CLOSING ACT

WHAT IS THE END OF DAY CLEANING THEATER ROUTINE?
Clean OT thoroughly after each day's list, and completely every week.


Decontamination of Furniture and Fixed Equipment

* The room itself and its furniture and fixed equipment can be cleaned and disinfected.
* All equipment and furniture used during a surgical procedure are thoroughly cleaned
* Floors should be cleaned using a wet-vacuum system. This can be a centralized built in system or a portable wet-vacuum. If neither is available, the following procedure may be used:

1) Two buckets are filled with disinfectant/detergent
2) Mop heads must be sterilized or a disposable mop head (used once only) used in the operating room suite.
3) Solutions and mop heads are changed for each suite and the buckets cleaned before new solution is mixed.

* The pads of the operating table are removed to expose the undersurface of the table. All surfaces of the table and pads are cleaned with particular attention to hinges, pivotal points, and castors.
* Doors and walls are spot cleaned with disinfectant

End of Day Cleanup

* Surgical lights and slide tracks
* All ceiling-mounted equipment
* All furniture including castors or wheels
* All shelves, counters, work tables and autoclave cabinet tops
* All floor surfaces in the department the surfaces are carbonized.
* Scrub sinks
* Soap dispensers

Weekly Cleanup

* Ventilation and air conditioning/heating duct grills must be vacuumed to prevent the release of bacteria-laden dust into the surgical environment
* Utility rooms, including those used to store house keeping supplies, sewer hoppers, and linens, must be cleaned
* OT Fumigation is utilized after occurrence of infection.
Cleaning Instruments:
Use an old scrub brush. Open hinged instruments fully,
scrub them, and take special care to clean their jaws and serrations
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ACT ONE SCENE ONE

THE MAIN EVENT



HOW DO YOU PREPARE THE OPERATION SITE?
Shaving:
The operation area should be clean and free of infection before the operation, and the ward nurse to check this in the ward before sending the patient to the O.T. (Figs 2.12A – E)
- Shave the area on the morning of the operation, or as part of operation.

Preparation:
Prepare the skin as soon as the patient is anaesthetized.
- Start with a soap solution, and follow this with spirit.
- If there is a low sensitivity to iodine in the community, use alcoholic iodine.
- Take a sterile swab on a holder start in the middle of the operation site, and work outwards.
- Discard both swab and holder, and repeat the process with a second swab (some surgeons use a third).
- The last is spirit which will evaporate to leave the skin dry.
- Be sure to prepare a wide enough area of skin.
- In an abdominal operation this should extend from the patient's nipple line to below his groin.

Draping
The skin has been prepared:
-Place the first towel across the lower part of the operation site. fig 2.13a
-Place another towel at right angle on the nearer edge of the operation site. fig 2.13b
-Apply a towel clip at the point of crossing of the two towels. fig 2.14
-Place another towel at the far edge of the operation site.
-The final towel goes across the top end of the site.
All the corners should have towel clips to prevent them from slipping they can go through the skin if the operation is under G.A.
-In an abdominal operation an abdominal sheet covers the abdomen on top of the towels. This sheet has an opening in its middle to provide access to the operation site [double toweling]
-If any area close to the operation site becomes contaminated at any time during the operation, place another sterile towel over the contaminated site.

SWABS
Ten cm. gauze squares folded and held in sponge forceps are used for swabbing
PACKS Large squares of gauze or linen are used as packs. These packs are placed in cavities so as to keep organs and vital structures out of reach of sharp instruments being used at the operation site.
All these swabs and packs are counted and placed on the sterile trolley
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A DAY AT THE THEATRE

PREPAREEVERY OT DAY


HOW TO PREPARE THE OT?
- All equipment, particularly the operating theatre table and
all storage ledges within the OT 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, lights are inspected for illumination and focus.
- All electro medical 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 UN-STERILE
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.
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JOIN THE TEAM

GOWNING
Hold the gown away from your body, high so as that it does not touch the floor.
- Allow it to open up and put your arms into the arm holes while keeping your arms extended.The inside of the gown is facing you
- Then flex your elbows and abduct your arms. fig 2.6
- Wait for the nurse to help you.
-She will hold the inner sides of the gown at each shoulder and pull them over your shoulders fig 2.7 and will tie the tapes of the gown at the back. fig 2.8

GLOVING
Dust your hands with powder and rub them together to spread it.
- Be careful to touch only the inner surface of the gloves.
- Grasp the inner aspect of the turned down cuff of a glove, and pull it on to your opposite hand. fig 2.9
- Leave its cuff for the moment.
- Put the fingers of your already gloved hand under the inverted cuff of the other glove, and pull it on to your bare hand. (fig 2.10, fig 2.11a, & b)
- It is a good practice to wash your gloved hands in sterile water to remove the powder.

EYE PROTECTION

Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids, the face should prevent exposure of mucous membranes of the mouth, nose and eyes of the surgeon.

They are lightweight, adjustable and do not obstruct vision. An educational programme is necessary to introduce surgeons to these new barriers.
You are now ready to prepare the op-site for cleaning.

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START THE DAYS WORK

SCRUBBING UP
ALL taking part in the surgical procedure and the OT .team must scrub.
The scrub rooms are situated before the entrance to the O.T.
Adjust the elbow tap levers to deliver water without splashing fig 1.1.In most tropical countries only a cold water tap is necessary.
- Wet your hands, apply a little soap or detergent, and work up a good FOAM.
- Scrub your hands and forearms to 5 cm above your elbows for one complete MINUTE.
- Wash your forearms.
- Then take a sterile brush and put soap on it. fig 2.1
- Scrub the lateral side of your left thumb, then its medial side, then the lateral and medial aspects of each successive finger. fig 2.3
- Scrub your nails, and then the back and front of your left hand.
- Follow same routine with your right hand. Scrub for 5 minutes in all.

Some surgeons only scrub their nails, and then thoroughly wash and rinse their hands and arms upto their elbows a number of times for 5 minutes.
Rinse the suds from your hands while holding them higher than your elbows. fig 2.4
- Turn off the taps with your elbows. fig 2.5
Dry your hands with a sterile towel before you put on a sterile gown.
- Dry your hands first, then your forearms.
- Grasp the folded towel with the fingers of both hands, then let it drop open, so that you don't touch anything with the open towel.
- Dry your hands on one corner, then dry your forearms.
- Try not to bring a wet (unsterile) part of the towel back to a dry area of your arms and hands
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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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