from the outdoors.
Operating rooms should have a minimum of :D air exchanges per
hour with a recommended range of C= to CD exchanges.
Soiled decontamination and sterili$er loading,unloading should have a
minimum of := air exchanges per hour.
Sterile storage# preparation and pac&aging should have a minimum of
H air exchanges per hour.
3ree standing fans# humidi2ers# or dehumidi2ers should not be used
in the operating room or sterile processing due to disrupted air06ow
patterns resulting in contamination of the sterile 2eld.
The soiled and decontamination area of the "entral rocessing
4epartment should be designed so that air 6ows into the area
(negative pressure)# with a minimum of := air exchanges per hour. +ir
from rooms or areas under negative pressure should be exhausted to
the outside via a non0re0circulating system.
Traic Control
8eneral!
The surgical suite is divided into three designated areas that are
de2ned by the physical activities performed in each area. )ncreasing
environmental controls and surgical attire as progression is made
from unrestricted to restricted areas decreases the potential for cross0
contamination.
The unrestricted area includes the central control point established to
monitor the entrance of patients# personnel# and materials. Street
clothes are permitted in this area and tra5ic is not limited.
Operating Room -- $
C H A P T E R 3
O P E R A T I N G R O O M
The front des&# patient hold# and supply are considered semi0
restricted support areas. Street clothes may be worn in these areas.
Semi0restricted areas include the peripheral support areas of the
surgical suite. This area includes storage areas for clean and sterile
supplies# wor& areas for "entral rocessing# scrub sin&s and corridors
leading to the restricted areas of the surgical suite. Tra5ic in semi0
restricted areas is limited to authori$ed personnel and patients.
ersonnel are re%uired to wear surgical attire and cover all head and
facial hair.
The care of the patient during surgery re%uires movement of patients#
personnel# and material within the surgical suite. lanning and
controlling these movements assist in the containment of
contamination. Only authori$ed personnel are allowed in the
restricted areas. .+uthori$ed/ personnel are those assigned to
Surgical Services to include!
erioperative 1urses and Surgical Technologists
+nesthesiologists# their residents# "'1+s# S'1+s# and +nesthesia
Technicians
Surgeons# their residents# interns# and medical students
The restricted area includes the Operating 'ooms (O's)# procedure
rooms and clean core areas. roper surgical scrub attire# hair
coverings# and name identi2cation are mandatory in the restricted
areas. Mas&s are re%uired where open sterile supplies or scrubbed
persons are located. Innecessary tra5ic is not permitted. +ll doors
must be &ept closed except as needed for passage of e%uipment#
personnel# and patients. +ll sta5 tra5ic to and from an operating
room will be via the sub0sterile door. Tal&ing and the number of
personnel allowed to enter the operating room# especially with a
surgical procedure in progress# will be &ept to a minimum.
ersons entering the semi0restricted or restricted areas of the
surgical suite for a brief time for a speci2c purpose# such as parents
or biomedical engineers# should cover all head and facial hair and
may don either freshly laundered surgical attire or a single0use
coverall suit designed to totally cover outside apparel.
atients should wear clean gowns# be covered with clean linens# and
hair coverings.
Surgical supplies prepared for surgical procedures outside the
surgical suite (e.g. in "entral rocessing 4epartment# "4) should be
transported to the surgical suite to maintain cleanliness and sterility
and to prevent physical damage. rotect items from contamination#
physical damage# and loss during transportation.
Sterile supplies and e%uipment should be removed from external
shipping containers and web edged or corrugated cardboard boxes in
the unrestricted area before transfer into the surgical suite. -xternal
Operating Room -- %
C H A P T E R 3
O P E R A T I N G R O O M
shipping containers may collect dust# debris# and insects during
shipment and may carry contaminants into the surgical suite.
Soiled supplies# instruments# and e%uipment should not re0enter the
clean core area. "ontaminated items should be in closed# covered
carts or containers for transport to the decontamination area.
4econtamination areas and soiled linen areas should be separate from
personnel and patient tra5ic areas.
Separate clean and sterile supplies and e%uipment from soiled
materials by space# time# and tra5ic patterns to decrease ris& of
infection.
