Infection Control in Operating Room

Learning Objectives:

By the end of this session the participant should gain knowledge about:

1) Location, layout of operating room

2) Infection control strategy including:

• Preparation of the patient

• Preparation of operating room personnel

➢ Hand hygiene

➢ Barriers (e.g: gloves and surgical attire )

• Maintaining a sterile field

• Using good surgical technique

• Maintaining a safe environment in the surgical procedure area

Operating room are busy units and therefore they require considerable planning and
discussion before they are built in order to prevent expensive mistakes.

➢ Location of the operating room:

They should be:

1-Separated from the main flow of hospital traffic and from the main corridors, however it
should be easily accessible from surgical wards and emergency rooms.

2-The floor should be covered with antistatic material and the walls should be painted with
antistatic paint this reduce the dust levels and allow for frequent cleaning.

➢ Layout of the operating room :

Operating room should be zoned and access to these zones should be under control of
operating room personnel.

It contains:

1
1-The outer zone

2-The clean or semi restricted zone

3-Aseptic or restricted zone

1-The outer zone:

This zone should contain

➢ A main access door

➢ an accessible area for the removal of waste

➢ A sluice

➢ storage for medical and surgical supplies

➢ an entrance to the changing facilities

2-The clean or semi restricted zone:

This zone contains

➢ The sterile supplies store

➢ An anesthetic room

➢ A recovery area

➢ A scrub-up area

➢ A clean corridor

➢ Rest rooms for the stuff

• Stuff must change into OR clothes and shoes before entering this area, there is
no need for a mask, gloves or a gown

• There should be unidirectional access from this area to aseptic area

• The operating room should be restricted to just the personnel involved in the
actual operation

3-Aseptic or restricted zone:

This area should be restricted to the working team it includes:

2
 ➢ The operating room

➢ The sterile preparation room (preparation of sterile surgical instruments and

equipment)

- Staff working in this area should exchange in to operating clothes, should wear masks
and gowns, and where necessary should wear sterile gloves.
➢ Temperature and humidity:

▪ Temperature and humidity play a very important role in maintaining stuff and
patient comfort. They must be carefully regulated and monitored.

▪ Ideally, the operating room should be 1 °C cooler than the outer area .this aids in the
outward movement of air because the warmer air in the outer area rises and the
cooler air from within the operating room moves to replace it.

▪ Temperature should be maintained and control between 18 - 24 degrees Celsius.

▪ Humidity: lower level of humidity is 20-30% and upper level is 60%. Relative
humidity >60% promote fungal growth.

➢ Ideal air ventilation system (air supply and exhaust ):

Positive pressure ventilation with respect to corridors and adjusting the area in the
operating room where surgical procedures are performed should be maintained.

1-Air changes:

Maintenance of 15-20 changes per hour, of which at least 3 should be fresh air from
outside

2- Filtration

Filter all air with appropriate pre filters (e.g: filtration efficiency of 30 % followed by final
filter (e.g. : 90%)

3- Air supply

Air should enter at the ceiling and be exhausted near the floor

3
4-Doors:

Keep operating room doors closed except as needed for passage of equipment, personnel
and the patient.

Infection control in operating room:

Aseptic techniques refer to those practices performed just before or during clinical
procedure including:

➢ Preoperative care and preparation of the patient

➢ Preoperative skin preparation of operating room personnel

▪ Hand washing

▪ Surgical hand scrub

➢ Using barriers (e.g.: gloves and surgical attire )

➢ Maintaining a sterile field

➢ Using good surgical technique

➢ Maintaining a safe environment in the surgical procedure area

1-Preoperative care and preparation of the patient

➢ Assessment for infection

➢ Preoperative antiseptic showering

➢ Preoperative hair removal

➢ Patient skin preparation in the operating room

➢ Management of infected organized surgical personnel

Common antiseptics used in operating room (Table 1):

1-Alcohol (60-90 % ethyl or isopropyl).

2-Chlorohexidine gluconate (4%)

➢ Must not be allowed to come in contact with the brain, meninges, eye or middle ear

4
3-Iodine compounds including tincture of iodine (iodine and alcohol)

➢ Can cause contact dermatitis therefore has limited usefulness as an operating room
hand antiseptic

➢ Because of the potential to cause skin irritation ,when iodine is used for pre
procedure skin preparation it must be allowed to dry then is removed from skin with
alcohol.

