Surveillance, Sterilization and Disinfection of Operation Theatres in the Developing World

SURVEILLANCE AND STERILISATION OF OPERATIon THEATRES
In the Developing World

Dr.T.V.Rao MD – Dr.Chithra.VN MD



In spite of brief stay of patients in the operation theatre (in majority of circumstances), the environment of operation theatre plays a great role in the onset and spread of infection because of a multifactor causation of infection. It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances as in most developing countries, work in isolation and few facilities to make any epidemiological surveys Many believe that routine Microbiological monitoring is most essential but in reality it is not practicable. But every hospital should pay good attention in proper maintenance of air conditioning plants, ventilator systems, and to have greater control on mechanisms and personnel involved in disinfection and sterilization of materials used in the theatres in operative procedures.

Operation theatres should be built with implementation of good civil Engineering standards.

OPERATION THEATRE - DISCIPLINE

1. Only people absolutely needed for an assigned work should be present.
2. People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres, which will greatly reduce bacterial count.
3. Air borne contamination is usually affected by type of surgery, quality of air which in fact depends on rate of air exchange.
All the persons including the least cadre of employers are partners in infection control and should be aware to comply with infection control regulations
4 Prompt disposal of Theatre waste out of the theatre is of top priority. Any spillage of Body fluids including Blood on the floors is highly hazardous and prompts the rapid multiplication of Nosocomial pathogens in particular Pseudomonas spp

SURVEILLANCE OF OPERATION THEATRE

Role of Microbiological Surveillance

The environments in the operation theatre are dynamic and subject to continuous change. Good infrastructures do not mean a safe environment as human make a greater difference in making the environment unsafe.
Microbiologists should be aware of organisms, sites and populations as surveillance cultures should be chosen carefully to allow meaningful interpretation of results.
Microbiologists should be familiar with the clinical techniques as those normally used for culturing clinical specimens may not yield correct result when applied to environmental specimens.
Sites and cultured reports should not be chosen as etiological sources in the present infections. Culturing unnecessary surface areas causes confusion and meaningful interpretation is lost.

AIR IS THE IMPORTANT SOURCE OF INFECTION

Bacterial counts in operation theatres are influenced by the number of individuals present, ventilation and air flow, the results should be interpreted taking the above facts into consideration.

Surveillance for Air borne Pathogens:

In resource poor Hospitals settle plates with blood agar are used and can detect pathogens, commensals and saprophytic bacteria. Multiple plates are kept and results are based on overall assessment rather than on a single plate study in the room. Microbiologists will clarify the acceptable counts at the different physical locations in multispeciality hospitals.

There is a sea change in analysis of bacterial counts in recent past with advances in medical technologies like Joint replacement surgeries dealing with critical patients. Slit sampler and Air centrifuge equipment for bacterial counts are replacing settle plates, the safe level of colony counts can be calculated as per the standards created with peer reviewed studies by the manufacturers.

How frequently we can do the Surveillance for Air borne Microbes.

Yet there is no definite answer to this question
Doing too frequent surveys are expensive and will not correlate the existing infection rate in the Hospital.
But can indicate the circumstance we operate which can have bearing effect if the safety standards fall

Surveillance for Clostridia spores

The age old tradition of detection of anaerobic spores of C.tetani, and Gas gangrene producing organisms are losing ground with onset of more awareness on theatre sterilization. Routine testing for the Anaerobes is not essential except when there were suspected cases of Tetanus or Gas gangrene attributed to operating in a particular Operation theatre.
But it is ideal to survey the Operation theatres for anaerobes when newly constructed or any remodeling or structural alterations are done. In such situations which will have trust worthy safety of the theatre.

STERILISATION AND DISINFECTION OF OPERATION THEATRES AND CRITICAL CARE AREAS

GENERAL INSTRUCTIONS

1. Keep the floor dry when in use.
2. Use only vacuum cleaners (booming to be forbidden as it will dispense the infected material all around and on the equipments.
3. Chemical disinfection of an operation room floor is probably unnecessary. The bacteria carrying particles already on the floor are unlikely to reach an open wound in sufficient numbers to cause an infection
(Ayliffe et al 1967. Hombroeus et al 1978)
Cleaning alone followed by drying will considerably reduce bacterial population.
4. Wall and Ceilings- Wall and ceiling are rarely contaminated. The numbers of bacteria do not appear to increase even if walls are not cleaned. Frequent cleaning is not necessary and has little influence on bacterial counts. Routine disinfection is therefore unnecessary, but only cleaned when dirty.
ENVIRONMENTAL CLEANING OF OPERATION THEATRES
At the Beginning of the Day
1. Only remove the dust with cloth wetted with clean water. ( Mop theatre furniture lamps, sitting tables, trolley tops, operation tables, procedure tables, Boyle’s apparatus)
Note: Need not use chemicals/disinfectants unless contaminated with blood or body fluids
Between the procedures
Clean operation tables or contaminated surfaces with disinfectant solutions.
1. In case of spillages of blood/ body fluids decontaminate with bleaching solution/ chlorine solution (10% available chlorine)
2. All discard waste in plastic bags (do not accumulate around surgical sites)
3. Do not discard soiled linen and gowns in the operation theatre floor.

At the end of the day

1. Clean all the table tops, sinks, door handles with detergent followed by low level disinfectant.
2. Clean the floors with detergents mixed with warm water.
3. Finally mop with disinfectant like phenol in the concentration of 1 in 10 (low concentrations of phenol will not serve the purpose).
4. Keep the operation theatre dry for the next day’s work

Fumigation
1. Seal the room with adhesive tapes round the edges of the doors/windows and ventilators and apertures.

2 For Each 1000 cu.ft of space place 500ml formaldehyde (40% solution) and 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door.

3. Seal the room for 24 hrs

4. Then open the door and neutralize any residual formaldehyde with ammonia by exposing 250ml of S.G 880 ammonia/ 1Lt of formaldehyde used. (Ref - Mackie and McCartney Practical Medical Microbiology 13th Edition)

5. Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous

6 Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theatres can be curtailed with Fumigation.

THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED THE RATES OF INFECTION

1. Every Hospital must constitute Infection control committee to monitor the events in the Hospital, on all matters related to control of Infections.
2. The entry of unnecessary personnel to be restricted into operation theatres as every one contributes to Infection.
3. A thorough washing with warm water and good detergent and carbolisation can bring overall improvement than mere fumigation.
4. Frequent monitoring and training of medical and paramedical staff must carry high priority than mere mechanical and chemical methods.
5. Thorough washing and carbolisation if done everyday after the surgeries will greatly enhance the safety standards and economize the repeated expenditure on fumigation.

TRAINING OF PARAMEDICAL STAFF/ RESIDENTS

1. The short solution to control infection lies with trained staff.
2. The principal and control of infection to all new comers and junior staff should be a goal of any good Institution.
3. Formulate guidelines update as per the changing situation in control the infection.
4. Institute should formulate ideas on infection control to the need of circumstances, as there are no fixed guidelines or formulae to control to suit all occasional.
5. Simple repeated hygienic hand wash is most cost effective method to reduce several infections in Hospitals, in particular operation theatres



Note

The knowledge on Maintenance, Sterilization and control of Infections in Operation theatres a rapidly evolving Science
Wish to know more about Operation theatre Maintenance for control of Infection Read through
Principles, And Practice of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe.

All Institutes wish to develop to improve hygiene and sterilization standards, and start critical surgeries doing Cardiothoracic, Organ replacement and prosthetic surgeries should subscribe to the internationally accredited Journal
“The Operating Theatre journal” published from U K.

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