!bservation
Observation of surgical procedures for medical education purposes is
an integral part of a teaching institution. Fisiting surgeons# hospital
sta5# nursing students and product representatives may receive
authori$ation for observation,participation on a case by case basis.
'e%uests are submitted by the sponsor to the *ead# Operating 'oom
Services via the 4irector# Surgical Services no later than CH hours in
advance.
+ll re%uests approved must also have the approval of the individual
room;s crew or nurse# anesthesia personnel# and surgeon.
)t is the sponsor;s responsibility to inform the patient of the observing
personnel.
Handling of Infectious "aste# $inen and Sharps
)nfectious waste and all potentially contaminated disposable items are
disposed of in accordance with hospital policy.
Soiled linen will be placed in an impervious linen bag of su5icient
%uality to contain used,soiled linen.
1eedles# syringes# and sharps are to be disposed of uncapped and
uncut# into puncture0resistant sharps containers# being careful to
avoid injury. Sharps used during a surgical procedure are placed in a
needle pad on the bac& table and discarded at the end of the
procedure in appropriate sharps containers.
Intra%operative Infection Control
'esponsibility of circulator!
*and hygiene is the most important factor in preventing the
spread of infection.
"lean# non0sterile gloves should be worn when touching blood#
body 6uids# secretions# excretions# and contaminated items.
"hange gloves between tas&s and patient procedures.
<imit tra5ic in room.
Operating Room -- &
C H A P T E R 3
O P E R A T I N G R O O M
(al&ing outside the periphery of the sterile 2eld or leaving and
returning to the O' in sterile attire increases the potential for
contamination.
Tal&ing is &ept to a minimum in the presence of the sterile 2eld
to reduce the spread of moisture droplets.
(ear a protective apron or cover gown if soiling with blood or
body 6uids is anticipated.
+ mas& and eye protection or a face shield is to be worn at any
time patient care activities are li&ely to generate sprays or
splashes of blood or body 6uids# secretions or excretions. +ll
primary scrub techs will wear eye protection.
Maintain a clean environment during procedures.
Single0use items should be discarded after use. 'eusable
e%uipment must be cleaned and re0processed to ensure safe use
for another patient.
<inens soiled with blood# body 6uids# secretions# or excretions
should be handled in a manner to avoid s&in and mucous
membrane exposure# clothing contamination and transfer of
microorganisms to other patients# personnel# and the
environment.
*andling of Specimens!
*ealthcare wor&ers should receive speci2c instructions
regarding the handling and transportation of cultures and
specimens.
'etrieve cultures and specimens from the scrub technician
wearing gloves or deliver specimen to container held by
circulator. <abel and appropriately process the specimen.
"ontamination of the outside of culture and specimen
containers with blood or other body 6uids should be avoided. )f
the specimen container is removed from the 2eld# the exterior
of the container should be disinfected with an approved hospital
grade disinfectant before the specimen is removed from the
surgical suite.
Jecause cultures and specimens are considered potentially
infectious# all personnel should use gloves when handling them.
*ands should be washed thoroughly after gloves are removed.
Standard precautions should be employed and specimens
should be put in lea&0proof containers to ensure safe handling#
processing# storage# transport# and shipping.
'esponsibilities of scrub technician!
'emain gowned and gloved while brea&ing down and disposing
of instruments# utensils# trash# linens# and sharps.
Operating Room -- '
C H A P T E R 3
O P E R A T I N G R O O M
1eedles# scalpels# and other sharps should be handled in a
manner to avoid injury. 4ispose of all sharps used on the
surgical 2eld by placing into the red sharps container.
4iscard suction tubing. + closed suction system is used.
Suction liners are taped shut and placed in infectious waste
bags. (ear personal protective attire if indicated.
House&eeping 'e(uirements.
olicy!
+ll cases are considered .potentially infectious/. 1o special
.%uarantine/ procedures of operating rooms or operating room
personnel involved with .septic/ procedures are practiced or
considered necessary. "lean up between clean and,or dirty
cases is the same. The .con2ne and contain/ principle of
operating room management shall be practiced therefore
maximally reducing the dissemination of contaminated
materials throughout the operating room suite.
The patient should be provided a clean# safe environment.