4-Iodophors

➢ Solutions such as povidone iodine (e.g.: betadine) that contains iodine in a complex
form making them relatively non irritating and nontoxic so it can be used on
mucous membrane

➢ Become effective >2 minutes after application. for optimal effectiveness wait
several minutes after application.

➢ Best antiseptic for use in the genital area, vagina and cervix.

Table (1): Antiseptic appropriate for use in clinical procedures

Pre
Surgical
procedure Mucous membrane
Antiseptic hand
skin (vagina and cervix )
antiseptic
preparation

Alcohol yes yes no

Yes, however products containing
chlorhexidine may not be the best
antiseptic to use in the genital area
Chlorhexidine
yes yes because of the small potential for
gluconate
irritation if an iodophor is not available
a product containing chlorhexidine is
the best alternative
Iodine compounds
including tincture
no yes no
of iodine (iodine
and alcohol)
Iodophors yes yes yes

5
Avoid using the following:

i. 1-Hydrogen peroxide preparation:

➢ They can be used to prevent infection in minor cuts, burns and abrasions.

➢ They are not appropriate for use in surgical hand antiseptic and patient skin
preparation.

ii. Product containing quantity ammonium compounds:

➢ Are disinfectant and should not be used as antiseptic

➢ These products are easily contaminated by common bacteria, easily inactivated by

cotton gauze and incompatible with soup

iii. Compounds containing Mercury:

➢ They should not be used because they are highly toxic, cause blisters and cause
CNS disturbance or death when inhaled

➢ They also be absorbed through the skin and can cause birth defects in pregnant
woman who is exposed to small doses.

Tips on using antiseptics

➢ Never leave cotton balls, cotton wool ,or gauze sponges soaking in an antiseptic

➢ Never dip cotton or gauze into the antiseptic container. Instead, pour some
antiseptic into a small container, dip the cotton or gauze into this small container
and discard the unused antiseptic after patient preparation.

➢ If an antiseptic is provided in larger container ,small amount (enough for one shift )
should be pulled in a small clean disinfected containers

➢ At the end of the shift, left over quantities should be discarded and the container
should be appropriately cleaned disinfected and dried before subsequent use

➢ Never leave antiseptic in open containers

6
2-Preoperative skin preparation of operating room personnel:

Hand hygiene: is one of the most effective ways to reduce the risk of infection

1-Surgical (antisepsic) hand wash:

➢ Must perform it preoperative by surgical personnel to eliminate transient and to

reduce resident flora

➢ Surgical hand wash with antiseptic before beginning surgical procedures will help
to prevent this growth for a period of time and will help to reduce the risk of
infection to the patient if the gloves develop holes, tears during the procedure

Indications for surgical hand wash:

➢ Needed for any invasive surgical procedures

➢ All personnel (doctors, anesthesiologists and the nurses) should perform surgical
hand antisepsis before any procedure.

2-Alcohol based surgical hand rub (2-3 minutes):

➢ Make sure that your hands are clean and dry, if not wash by routine hand wash first.
➢ Pour 3-5 ml of alcohol (60-90%) into palm of the left hand, then dip the fingertips
of the right hand in it to decontaminate under nails (5 seconds) then smear the hand
rub on the right forearm up to the elbow in circular manner until the handrub is fully
evaporated (10-15 seconds).

➢ Repeat the previous step to the other forearm.

➢ Apply another dose of alcohol to rub both hands in the same time up to the wrists as
in antiseptic hand rub for 30 seconds, allow hands to dry

➢ Repeat twice and proceed to the OR holding hands above the elbows

3-Surgical hand scrub: (5-6 minutes)

➢ Brushing :

- Surgical hand antiseptic wash may be performed using either a soft brush or a
sponge or using an antiseptic alone (some studies have shown that using a brush

7
 provides no greater reduction of microorganisms on the hand than washing with
antiseptic soup alone).

- Avoid using hard brush which is not necessary and which may irritate the skin

- The brush should be single use and should be discarded if disposable or sent for
autoclaving if reusable.

