OTMANAGE CRITICAL CONTROL

INFECTION CONTROL, STERILIZATION & OT CLEANING

How does Air Entry Air Conditioning Effect Infection in OT?

There must be a positive pressure in the OT compared to wash rooms, utility rooms and corridors to prevent entry of contaminated air.

The temperature be kept at 68 to 700F (20-23 C) with a humidity of 30-60 percent.
-This reduces bacterial growth and static electricity.
-Each O.T. should have independent temperature controls.

Air in flow should be filtered through high efficiency particulate system (HEPA) with 15 air exchange per hour at least three of these must be fresh air.
-Air must enter the OT through vents in the ceiling and leaves through vents near the floor.

-The air ventilation system must have a regular routine for inspection and maintenance including change of filters.

-All these steps will control bacterial growth and thus wound infections.

What are Infection Control Mechanisms?

Infection will occur if high standards of preoperative,
intra-operative,
and postoperative rules are not observed in relation to the care of instruments and patients.
If there is any break of these rules by the surgical team;
-The occurrence of infection and cross-infection will rise.
-Resulting in anything from minor wound infections to a major disaster(tetanus)
-Standing rules and procedures need to be DEFINED by hospital Infection Control Committees (ICC) and OBSERVED by the surgical teams.

The infection control committee, usually headed by a physician, infection control nurse, or nurse epidemiologist.
Following the standards set by the ICC, provides the hospital with an effective program with the following goals:

-Investigate and identify source of the infection in each case.
-The source may be a person, a patient or an employee or may be the practice of one or more employees of poor aseptic technique. or
-A team member may be harboring a specific disease organism that is transmitted to the patients in his or her care.
-Provide effective isolation of infected patients.

-The ICC also identifies need for change in rule book to prevent a future outbreak

What are Common Bacteria on Skin and Surface?
Bacteria include staphylococci and streptococci these are responsible for the majority of cases of cellulites and abscesses seen on the skin.
-Most respond to an appropriate broad spectrum antibiotics.

-Abscesses in the perineal area are frequently infected with anaerobic bacteria or are mixed infections.
-In these situations metronidazole or some similar antibiotic needs to be given

• WHERE INFECTION is suspected in patent or staff, a bacterial SWAB should be taken, this will guide the treating physician to select the correct antibiotic.
• Fungal infection on toe-nails and finger-nails may be easily recognized by sending nail clippings or even the complete nail for mycology. Such action may avoid the need for surgery and establish a definitive diagnosis.
• Candida (fungus infection in mouth) infections are easily recognised and treated with any of the antimycotic agents.

Most cases of infection in surgery can be avoided by:
• Careful aseptic technique in the OT (given below).
• Attention to rules and procedures for sterilization of instruments and dressings (to be defined by the hospital administrators).
• However, in addition to problems of common bacterial pathogens, surgeons are now having to address themselves to the problems of viral agents such as HEPATITIS B, C, and HIV infection, which may have very many more serious long term consequences (guidelines at the end of this chapter).
• Infection is not always a one-way problem of patients infecting doctors and other patients: in a few instances an infected surgeon or his team can infect the patient, or other colleagues.
• It is therefore important for all members of the surgical team to be aware of the potential DANGER of their personal infections, and to know how to avoid them by strict personal hygiene and to treat these infections if they occur.
They must be freed from OT duties for the duration of their infection
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DOWN MEMORY LANE

REVIEW AND RECALL



SELECT DEFINITIONS YOU NEED TO KNOW

ANTISEPSIS

A process that destroys most harmful microorganisms on
The surface of Instruments

BACTERICIDAL

Drugs, chemicals, and other agents able to kill bacteria

BACTERIOSTATIC

Agents capable of inhibiting the growth of bacteria but not killing them


CAVITATION

A process in which air pockets are imploded (burst inward),
Releasing energy to dislodge particles of soil or tissue debris
Sticking to instruments. Antiseptics chemicals used for reducing
Contamination of body surfaces