*ealth care0associated infections (*+)) have been lin&ed to
external sources# which can include environmental surfaces.
The ris& of infection from pathogenic organisms on
environmental surfaces is due not only to their presence but to
their ability to survive on and be transferred to many surfaces.
Sanitation protocols for cleaning and disinfection are re%uired
before# during# and after each procedure. -nvironmental
cleaning is the framewor& and basis for all aseptic practices.
Measures should be ta&en to prevent vermin infestation.
'emove food sources and any environment that attracts pests
and &eep doors and windows closed.
"leaning before procedures!
roper cleaning reduces the amount of exogenous
microorganisms# dust# and debris in surgical environments# and
it helps to reduce airborne contaminants. 'ooms should be
visually inspected prior to bringing in any carts or supplies.
+ll surfaces within the O'# including furniture# surgical lights
and e%uipment should be damp0dusted before the 2rst
scheduled surgical procedure of the day. 4amp dust with a lint0
free cloth and an approved hospital grade disinfectant. lasma
screens and monitors should be cleaned according to
manufacturer;s guidelines.
<ights and overhead trac&s become contaminated %uic&ly with
dust# debris# and microorganisms# which can fall onto sterile
surfaces or into wounds during surgical procedures and should
be cleaned on a daily basis before the 2rst procedure of the day.
Operating Room -- (
C H A P T E R 3
O P E R A T I N G R O O M
String and micro2ber mops and cleaning cloths should be
changed after each use. Ised cleaning mops or cloths should
not be returned to the cleaning solution container.
"leaning during procedures.
4uring a procedure the practice of .con2ne and contain/ should
be practiced to limit contamination. Ise appropriate - when
handling contaminated items.
+ccidental spills of contaminated debris in areas outside the
surgical 2eld should be cleaned promptly with an approved
hospital grade disinfectant.
Soiled sponges are placed in a plastic lined buc&et or plastic
pouch and not on a draped table or spread out on an impervious
barrier on the 6oor.
+ll disposable sharps are considered infectious waste and
should be placed in puncture0resistant containers and labeled
as bioha$ardous waste.
"ontaminated disposable items used in patient care are
discarded in lea&0proof# tear0 resistant containers.
"leaning between and after procedures.
+ll trash is collected in sturdy plastic or impervious bags.
4amaged or worn coverings should be replaced.
erform in each individual operating room beginning with the
2rst case of the day and between consecutively scheduled
surgical cases.
Ising appropriate disinfectant and a clean cloth# damp dust all
lights and vertical surfaces of all furniture and 2xtures in the
room. +ll reusable items such as pneumatic tourni%uet cu5s
should be cleaned with an approved hospital grade
disinfectant. +ll receptacles such as bins# &ic& buc&ets# and
pails should be cleaned and disinfected.
+ll hori$ontal surfaces and surfaces that have come in
immediate contact with the patient# body 6uids# or with
electrical or laser plume are cleaned with an approved hospital
grade disinfectant.
"lean any areas of the room# other than those speci2ed which
have become soiled with blood# irrigation 6uids# etc.# during the
just completed case.
Move furniture as necessary# dispense cleaning solution over
the entire area of the 6oor# and areas soiled with blood or bodily
6uids or gross contamination. +llow a B0D minute contact time
for disinfectant. Ising (et0Fac# remove the cleaning solution
from the 6oor.
The O' bed is cleaned and all surfaces and mattress pads are
wiped with an approved hospital grade disinfectant. articular
Operating Room --
C H A P T E R 3
O P E R A T I N G R O O M
attention is given to all surfaces of the O' bed# mattress# and
positioning aids where contamination with blood or 6uids may
have occurred. The O' bed is moved to the periphery of the
room so that access is gained to the center of the room for
cleaning.
Move all furniture to the other side of the room and repeat the
previous steps on the newly exposed 6oor area.
+fter room is cleaned# gloves are removed and hands are
washed and the room is prepared for the next patient.
'eplace all furniture to its correct location.
Set out clean &ic& buc&et# linens# covers on arm boards# clean
linen hamper# instrument brea&down tray# and suction bottle.
lace clean linens on operating table.