- Don't share brushes between personnel.

➢ Allergy:

- When surgical staff develops sensitivity to the available antiseptic solutions or

when antiseptic are not available perform a surgical scrub with soap and water
followed by an alcohol hand rub.

➢ As in antiseptic hand wash except:

➢ Open the water flow with an elbow or foot pedal.

➢ Wet hands and forearms till elbow, pour antiseptic preparation, scrub under nails
then rub the hand and forearm starting at fingertips of one hand, then each side of
each finger, between the fingers and the back and front of the hand and forearm in a
circular movement and repeat for the other hand and forearm for at least 5 minutes
keeping hands higher than the arms at all time.

➢ Rinse hands and forearms by passing them through the water in one direction
(from fingertip to elbow), do not move forearm back and forth through water,
always keeping the hands above the elbows, and proceed to the OR holding hands
above the elbows.

➢ Dry hands with a sterile towel by dabbing from fingers to elbows, taking care
that the forearms are away from the body:

8
3- Protective clothing for use in the operating room:

- The use of barriers minimize a patients exposure to microorganisms that might be

shed from the skin, mucous membrane, or hair of surgical team members as well
as protects surgical team members from exposure to blood and blood borne
pathogen.

- Surgical attire can include items such as sterile gloves, caps ,masks, gowns or
waterproof aprons and protective eyewear.

➢ Masks:

- Standard surgical masks are sufficient for operating room personnel

- Masks should cover the mouth and nose at all times

- Mask should not be worn hanging around the neck or be put in pockets to be reused

- Masks should be changed frequently when they become moist and in between cases

- Cotton masks are not considered protective

- High efficiency masks should be available for surgical procedures on patient with
suspected or proven active disease caused the M.tuberculosis.

➢ Gowns:

- Gowns and waterproof aprons prevent contamination of the operating room

personnel arms, chests and closing with blood and body fluid.

- They also minimize shedding of microorganisms from personnel thus protecting

the patient.

- Sterile gowns should be worn by all personnel in operating room.

➢ Sterile drapes (placed over the patient):

- The Sterile drapes are used to create a barrier between the surgical field and the
potential source of bacteria.

9
➢ Scrub suits:

- Surgical member often wear a uniform called a scrub suit or theater suit or
clothes that consists of pants and a shirt.

- It is a uniform over which sterile gown or apron is worn.

- There is no evidence that scrub suites worn by personnel prevents surgical site
infection.

- Scrub suites should be changed when they become visibly soiled.

➢ Surgical caps:

- Hair on the face and head must be covered completely either by disposable or
recyclable coverings.

- Coverings reduce contamination of surgical field by organisms shed from the

hair and from the scalp.

- Hair covering is donned first in order that hair doesn't fall onto clean scrub
clothing.

➢ Eye protection and face shields:

- Should be worn to protect operation room personnel’s eyes, nose and mouth
from splashes of blood or other fluids

➢ Footwear:

- Dealing with heavy blood or body fluids contamination are advised to wear
boots that are adequately covered by plastic apron in order to avoid fluid from
going onto shoes.

- Shoe covers have not been shown to prevent surgical site infection.

➢ Surgical gloves:

- Well-fitting latex sterile surgical gloves should be worn by all operating room
personnel involved in the surgical procedure.

- Gloves must be changed if they become contaminated or if their integrity is

compromised.
10
 - Wearing 2 pairs of gloves has been shown to reduce skin contact with blood or
body fluids from patients specially during complicated procedures.

- Outside of the glove package is not sterile, have another member of the
operating room team to open it for you e.g.: circulating nurse.

▪ Change gloves :

i.When gloves become contaminated

ii.after touching the outside of gloves with a bare hand

iii.after touching anything that is not sterile or high level disinfected

iv.when gloves develop holes, tears or punctures

4- Stablishing and maintaining a sterile field:

➢ A sterile field must be established and maintained in order to reduce the risk of
contaminating the surgical procedure site.

➢ The sterile field is created by placing sterile towels and / or surgical drapes around
the surgical procedure site

➢ additional sterile fields may be also established such as on the stand that will hold
instruments and other items that are needed during the procedure

➢ A sterile field is maintained by:

- Placing only sterile items within the sterile field.