CLEANING

A process that removes organic or inorganic residue or debris by hand cleaning and brushing

CONTAMINATED

Any instrument or body surface that is known to be unsterile.
A sterile instrument comes in contact with non-sterile objects and thus may harbor Microorganisms

DECONTAMINATION

A process of disinfection

DISINFECTION

A process by which most but not all harmful microorganisms are
Destroyed on instrument surfaces

CRITICAL ITEMS

Those items that must be sterile before use in or on a patient; items
That goes into body tissues or the vascular system

STERILIZATION

A process by which all microorganisms are destroyed

ULTRASONIC CLEANER

Equipment that cleans instruments through cavitations

WASHER STERILIZER

Equipment that washes and sterilizes instruments following an
Operative procedure

FOMITE
An item(towel, bedsheet) that is capable of harboring bacteria and transmitting
Disease.

HOST
Organism that provides nutrition for parasites

PATHOGENIC
Disease causing bacteria

STRICT AEROBES
Bacteria that cannot survive without oxygen

STRICT ANAEROBES
Bacteria that cannot survive in the presence of oxygen
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RECYCLED INSRUMENTS AND MEDICAL WASTE

HOW TO DECONTAMINATE SURGICAL INSTRUMENTS?

Washer Steriliser

The washer-sterilizer operates much the same as the steam
sterilizer.
The washer-sterilizer sends large amounts of soapy
water over the instruments.
Steam under pressure and air are then injected into the water, which activates the water significantly.
As the water is drained from the chamber, tissue debris and scum are filtered off and steam fills the entire chamber.
The temperature is then maintained at 270oF for 3 minutes.
Near the completion of the cycle, the steam is released
through the exhaust system.

Ultrasonic Cleaner

Following processing in the washer-sterilizer, all instruments
should be placed in the ultrasonic cleaner.
This process further removes particles and debris through a process called cavitation.
During cavitation, high frequency sound waves are generated
through a water bath in which the instruments are placed along
with a neutral to slightly alkaline detergent.
Cavitation explode inwardly (implosion), and this causes their release from the surface of the instrument.
Following cavitation, instruments are rinsed thoroughly and dried.

WHAT ARE DISPOSAL MEDICAL WASTE?

The operation of a single surgical OT generates a large amount
of medical waste.

Among these are:

* gloves
* gowns
* backtable covers
* patient drapes
* needles and other sharps
* body fluids and secretions
* and other items that must be disposed of.

The types of regulated waste from health care facilities.

* These are radioactive waste, which is regulated by the
Nuclear Regulation Agency
* Hazardous chemical waste, which is regulated by environmental
protection agency
* The third type is potential infective waste, are for
the purpose of this text will be referred to as regulated
medical waste.

CATEGORIES OF MEDICAL WASTE

Sharps (used and unused)

Discarded medical devices that have been used in human
patient care, medical research, or industrial laboratories and
that are capable of pucturing or cutting the skin and thus
transmitting bacterial or virus infections.

This includes:
* needles
* syringes with needles attached
* trocars
* pipettes
* scalpel blades
* blood vials
* broken or unbroken glassware

Cultures and stocks of infectious wastes

Discarded cultures and stocks of infectious agents and associated
microbiologicals should be considered regulated medical waste.

Animal Waste

Discarded material originating from animals inoculated with
infectious agents during research or production of biological or
pharmaceutical testing.

Pathological waste

Discarded pathological wastes (eg. human tissues, organs, body
parts) removed during surgery, autopsy or other medical
procedures


Human blood, blood products, body fluids

This category includes discarded free-flowing human blood and
blood products (eg. plasma, serum), any free-flowing body
Secretion containing blood components (egg. pleural, peritoneal,
Amniotic fluid), human excretions (egg. urine, stool)
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THE INSTRUMENT CARE

Preparing the Tools for a Procedure







HOW TO TAKE CARE OF SURGICAL INSTRUMENTS?
Like all other equipment,medical and surgical instruments also
require a regular care and maintenance protocol so that they
retain their useful character and prolong their life.
Instruments that are dirty or rusty are not only a source of
infection, but ultimately break before their expected life span.