Terminal cleaning!
erform in each individual operating room every CH hour period if
the room has been opened and used for a surgical case. The
decontamination process begins at the highest0level (light trac&s#
ceiling 2xtures) and progresses downward (&ic& boards and 6oor).
Inused rooms should be cleaned at least once every CH hours
Ising a clean cloth and appropriate disinfectant# thoroughly
wipe down operating room lights and light trac&s.
Sponge mop the bul&heads using appropriate disinfectant and
water solution prepared in buc&ets.
Move all furniture to one side of the room.
Ising the sprin&ler can# sprin&le the cleaning solution on the
6oor. This solution shall be allowed to remain on the 6oor (B0D
minutes) while the furniture is being cleaned.
Ising clean cloth and disinfectant solution# wipe down all
surfaces of all furniture. 'oom 2xtures are also to be wiped
down (windowsills# x0ray view box# tape dispenser# operating
lights# control box# etc.).
+ll room e%uipment is to be wiped down. Special attention
should be given to electro0surgical generator# foot pedal#
suction e%uipment# control table# sponge scale# positioning gear
table parts# wheels# and pads.
Scrub bu5 the 6oor and wet vacuum the 6oor.
Move all furniture to the opposite side of the room. Scrub bu5
and wet vacuum the remaining 6oor area as previously
described.
'eturn all furniture to its correct location.
'eplace &ic& buc&et# liners# covers on arm boards# clean linen
hamper# instrument brea&down tray# and suction bottle.
Operating Room -- !
C H A P T E R 3
O P E R A T I N G R O O M
3ield day!
Total cleaning of any speci2c area including hallways# 6oors#
substeriles# scrub,utility areas# and sterile storage areas. +ll areas
and e%uipment in the surgical suite should be cleaned according to an
established schedule.
+ll refrigerators and ice machines should be cleaned on a
routine basis.
+erators on faucets should be cleaned and disinfected wee&ly
by removing the aerator# scrubbing with detergent and brush
and immersing in disinfectant.
-ye wash stations should be cleaned and chec&ed wee&ly to
ensure that they are in wor&ing order.
erform 2eld day on every area of the MO' suite (inner and
outer) once each wee&.
Sponge mop the ceiling using appropriate disinfectant solution.
4ust all vent covers.
4ust thoroughly the sterile supply cabinet inside and out within
the operating room and chec& all gear for proper expiration
date.
Operating Room -- 3
C H A P T E R 3
O P E R A T I N G R O O M
Care o) Patients *it+ T,-erc,losis in Operating Room
atients with suspected or con2rmed tuberculosis treated in the MO' re%uire
+irborne recautions.
Only emergency or medically necessary surgery is performed on a patient with
suspected or con2rmed tuberculosis disease. -lective operative procedures on
patients with tuberculosis should be delayed until the patient is no longer
infectious.
)f at all possible# patients with tuberculosis should be scheduled at the end of
the day to limit ris& to other patients and healthcare wor&ers. erform the
procedure with a minimal number of personnel.
*-+ respirators or 10GD respirators are indicated for all persons entering the
O' room for respiratory protection. Falveless *-+ respirators or 10GD
respirators will be worn in the O' setting to protect the sterile 2eld.
The doors to the O' will be &ept closed and the number of personnel allowed in
the O' will be &ept to a minimum.
Tuberculosis patients must be recovered in a negative pressure ventilation
room and personnel will follow +irborne recautions and wear 10GD
respirators. atients should then be transported to a negative pressure
ventilation room as soon as possible. The patient will have both nose and
mouth covered with a regular surgical mas& during transport.
ersonnel performing environmental cleaning and disinfection in the room of a
patient who has an airborne disease must use a properly 2t tested 1GD mas& or
powered air purifying respirator until complete air exchange has been
achieved.
The period of time re%uired for the ventilation system to achieve a GG.GE air
exchange should be noted# for example C? minutes for a :D air0exchanges0per0
hour cycle.
+ccess to the room should be restricted until the GG.GE air exchange has been
completed.