- Opening, dispensing or transferring sterile items without contaminating them.

- Considering items located below the level of the draped client to be unsterile.

- Not allowing sterile personnel to reach across unsterile area or vice versa or to
touch unsterile items.

- Recognizing and maintaining the service providers sterile area. When gowned
this area extend from chest to the level of the sterile field, sleeves are sterile
from 5 cm above the elbow to the cuff. The neckline, shoulders and back are
considered to be on unsterile areas of the gown.

11
 - Recognizing that the edges of package containing sterile items are considered
unsterile.

- Recognizing that a sterile barrier that has been penetrated with cut or torn is
considered contaminated.

- Being conscious of where your body is at all times and moving within or around
the sterile field in a way that maintain sterility.

- Not placing sterile items near open windows or doors.

- When in doubt about the sterility or high level disinfection of an item or an area
considers it contaminated.

- Moisture in the sterile field should be avoided if a solution soaks through a

drape then it should be covered with another sterile drape.

5-Using good surgical technique :

➢ Post procedure infections are more likely to appear in tissue that has been damaged
due to rough or extensive manipulations during surgery.

➢ In addition damaged tissue heals more slowly, this increase the time that it remains
more susceptible to infection.

➢ When excessive bleeding occurs, the tissue is more susceptible to invasion by

microorganism, therefore paying meticulous attention to control bleeding and to
gentle tissue handling during surgery can reduce the risk of infection.

6-Maintaining a safe environment in the surgical procedure area :

Specific rooms should be designed for performing surgical procedures

➢ Traffic

- Limit the number of personnel entering the operating room to only those
necessary for the surgical procedure.

- The microbial level in the operating room is directly proportional to the number
of people moving in the theater

12
➢ Laminar flow & ultraclean air:

- Laminar air flow is designed to move particles free air over the aseptic operating
field in One Direction

- It can be designed to flow vertically or horizontally and is usually combined

with high efficiency particulate air(HEPA) filter

- HEPA filters remove particles ≥ 0 .3 microns in diameter with an efficiency of

99 .97%

- Ultra clean air can reduce the incidence of surgical site infection especially for
orthopedic implant operations

- However some studies suggests that other interventions such as appropriate

timing of preoperative antibiotic and good operating room practice such as
limiting nonessential traffic can also lower the incidence

- Therefore if resources are limited laminar flow with HEPA filtration is not
required for high quality surgical care

➢ Equipment

- Equipment such as suction operators and ventilation must be fitted with

bacterial filters in order to prevent contamination of the machines

- Used instruments should be counted and minimally and then sent to

sterilization

➢ Waste

- Waste should always be disposed of with minimal handling because there is a

risk of blood borne pathogen transmission

- Body fluids can be disposed of in a sluice by staff with appropriate protective

clothing such as gloves, aprons and eye protection

- Equipment should not be rinsed before sending to the sterilization unit

➢ Linen

- Linen that is saturated with body fluids should be placed in fluid proof bags

13
➢ Maintenance in the operating room :

- Equipment should be checked every week

- Ventilation should be checked periodically(each quarter ) and the filters should

be changed as required (usually annually)

➢ Environmental microbiological sampling in the operating room:

- Routine microbiological sampling of operating air or surface is not

recommended because the results obtained are only valid for the time period
and for the location sampled.

- Instead, such studies should be limited to investigations of clusters or outbreaks

of infection or to validate it changes in the ventilation system for example (
installation of new AHU).

14
 Infection Control in ICU

Learning Objectives:

By the end of this session the participant should gain knowledge about:

1) Risk factors in ICU

2) Strategy for infection control in ICU.

Patients in the ICU or at increased risk of developing nosocomial

infections:

a) Host factors:

1) Alternations may be present in the host defense.

➢ Genetic

➢ Acquired

➢ Secondary to underlying disease

2) The severity of a patient’s illness and underlining conditions.

b) Intervention factors:

➢ Exposure to multiple invasive procedures (ventilator, PVC, CVC, etc,.)

➢ The increased length of exposure to invasive devices.

➢ The increased contact with health care personnel.

➢ The length of the ICU stays.