CARE OF STAINLESS STEEL:
Stainless steel is the material of choice for most surgical
instruments;it combines a high resistance to corrosion and rust
and has a smooth surface. However the surface of the finest
stainless steel instruments can become pitted and stained, if
great care is not used in washing, cleaning, polishing and
lubrication of these instruments. Rough handling or the use of
abrasives can permanently mark stainless steel.
- So to start with all instruments after use should be cleaned
with a hard brush under running cool water.Very hot water will
cause coagulation of blood and exudate and make subsequent
cleaning more difficult.
- If use of an Ultrasonic cleaning bath using instrument
detergents is available, this will be ideal and insure good
cleaning and continued high polish of the instruments. This
equipment is available only in some hospitals in India.
- After washing,instruments should be dried to avoid water
remaining in any joint and causing corrosion.
- Lubrication using a water-soluble lubricant applied on joints is
recommended and will greatly prolong the useful life of any
instrument if they are to be stored.
- Salt solutions are a major cause of pitting,and instruments
should never be soaked in them, nor should a saline solution be
allowed to dry on an instrument.
- Whenever cleaning or washing instruments, keep all ratchets
unlocked and box joints open and avoid using wire wool or rough
brushes on the surface of instruments.
- Surgical blades and needles, both of which may rust and corrode
more easily than stainless steel instruments and therefore the
rules above apply to them also.
- Serrated surfaces on artery forceps and needle holders can be
effectively cleaned with a small brass wire brush
- Instruments or plastic parts of instruments are washed
with warm soapy water with a soft cloth sterilization may be
by either soaking in antiseptic solutions or autoclaving at a
lower temperature (121 degree C under 151b/in2 for 15 min.)
than is used for steel instruments.Cleaning and polishing
should only be undertaken using recommended cleansers and
polishers. Most plastics are best stored in a dry state rather
than prolonged soaking in antiseptic solutions.

WHAT ARE CRITICAL ITEMS?

Critical items are those that must be sterile. These objects
enter sterile tissue or the vascular system. Examples of
critical items include:

* Surgical instruments
* Cardiac and urinary catheters
* Implants
* Needles

NONCRITICAL ITEMS
This group of items comes in contact with skin. Skin is
effective in protecting the inner tissues of the body against
bacteria and viral invasions. This category includes items :

* Blood pressure cuffs
* Bed linens
* Bedside tables
* Crutches
* Some food utensils
* Bed frames
* Floors
* Walls
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TO PREPARE FOR THE EVENT

An OT Day
HOW TO PREPARE OT?
- All equipment, particularly the operating theatre table and
all storage ledges,within the rooms,should be cleaned with damp
duster.Floors are cleaned before sterile trolleys are prepared.
- Sterile nail brushes,scrub solution gown packs and all items
required in the OT should be checked and replaced if required
- The required number of bottles or flasks of sterile saline or
water for hand-lotion bowls are placed in position.
- Fresh replacements of bandages, strapping, splints and lotions,
etc., should be available before the operation list commences.
- Finally equipment required for the first operation is checked by
the senior operating theatre nurse or the scrub nurse also selects
sterile packs, may prepare instruments and special apparatus for
sterilization.
- Special attention is given to the operation table and
accessories to ensure that these are present and in working
order, are inspected for illumination and focus of lights.
- All electromedical apparatus such as the diathermy and suction
machines or pipeline suction set are switched on and tested.