Operating Room -- "
C H A P T E R 3
O P E R A T I N G R O O M
Central Processing Division
The "entral rocessing 4ivision ("4) recogni$ed its responsibility for
infection control# reali$ing that this is an integral part of the total care of the
patient. "4;s primary goal is to provide the highest %uality of support so as to
contribute to the total care of the patient. "4 will coordinate its activities
with all departments in the hospital in order to provide the highest standard of
care uniformly throughout the hospital. "4;s infection control guidelines
provide for standardi$ed policies and procedures for receiving#
decontaminating# pac&aging# sterili$ing# storage# and issue of instrumentation
and other medical e%uipment. Sound principles of infection control will be
practiced on a daily basis.
Personnel Policies
"lothing and other re%uirements!
Scrub attire in accordance with 1+FM-4"-1TSF+)1ST :=C=.:
including water proof apron# hair cover# gloves# eye protection,face
shields and mas&s (as wor& re%uires) shall be worn while wor&ing in the
decontamination areas.
ersons wor&ing in any other part of "4# except the
decontamination area# will wear scrub attire# hair covers# and shoe
covers (with the exception of dedicated wor& area shoes).
+ll personnel from other departments desiring entrance to "4
will be properly attired and re%uest entrance. )f not properly attired or if
they have no need to be in the area# entrance will be denied.
+ll repair and maintenance personnel will observe the dress code
for the area in which they are wor&ing.
Inder no circumstances shall street clothes be worn in the "4
area.
3ood and beverage consumption!
3ood and beverages will only be allowed in "4 o5ice spaces in
covered containers.
Smo&ing is prohibited in this facility.
ersonal hygiene and hand washing!
+ll personnel will practice fre%uent and thorough hand washing with
an appropriate soap.
ersonnel wor&ing in "4 shall be free from active infection.
+ll personnel shall adhere to good hygiene practices# such as daily
bathing and wearing a clean scrub uniform.
3ingernails must be &ept short (not beyond 2ngertip) and clean.
+ll personnel handling contaminated items will wear disposable
gloves.
Operating Room -- #
C H A P T E R 3
O P E R A T I N G R O O M
-mployee illness,exposure!
+ll personnel suspected of having communicable infections shall
be excluded from wor&ing in "4 until they have been cleared by
Occupational *ealth.
+n employee who feels he,she has been exposed to a
communicable disease (i.e.# occupational injury via needlestic&,sharps)
or ha$ardous chemical exposure (i.e.# cleaning,decontamination
solutions) should report immediately to his,her supervisor who will send
the employee to the -mergency 'oom for evaluation.
-ducation!
Jasic training in aseptic techni%ue for all "4 personnel must be
provided and documented in education 2les.
eriodic infection control programs will be provided and
documented on no less than a %uarterly basis.
Traic Control
3low
+ll personnel will be taught the proper 6ow of tra5ic within "4.
assage between the areas is to be &ept to a minimum and re%uires
&nowledge of proper dress codes.
'eceiving,decontamination 6ow pattern!
Ised trays and e%uipment must be returned free of gross
contaminants to the decon area. These items should be transported to
"4 in an impervious bag or e%uipment cart.
+ll used trays will be jointly inventoried and a .8ear
'e%uisition,'eceipt/ form will be completed and signed by both the
"4 and departmental representative before the gear is accepted. +
copy of this form will be given to the departmental representative and
a copy &ept for "4 2les.
+ll instruments and e%uipment received from clinics and the MO' will
undergo manual decontamination and a minimum of a ten minute
en$ymatic soa&. )nstruments which are grossly contaminated will
follow the en$ymatic soa& with processing in the ultrasonic cleaner.
<astly# the instruments will be processed through the washer
disinfector.
<inen bags and trash shall be emptied at the end of each shift. +ll
tables and counters shall be wiped down and the 6oor shall be wet
vacuumed at the end of each shift.
Operating Room -- $
C H A P T E R 3
O P E R A T I N G R O O M
+fter instrumentation and e%uipment has been decontaminated# it
will be passed to the clean area of "4 to be processed for sterili$ation.
Sterile Processing
Sterili$ation!
re0vacuum steam sterili$ers# operate at CA=@ 3 and above B= S)
with an exposure time of > minutes.
ac&s that have been removed from sterili$ers will not be put away
until they are cool to the touch. (et and,or hot pac&ages will transfer
bacteria and act as a wic&.
