INFECTION CONTROL IN OPERATION THEATRE

INFECTION CONTROL IN OPERATION THEATRE

Infection Control Practices:
Infection control practices can be grouped in two categories: (1) Standard precautions. (2) Additional (transmission-based) precautions. Transmission of infections in health care facilities can be prevented and controlled through the application of basic infection control precautions which can be grouped into standard precautions, which must be applied to all patients at all times, regardless of diagnosis or infectious status, and additional (transmission-based) precautions which are specific to modes of transmission (airborne, droplet and contact)

Standard precautions:
Treating all patients in the health care facility with the same basic level of Standard precautions involves work practices that are essential to provide a high level of protection to patients, health care workers and visitors. These include the following: hand washing and antisepsis (hand hygiene) use of personal protective equipment when handling blood, body substances, excretions and secretions appropriate handling of patient care equipment and soiled linen prevention of needlestick/sharp injuries environmental cleaning and spills-management appropriate handling of waste.

Additional (transmission-based) precautions:

Additional (transmission-based) precautions are taken while ensuring standard precautions are maintained. Additional precautions include: Airborne precautions Droplet precautions Contact precautions.

Airborne precautions:
Airborne infection usually occurs by the respiratory route, with the agent present in aerosols (infectious particles < 5mm in diameter). These are additional to standard precautions and are designed to reduce the transmission of diseases spread by the airborne route.

 Contact precautions:
Contact transmission when Micro-organisms that are transmitted by direct contact with hands/ equipment or indirect contact between and infected or colonized patient and a susceptible patient. These are additional to standard precautions and are designed to reduce the risk of transmission of micro-organisms by direct or indirect contact.

Droplet precautions:
Droplet infections when Large droplets carry the infectious agent (>5mm in diameter). These are additional to standard precautions and are designed to reduce the transmission of infectious spread by the droplet route.

UNIVERSAL PRECAUTIONS:
Universal precautions are based on the concept that all blood, blood products and body fluids of all persons are potential sources of infection, independent of diagnosis or perceived risk. Transmission of HIV and the Hepatitis B virus in the workplace has occurred in two major ways: when sharps contaminated with infected blood or body fluids penetrate the skin; and when infected blood or body fluids splash into the eye or onto broken skin or into a cut.

Preventing the transmission of HIV and the Hepatitis B virus in the workplace, therefore means preventing injuries from sharps and other instruments contaminated with blood or body fluids; and contact between blood or body fluids and the eye, or other mucous membranes, and broken skin or cuts. All staff must adhere rigorously to protective measure, which minimise exposure to these agents. The use of universal precautions involves placing a barrier between staff and all blood and body fluids. It is essential that all post-mortem workers receive initial and ongoing training to enable them to do their duties in a healthy and safe manner. This training should enable them to anticipate and manage situations in which they may be exposed to infectious organisms such as HIV or the Hepatitis B virus. It is also important that postmortem staff have access to appropriate professional counseling and follow-up services available after any possible and definite exposures to blood and body fluids.

Safe work practices

Safe work procedures should be developed within the framework of risk identification, risk assessment and risk control. The implementation of effective controls impacts on many

areas in the workplace, including the selection and purchasing of equipment, staffing, policy and procedures in the workplace, provision of information and training and the recording and monitoring of exposures to blood or body fluids. Work practices and the choice of personal protective equipment should be based on the universal precautions. The following procedures should be observed by operating theatre staff: Pre-operative shaving should be avoided. Where practicable, hair should be clipped. Sharp instruments should not be passed between surgeons and assistants. Surgeons should be responsible for the safe placement of sharp instruments. A sharps dish should be used to transfer all sharp instruments. Only one sharp should be placed in the dish at a time. When two surgeons are operating simultaneously, each must have his/her own sharps dish. Used needles and other disposable sharp instruments must be discarded into an approved sharps container as soon as practicable. Disposable one-piece scalpels should be used where practicable to avoid injuries that occur when removing scalpel blades from reusable handles. Surgeons should avoid using their less dexterous hand to hold a needle holder or instrument when suturing. Surgeons may wish to use sterile thimble for protection when suturing. Needles must never be picked up, nor the fingers used to expose and increase access for suturing. Heavy tissue forceps with grooved pads at the ends should be used to pick up the needle or the needle grasped by the assistant with another needle holder and drawn through the tissue. Needles should be cut off before knots are tied to prevent needle stick injury. Where practicable, the hands of assisting staff should not be used to retract viscera during surgery. New techniques of cutting by laser to minimise the risk of scalpel cuts should be used where practicable. Blood-soaked sponges and swabs should be kept in a bowl and counted into a plastic bag. If a glove is torn or a needle stick or other injury occurs, the glove should be removed and a new glove worn promptly after washing hands with scrub solution. The needle or instrument involved must also be removed from the sterile field. Needle stick and mucous membrane exposures should be attended to as soon as safety permits. Following a surgical procedure, the skin should be closed with staples whenever practicable. Closed, rather than open wound drainage is preferable where clinically appropriate. Wound dressings should contain and confine wound exudate. All blood should be cleaned from the patient after the operation. Blood and body fluids should be confined and contained in a fluid-resistant drape and/or a closed, preferably disposable, suction system.