HOW TO PREPARE AN INSTRUMENT TROLLEY?
- Instrument trolley should be prepared immediately before an
operation.
- It is a bad practice to prepare all trolleys required for a
list in the morning,for even if they are covered carefully,it
is impossible to guarantee sterility when required later.
- All metal surfaces of trolleys and tables which are to be used
for setting out sterile instruments and apparatus should first
be covered with a sterile water-proof material before the
application of sterile drapes.
- If the instrument trays have been placed on the trolleys
aseptically,the instruments are laid out by a nurse wearing
sterile gown and gloves.
- It is a bad practice for an" unscrubbed"person to complete
this arrangement using Cheatle forceps, because of the great
risk of contamination occurring when ungloved hands are moved
to and fro over the sterile trolley.
THERE IS NO PLACE IN A MODERN OPERATING ROOM FOR USE OF UNSTERILE
FORCEPS STORED HALF SUBMERGED IN A CONTAINER OF DISINFECTANT.
- Prepared sterile packs containing all the necessary equipment
relevant to a listed operation, and incorporating trolley
drapes which fall into position as the pack is opened, will
shorten the time taken for preparation and cut down bacterial
contamination in the O.T.
WHAT ARE THE DUTIES OF THE SCRUB NURSE?
- The nurse or operating department assistant (ODA) acting as
scrub nurse, scrubs up puts on sterile gown, and sterile gloves
on the hands like the rest of the surgical team
- When scrubbing up to carry out surgical hand disinfection, care
must be taken to ensure that all parts of the hands and
forearms are cleaned thoroughly, special attention being given
to the nails and between the fingers.
- It is important that no person should scrub unless free from
upper respiratory infection and skin lesions.
- Cuts and abrasions or infected pimples can endanger the patient
by increasing the possibility of post-operative infection.
- She/he anticipates and provides all instruments required by the
surgeon.
- Keeps count of them and all swabs used.

WHAT ARE YOUR DUTIES AS CIRCULATING NURSES?
- In addition to the scrub nurse,one or two nurses or ODAS are
on duty to act as circulators.One stays in the operating
theatre, watching the scrub nurse and ready to bring anything
she requires.
- The main duties of the second circulating nurse are to see
that the instruments and trolleys are READY for the NEXT CASE,
and she should help in PLACING the PATIENT on the operation
table if a porter or technician is not available.
- She anticipates and gives to the scrub nurse articles from
sterile bags or packs, she REPLACES sterile gowns and gloves
used up on the sterile trolley reserved for the purpose.
- The first circulating nurse also TIES up the gowns, being
careful to avoid touching any part of the gown other than
the tapes.
- She should identify the patient by the identity tag and case
notes before he/she enters the OT.
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DRESS CODES AND TABLE POSITIONS

ENTRY RULES & POSITIONS



Some more positions


HOW DO YOU GET THE LATERAL POSITION OF EXTENSION?
This is used for operations on the kidney and chest, but may be
modified slightly for operations on the hip.
For the former operations the patient is positioned over the kidney bridge which is raised to extend this region.
Alternatively if an operation which incorporates a `break back' is used, extension is achieved by positioning the patient over the division in the centre section before adjusting the angle of the table top. Fig 8

HOW TO GET THE PRONE CRANIAL POSITION?
This position is used for cerebella operations and high cervical
laminectomy.
Some reverse Trendelenburg tilt is used and a padded strap placed round the thighs and the table top for additional security.
The shoulders and thorax are supported by shoulder supports in conjunction with small pillows. Fig. 9

HOW TO GET PATENT IN SITTING CRANIAL POSITION?
This is a position for cerebella cranial operations and high
cervical laminectomy and is an alternative to that described.
The patient is sitting and stabilised by the cranial support.
The hands are placed in the lap and the body immobilised by
securing the arms with body supports which are attached to the
operation table at each side.
These have been omitted in the illustration in order to show the position of the arms. fig 10