Sterrad sterili$ation utili$es hydrogen peroxide in gas form
(forming free radicals when placed under speci2c temperature# time# and
pressure conditions) to sterili$e instrumentation. The cycle ta&es
between CH and AD minutes and re%uires no aeration phase.
Kuality assurance,improvement!
Testing and documentation shall be performed daily# according to
"4;s policies,procedures as well as the manufacturer;s instructions.
+ biological test (spore test,8eobacillus Stearothermophilus for
steam and Sterrad) will be performed on each load of gear for steam and
Sterrad. Testing will be performed with the 2rst load of the day on
Sterrad. )ncubation of these tests are read as follows!
B hours on steam claves in "4 and MO' sub0sterile areas
: hour on steam claves in the MO' sub0sterile areas
H? hours on Sterrad
The steam clave is to be secured if a biological indication test fails.
Medical 'epair will be noti2ed. 3ollowing the completion of repairs and
three subse%uent negative biologics the steam sterili$er may be brought
bac& into service.
+ vacuum test (Jowie 4ic&) will be performed on each pre0vacuum
sterili$er and 6ash sterili$er as the 2rst cycle of each day. +n
unsatisfactory result re%uires the medical repair technician on duty to be
noti2ed to chec& for problems. +fter completion of repairs# another
vacuum test will be performed to ensure correction of the problem (along
with the three consecutive negative biologicals) prior to the sterili$er
being used to sterili$e gear.
"hemical testing will be performed once daily on steam sterili$ers
as part of the challenge pac& (2rst pac& of the day)# in every 6ash load#
and once a day with the biological test pac& on the Sterrad. )n addition#
each piece of instrumentation placed in a steam or Sterrad sterili$er will
contain its own external and internal chemical indicator.
Sterile commercially prepared items will not be re0sterili$ed except
under unusual circumstances with proper recommendations from the
manufacturer.
Operating Room -- %
C H A P T E R 3
O P E R A T I N G R O O M
+t no time will any dirty gear be allowed into the sterili$ation area
of "4.
ac&aging# storage# and distribution!
)tems sterili$ed by the "entral rocessing 4ivision will have an
inde2nite shelf life (event related sterility) as long as the integrity of the
pac&aging is not compromised and environmental criteria have been
maintained. 1o expiration date will be present.
ac&age integrity is de2ned as!
+ pac&age is considered un0sterile if the wrapper has been torn#
punctured# or is wet or moist (or has the appearance that it was
wet and then dried)# opened# mishandled# or damaged in any
other way.
ac&aged or wrapped items are not sterile if the tape is bro&en.
eel pac& pouches are not sterile if they are not sealed correctly
or if they are excessively wrin&led.
)tems with an external chemical indicator# which has not
changed# are not sterile.
"losed container systems that do not have loc&s# 2lters#
external indicators# or lids that do not 2t properly are not
sterile.
)tems in a plastic dust protector# which is unsealed# are not
sterile.
)f the pac&age has not been handled and stored properly# it is
not sterile (see below for speci2c guidelines).
rocedure!
Sterile items may be used as long as the integrity of the
pac&age is not compromised.
+ sterili$er load stic&er will be placed on each pac&age for
recall purposes only. )t will include the date the item was
sterili$ed and also a load control number indicating the
sterili$er used and the load number.
+ll items will be properly wrapped and processed in such a
manner as to provide an e5ective barrier to microorganisms
and allow aseptic presentation upon opening.
+ll items processed for sterili$ation will be wrapped in C ply
Limberly0"lar& LimguardM disposable sterili$ation wrap#
paper,plastic peel0pouches# or placed in a closed container
system.
"ertain items may be dust0covered to maintain the integrity of
the pac&age. 4ust cover use will be determined by fre%uency of
use# storage# and handling conditions.
Medications or materials within a pac&age that deteriorate over
time will be dated with an expiration date.
Operating Room -- &
C H A P T E R 3
O P E R A T I N G R O O M
"ommercially prepared items that do not have an expiration
date from the manufacturer are sterile unless the pac&age has
been compromised. The loss of sterility is event0related# not
time0related.
)t is important to ensure proper handling# transport# and
storage of items in a manner that does not compromise the
pac&aging of the product.