➢ Long term treatment with antibiotics

➢ Use pf multidose vials for treatment between patients.

c) Environmental factors

➢ The special environmental characteristics of the unit such as space limitation.

➢ lack of adequate spatial separation between patients.

15
 ➢ Lake of physical barriers between patient beds with open wards.

➢ Lack of adequate ventilation to prevent the spread of airborne infection.

➢ Hand washing facilities may be limited or may not be easily accessible.

➢ Lack of adequate number of healthcare personnel

The most frequently encountered problems facing patients and health

care workers in the ICU:

➢ Nosocomial pneumonia.

➢ Urinary tract infection.

➢ Intra vascular related infection.

➢ Surgical site infection.

➢ Antibiotic resistance.

Strategy for infection control in ICU:

I. Hand hygiene:

▪ Hands are the most common vehicle for transmission of infection.

▪ Hand washing facilities may be limited or may not be easily accessible.

▪ Hand washing may occur less often which may result in hand carriage of
microorganisms with subsequent transmission to patient.

▪ Solution:

➢ Practice hand washing between patients and between procedures on each patient.

➢ Hand washing facilities should be available and easily accessible.

➢ Provide antimicrobial soup for use prior to performing invasive procedure.

➢ A waterless alcohol-based product may be used.

16
 II. Use of PPE:

➢ Health care providers are required to wear the unit’s uniform only inside the
unit, and it is not required to wear any PPE when entering the unit, but it is used
only when providing health service to the patient (except, when there is an
epidemic spread of some diseases).
➢ The type of gloves should be chosen according to need, and according to the
nature of the procedures (e.g: Gloves are sterile in case of invasive procedures
such as insertion of a central venous catheter and dressings for wounds).
➢ A gown must be worn when suspecting the possibility of contamination with
secretions. It must be changed before providing the health care service to
another patient.
➢ Respiratory protection must be worn while dealing with confirmed or suspected
patients infected with airborne diseases.

III. Environmental factors and design aspects of the intensive care unit

a) Unit design

It must be near to the operating room or emergency room.

➢ Beds:

A distance of 2.5-3 meters must be left between each bed and the next bed in
order to the staff is able to move smoothly, facilitate the process of transporting
medical equipment and to reduce the spread of infection.

➢ Partitions:

Separate patients from each other to prevent the spread of infection and
ensure patient privacy. Designated partitions must be made of materials that are
easy to clean and disinfect. Curtains should also be changed or re-treated weekly
or after entry and exit of patients.

➢ Floors, walls, and ceilings:

They must be made of materials that are easy to clean and disinfect.

17
 ➢ Preparation of medication:

Areas for preparing medications and treatments must be separated from

patient rooms. It must be maintained as a clean area.

➢ Storage area:

• A separate storage area for storing clean supplies, and medications.

• A separate storage area for the temporary storage of contaminated tools,
supplies and furnishings as well as hazardous waste.

➢ Ventilation:

A minimum of six air changes per hour is required with a minimum of two
changes being outside air. Doors & windows remain closed.

➢ Hand washing facilities:

• Hand washing facilities near the entrance to the intensive care unit and in
important places in the unit to facilitate access to them by health service
providers (One basin for every four beds).
• Alcohol hand rub containers should be provided at the entrance in the intensive
care unit and next to every bed.
• It is also recommended to provide enough elbow, foot basins and it is also
prohibited to use them for any purposes other than washing hand.

b) Environmental cleanliness

• Daily cleaning and disinfection while the patient is in care. This includes beds,
work surfaces, floors, doorknobs and drawers twice daily at least.
• All surfaces must be erased with a cloth dampened with water and detergent or
disinfectant cleaner.
• Carry out comprehensive cleaning of all places at least every week or two,
which includes: ceilings, walls, floors, doors, storage areas, and air conditioning
filters.
• Use only tools and equipment specific to the unit and keep cleaning materials in
closed containers.

18
c) Visits:
• Visits should be limited as much as possible to provide comfort to patients and
facilitate caregiving procedures.
• Prohibiting visits from visitors infected with any contagious diseases.
• The need to instruct visitors to wash their hands if they are helping the patient.
• Other instructions may be added regarding visitors at the time of an epidemic
outbreak for some diseases that are transmitted through air.

19