RULES YOU OBSERVE IN OT?
No one should enter the operating rooms without first washing his
hands and changing into clean OT clothing and footwear such as
theatre rubber shoes, sandals or slipper.
The main objective is to prevent entry of street bacterial contamination into the operating rooms.
This rule must apply even when there are no operations in progress.
- Personnel preparing to assist at operations cover their hair
and wear masks in addition to wearing suitable clothing and
footwear.
Visitors and other staff are similarly attired.
- Cotton, poplin or polyester cotton are the most commonly used
materials for theatre clothing; Blue, grey colour or white for
scrub suits, and green colour or white for operating gowns.
- The hair should be completely covered with a closely fitting
caps.
- The most efficient mask is one made from synthetic fibres or
fibre glass, linen masks can be used in case these are not
available.
- These masks, which should be moulded to fit the facial outline
snugly when worn, actually filter the air rather than deflect
as with the paper or cloth masks.
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NEED TO KNOW

TABLE MANNERS





Who Should Know?
It is essential that all members of the theatre staff familiarize
Themselves with the operation table and its accessories which
must be easily available and ready for immediate use.
To insure this, passing on of this information is a part of the introductory briefing of all new staff.
- The whole apparatus must be maintained in good working order
and checked before each operation list.
Careful and correct positioning of the patient is very important.
- It is essential to provide good access for surgery.
- And also to take into account patient safety.
- Anesthesia technique requirements.
- Monitoring and position of i.v. lines.
- The table top rubber mattress must provide insulation and
Prevent harm to the patient due to pressure, especially on
Nerves and bony prominences.
Most of the following positions are demonstrated on an general
purpose operation table which incorporates the majority of the
features described already.

What are the Positions?
In Supine or Dorsal Recumbent Position (Fig.2)
In this position the patient lies on his back and is used for MOST operations, including those on the
- Eye
- Ear
- Face
- Chest
- Abdomen
- Legs or Feet
- And with modifications is suitable for operations on the breast
and arms or hands, which may be placed across the chest or
extended on an arm table.

WHAT IS BREAST AND AXILLA POSITION?
This is the position for operations on the breast and axilla. It
is a modified supine position, either with both arms extended and
secured on arm tables, or one arm secured by the side of the
patient and the other on the affected side abducted and
supported by a nurse (Fig 3).

WHAT IS NECK POSITION?
This position is used for operations on the neck, especially
Thyroidectomy, and tracheotomy.
The patient is placed in the supine position with a pillow or sandbag under the shoulder blades, and the head is held by a nurse or assistant with the neck well extended, a padded horse-shoe provides a good support for the head in such operations.

WHAT IS SUPINE HIP POSITION?
This is used mainly for nailing a femoral neck fracture, but is
suitable for osteotomy, slipped femoral epiphysis,etc.
The patient is in a supine position, with his pelvis supported by a
supplementary table top which is translucent to X-rays and
incorporates a slot for introducing anterior position film
cassettes under the pelvis fig 4.

WHAT IS THE TRENDELENBURG POSITION (HEAD DOWN)?
This position, a modification of supine, is used for intrapelvic
operations. Fig 5.
- The object being to allow the intestines to displace away from
the pelvic cavity by gravity towards the upper abdomen.
- They may also be packed off readily to leave easier access to
the pelvic organs.

HOW IS THE GALL-BLADDER AND LIVER POSITION ARANGED?
This is another modified supine position which is used for
operations on the gall-bladder or liver.The patient is
positioned over the back elevator which is raised to produce
extension; and thereby push the gall-bladder towards the anterior
abdominal wall. Fig.6

HOW TO ARRANGE FOR LITHOTOMY POSITION?
This is used for operations on the external genital organs,
perineum and anal region. The buttocks project well over the
edge of the table at the junction of the centre and foot section
which is lowered or removed.The legs are flexed at the hips and
knees, and raised with the feet supported in webbing slings
suspended from the lithotomy poles. A douching funnel may be
fitted below the perineal area to collect blood.
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