Sterile items obtained from "4 should be covered for
transport. Ise of clean transport carts or plastic bags is
re%uired.
)tems should be handled with care and only as needed.
ersonnel should wash their hands prior to handling sterile
items. Sterile items should not be carried under the arms or
cradled in the arms. )f the item is too heavy for transport# the
item should be covered in plastic and transported on a clean
cart. )tems should be properly stored immediately after
transport and remain stored until used for patient care.
)tems that have been dropped must be inspected for damage to
the pac&age. Inless the pac&age is heat0sealed in impervious
plastic and the seal is still intact# the pac&age should be
considered contaminated if it has been dropped.
Storage spaces should not compromise the integrity of sterile
pac&ages in any way. +ll storage spaces must be cleaned on a
wee&ly basis.
Outside shipping cartons are not allowed in either a clean
storage area or a sterile storage area and they should never be
used as storage containers in these areas. These boxes are
dirty from the shipping process and they may contain insects.
)n particular# corrugated cardboard boxes harbor dust and
bacteria in the grooves and are sources of fungal contamination
and bacterial spores.
Sterile Storage +rea 'e%uirements!
'oom temperature! <ess than or e%ual to AD@3
'oom humidity! <ess than or e%ual to A=E
+ir movement! ositive (out) air 6ow with a minimum of H
(downdraft type) air exchanges per hour for clean,sterile
storage areas.
Tra5ic! <imited to those personnel who need to be there.
Space! "losed shelves are the preferred method of storage.
Open doors slowly and avoid crowding and stac&ing. )f open
shelves are used# they should be wire mesh or &ept dust free.
The shelves should &eep sterile pac&ages at least ?0:=/ from the
6oor# :?/ from the ceiling or ceiling 2xture# and C/ from the
Operating Room -- '
C H A P T E R 3
O P E R A T I N G R O O M
outside walls. The shelves should be &ept away from sin&s#
windows# doors# and exposed pipes and vents. -nsure a barrier
between the bottom shelf and the 6oor and that items on the
top shelf are protected. Space between pac&ages should be
su5icient to avoid compression of supplies. articular attention
should be paid to the storage of paper,plastic peel0pac&
pouches.
+ll sterile pac&ages must be rotated on a :
st
in# :
st
out basis.
Some items will remain on storage shelves for varying lengths
of time. )tems should be evaluated as to the need to &eep them
sterile. )f necessary# items may be placed in plastic dust covers
at the re%uest of the departments sending items to be
processed.
+ll pac&ages must be inspected before using.
+ dating label must be applied to each pac&age to be used only
for recall purposes. This is not to be used as an expiration date.
The user must inspect all pac&ages before the pac&age is
opened. )f the pac&age is damaged# then item is not sterile and
cannot be used. +lways verify that the external indicator has
been exposed to the sterilant.
CPD Environment
'outine cleaning!
"4 will be cleaned at the change of each shift. This will include
re0stoc&ing vital supplies# sweeping the entire area# wet vacuuming as
necessary# wiping down 6at surfaces# and emptying all trash.
"4 2eld days will be held. The senior technician on board will
ta&e charge and assign the various duties.
"ompletely clean the sterili$ation room. The decontamination
process begins at the highest level and progresses downward.
"lean ceiling and walls with sponge mop.
"lean lights and venting.
(ipe down all furniture and carts with appropriate disinfectant.
'emove all load stic&ers from the 6oor.
Ju5 and wet vacuum 6oor with disinfectant solution.
'estoc& area.
"ompletely clean the pac& room.
"lean ceiling and walls with sponge mop.
"lean lights and venting.
(ipe down all furniture and carts with appropriate disinfectant.
'emove all load stic&ers from the 6oor.
Ju5 and wet vacuum 6oor with disinfectant solution.
'estoc& area.
Operating Room -- !(
C H A P T E R 3
O P E R A T I N G R O O M
"ompletely clean trash# linen# and receiving rooms.
"lean ceiling and walls with sponge mop.
"lean lights and venting.
(ipe down all furniture and carts with appropriate disinfectant.
'emove all load stic&ers from the 6oor.
Ju5 and wet vacuum 6oor with disinfectant solution.
'estoc& area.
"ompletely clean clinical supply room.