All specimens and body tissues should be placed in impermeable containers or biohazard bags for transport. Routine cleaning procedures are adequate between cases. Any traces of blood and other organic substances should be removed from equipment, walls and floors as soon as practicable. Gross soiling should be rinsed off instruments in the operating theatre before they are placed in a closed container for transport to a central processing area. Where practicable, used instruments should be washed mechanically rather than by hand. If this is not possible, they should be washed in a sink of warm water with detergent, not under running water.

Personal protective equipment

All staff who are required to wear personal protective equipment while on duty should be trained in its correct fit and use. While on duty, operating theatre staff should have access to the following items: Gloves (double gloving is advisable in high risk procedures). Plastic aprons should be worn by scrub staff where there is likely to be excessive blood and/or body fluid loss. Impermeable gowns with long waterproof sleeves and full length front paneling are recommended if gross contamination is likely. Gowns should be made of waterproof fabric with the ability to breathe. See Australian Standard AS 3789.6 Textiles for health care facilities and institutions Fabric Specifications. Open footwear should not be worn. Galoshes, calf-length rubber boots or other protective footwear are preferable to shoes. Fluid-resistant face mask. Protective eyewear, that is, goggles or a full-face mask. An approved sharps container. The appropriate equipment must be accessible to operating theatre staff at all times. Equipment must be checked regularly, maintained and restocked as necessary.

Infection Prevention in the Operating Theatre:

Infection prevention in the operating room is achieved through prudent use of aseptic techniques in order to: Prevent contamination of the open wound. Isolate the operative site from the surrounding unsterile physical environment. Create and maintain a sterile field in which surgery can be performed safely. Although all infection prevention practices contribute to this effort, aseptic technique refers to those practices performed just before or during clinical procedure including: Properly preparing a client for clinical procedures Handwashing Operating Theatre Surgical hand scrub

 Using barriers such as gloves and surgical attire Maintaining a sterile field Principles and maintenance of aseptic practices are imperative in the operating room. Each facility should develop policies and procedures pertaining to aseptic Using good surgical technique Maintaining a safe environment in the surgical/procedure area technique.

Infection Control Guidelines for Operating Theatres

Theatre Infection Control Policy
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. Skin preparation & use of antiseptic agents: Alcohol solutions are more effective than and preferable to aqueous solutions for skin preparation. They should be allowed to dry thoroughly.

Infection control policies: Theatre areas

Sharps use and disposal
Ensure removable blades can be easily detached using an appropriate device. Use an appropriate size and type of sharps bin/boxfor the area and anticipated volume of usage Do not place sharps bins/boxes in areas wherethere may be an obstacle to environmental cleaning. Avoid overfilling: the sharps containers must beclosed securely when three-quarters full. Used needles must not be resheathed. As per Trust Waste disposal policy. Surface contamination by blood or body fluids should be dealt with promptly and removed as soon as possible.

Clinical waste

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.

 Gloves
Wearing double gloves at surgical procedures helps to reduce hand contamination and protect the wearer from viral transmission.

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

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.

Theatre footwear
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.

Visitors
If a visitor is to enter any of the main operating theatres, then they should change into theatre suits. Scrubbed staff should wear disposable caps, Mask, foot wear because of their proximity to the operating field, particularly in a laminar flow field.

Dress when leaving theatre

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

Movement in Theatre
The main routes of microbial entry into an open clean surgical wound are from the patients skin, from the surgeons 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 optimise the efficiency of the ventilating system. Keep traffic in and out of the operating room to a minimum during surgical procedures.

Order of patients on operating list: dirty/clean cases

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. 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.

Patients with blood-borne virus: Hepatitis B, C or HIV

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

Responsibilities
It is the responsibility of all theatre and clinical staff to ensure standards in this guidance are complied with. It is the responsibility of theatre co-ordinators to ensure standards of cleanliness are met or to initiate appropriate action if standards are not met. (Theatre operational managers should also perform regular audits of theatre standards of cleanliness and keep written record of this).

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