'emove all carts from room.
"lean ceiling and walls with sponge mop.
"lean lights and venting.
Ju5 and wet vacuum 6oor with disinfectant solution.
+utoclave sterili$ers will be cleaned wee&ly during the wee&end
shifts. Sterili$ers : and C will be secured 3riday night to allow
cooling prior to cleaning on Saturday. Sterili$ers B and H will be
secured Saturday night to allow for cooling prior to cleaning on
Sunday. "leaning will be performed in accordance with the
cleaning solution;s manufacturer;s directions. Sterili$ers are to be
returned to service as soon as cleaning is completed.
reventive maintenance!
+ll e%uipment within the division is evaluated and routinely
maintained under the reventative Maintenance rogram. The 3acility;s
4epartment maintains and performs repairs on all structural aspects of
"4.

'ecall of )aterial Sterili*ed by CPD
Jiological spore tests are run for each steam sterili$ers and
Sterrad sterili$er.
)f a positive test should occur# all sterili$ed e%uipment from that
load will be recalled and reprocessed by the "4 sta5.
The "4 4ivision O5icer shall initiate the recall and "4
personnel will contact each area suspected of having materials from the
failed load.
The "4 4ivision O5icer shall submit any follow0up reports
re%uired by the a5ected departments. This report will re6ect 2nal
disposition of any suspected item. )f any suspected items were used
prior to recall# a list of patients and their physicians must be included.
+ll individual areas are responsible to follow0up with patient;s physician.
)n addition# the )nfection "ontrol 4epartment should be noti2ed of these
events when they occur.
Operating Room -- !
C H A P T E R 3
O P E R A T I N G R O O M
G,idelines )or Immediate .se /0las+1 2terili3ation
'eferences
+O'1 Standards and 'ecommended ractices# C=::# +ssociation for the
+dvancement of Medical )nstrumentation
Policy
)mmediate Ise (3lash) sterili$ation should be used only when time
does not permit sterili$ation by the preferred wrapped procedure.
The unwrapped method may be used in emergency situations for
individual items (i.e.# dropped instruments). "omplete sets or trays of
instruments may be immediate use sterili$ed,6ashed if the following
conditions are met!
There is an urgent need.
roper decontamination# cleaning# inspection# and
arrangement of instruments prior to sterili$ation.
Procedure
+ll contaminated instruments to be immediate use
sterili$ed,6ashed will be manually decontaminated prior to placement in
the steam sterili$er.
4on protective gear (i.e.# eye protection# gloves# apron if
appropriate).
'inse items under cold water.
Spray instrument with en$ymatic solution.
"lean items with scrub brush under water to avoid aerosoli$ation.
)nspect for cleanliness.
lace items in immediate use,6ash sterili$ation pan with chemical
indicator. Metal or nonporous items are sterili$ed for B minutes at CA=@
3 (:BD@ ") in either the gravity or prevac cycle. )tems with lumens or
complex items re%uire a := minute CA=@ 3 (:BD@ ") gravity cycle or H
minute CA=@ 3 (:BD@ ") prevac cycle.
)f time permits# all instruments needed for another scheduled case
should be ta&en to "4 for decontamination and returned to O' for
immediate use sterili$ation,6ashing. This will ta&e approximately :
hour. 1otify "4 in advance for prompt service.
)mmediate Ise (3lash) sterili$ation should not be used for
implantable devices except in cases of emergency when no other option
is available. )n an emergency a rapid0action (: hour blue top) biological
indication will be run with the load. 3ollowing sterili$ation# the implant
should be %uarantined until the rapid0action biologic provides a negative
result.
Operating Room -- !!
C H A P T E R 3
O P E R A T I N G R O O M
Documentation
4ocumentation of cycle information and monitoring results will be
maintained in a 2le to provide trac&ing of the 6ashed item(s) to the
individual patient.
4ocumentation allows every load of sterili$ed items used on a patient
to be traced.
Sterili$ation records should include information on each load#
including!
The item(s) processed7
The patient receiving the item(s)
The cycle parameters used (eg# temperature# duration of cycle)
The date and time the cycle is run
'evised! Mar C==>7 C= Mar C=::
Operating Room -- !3