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Theatre Infection Control Policy

Read in conjunction with Trust Infection Control Manual and Trust Infection Control policies.

Scope of policy:

Applies to all operating theatres, including day procedures and recovery

Prepared by Infection Control: SC/JT/MO


with Jim Rainer/Julie Russ
Approved by ICC January 2005

February 2005

Review date 2007


Theatre Infection Control Policy

INDEX Page

Skin decontamination & use of antiseptic agents: 2

- Hand hygiene: surgical scrub 3


- Skin preparation and use of antiseptic agents

Infection control policies in theatre areas: 4

- Sharps use and disposal


- Clinical waste
- Blood spillage

Theatre wear and codes of practice: 5

- Theatre wear
- Visitors 6
- Dress when leaving theatre areas 7
- Movement in theatre 7
- Order of patients on operating list (dirty/clean
cases; patients with MRSA) 8
- Patients with blood-borne viruses

Environmental cleaning and decontamination 9

- Cleaning between patients 9


- Daily cleaning schedule 10
- Annual cleaning & maintenance
- General guidance: standards of cleanliness 11

Ultra Clean Ventilated (UCV) theatre (theatre 4)


12
- Codes of practice
- Air quality monitoring

Governance: roles and responsibilities

Page 1 of 14
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.

Chlorhexidine gluconate 4% “Hibiscrub”


How long the preoperative wash
or ‘surgical scrub’ should be and
what type of antiseptic should be Povidone iodine 7.5% “Betadine”
used is not universally agreed.
Box 1: Recommended antiseptic agents for surgical scrub

Recommendations for pre operative surgical scrub

• Agents or methods of skin decontamination that


See also Trust Hand cause skin abrasions should not be used.
Hygiene Policy.
• Using a scrubbing brush on the skin is not
recommended.

• The first wash of the day should include a thorough


clean under the fingernails; a brush or orange stick
can be used.

• Nailbrushes should be single use disposable.


Handwashing should be for
minimum of 2 minutes
(studies show this duration is • An approved antiseptic agent (see box 1) should be
effective in reducing hand used for handwashing.
bacterial colony counts); the
optimal duration for washing is not • ‘Surgical scrub’ handwash should be for a minimum
known. of 2 minutes, however, there is no evidence that
more than a two minute wash (decontamination)
using aqueous disinfectants is required.

Alcohol gel handrubs are an


acceptable alternative to repeated In between cases, use of alcohol gel hand rub, applied
hand washing. using correct technique, is considered adequate in the
operating theatre where the surgeon’s hands are clean
and have already been decontaminated by conventional
methods.

If skin irritation, dermatitis or sensitivity to a particular


hand cleaning product or antiseptic agent occurs seek
advice from Occupational Health and Safety.

Page 2 of 14
Skin preparation & use of antiseptic
agents:

Alcohol solutions are more effective than and preferable


to aqueous solutions for skin preparation (see table 1).
They should be allowed to dry thoroughly.
It is important to allow sufficient
time for alcohol based skin
Box 2: Recommended antiseptic agents for skin
preparations to dry thoroughly
preparation
after application and before
commencing the procedure to
ensure that all combustible
ingredients have evaporated. Chlorhexidine gluconate 0.5% w/w in spirit 70%.

Povidone iodine 7.5%.

Recommendations for use of antiseptic agents

• Gross contamination at the site of incision should be


removed before the antiseptic skin preparation.

• Apply the antiseptic skin preparation in concentric


circles moving away from the proposed incision site
Antiseptic ‘cocktails’ should not be to the periphery; allow sufficient prepared area to
used because many antiseptics accommodate an extension to the incision or new
are mutually inactivating. (If incisions or drain sites to be made.
several consecutive applications
are made to the same body site, • Allow the alcohol to dry after application and before
the same agent should be used). the use of electrocautery.

• The application of the skin preparation may need to


be modified according to the condition of the skin
(e.g. burns) and the location of the incision site (e.g.
face or mucous membranes).

Ideally antiseptics should be supplied at ready-for-use


dilution in small, single-use containers with dispensers
attached where necessary. The 500ml bottles should
normally be changed at least daily.

Multiple-use containers are liable Multi-use bottles of antiseptics - if used:


to contamination each time they
are opened. • Label with date first opened

• Use within the ‘Use by Date’ or discard once


‘use by date’ reached

• Never refill or ‘top up’; discard container and


dispenser after use or when use by date has
been reached.

Page 3 of 14
Infection control policies: theatre areas

Sharps use and disposal


See ‘Sharps use, sharps injury • Ensure removable blades can be easily detached
and contamination incident using an appropriate device.
Policy’ in Infection Control
Manual • Use an appropriate size and type of ‘sharps’ bin/box
for the area and anticipated volume of usage
Treat all sharps with care and
avoid practices such as passing • Do not place ‘sharps’ bins/boxes in areas where
‘sharps’ from person to person there may be an obstacle to environmental cleaning.

• Avoid overfilling: the sharps containers must be


closed securely when three-quarters full.
Report any sharps
inoculation injury • Used needles must not be resheathed.
promptly according
to Trust policy.

Clinical waste
As per Trust Waste disposal policy.

Blood spillage

Surface contamination by blood or • Larger spills: sprinkle with chlorine releasing granules
body fluids should be dealt with (NaDCC as ‘PreSept’ or approved brand) until the
promptly and removed as soon as fluid is absorbed.
possible.
• Small blood splashes or drops: wipe up using fresh
hypochlorite solution 10,000 ppm available chlorine
(as per manufacturer’s instructions on container:
‘PreSept’ or approved brand); apply solution using
disposable paper towels.
Chlorine solution may damage
equipment and some metal • Leave the granules to solidify or paper towels with
surfaces so it is important to rinse hypochlorite solution for a contact time of 2-5 minutes
surfaces well after cleaning
splashes or blood spillage. • Clear up using scoop (granules) or with disposable
paper towels and dispose of as clinical waste. Wipe
the area clean using hypochlorite solution.

• Rinse well using detergent and hot water


(hypochlorite is corrosive). Dry using paper towels.

See also ‘Blood spillage’ in section 5 of


the Infection Control Manual.

Page 4 of 14
Theatre wear and codes of practice

Theatre wear

Gloves have a dual role: Gloves

- as a barrier for personal • Scrub team members should wear sterile surgical
protection from patients’ blood gloves donned after the sterile gown.
and exudates
• A fresh pair of sterile gloves should be worn for
- to protect bacteria from the each procedure.
surgeons hands entering the
surgical site.
Wearing double gloves at surgical procedures helps to
reduce hand contamination and protect the wearer from
viral transmission. However double gloving may be
uncomfortable and reduce manual dexterity and tactile
Surgical gloves must conform to
sensitivity.
BS EN 455-2
Puncture of a glove is not necessarily an indication to
change gloves (there is no evidence that perforated
gloves increase the incidence of infection). It may be
preferable to don a second pair of gloves to protect the
operating surgeon or individual undertaking the
procedure.1 If glove punctured: change gloves or put a
second pair over the first pair.

Face Masks

There is insignificant evidence to The use of masks to reduce post-operative wound


support the continued wearing of infections is questionable; studies have shown no
masks to prevent wound increase in infection rate when masks were not worn for
infection1. general surgery.1 Masks do however provide a barrier for
airborne organisms and also protection for the wearer
Risk assessment should be against blood and body fluid splashes.
undertaken and if necessary
masks should be worn for the • A mask (with a filter size <1.1 microns) may be worn
protection of the wearer. over the mouth and nose by all members of the
‘scrub’ team; a visor or goggles should also be worn
for added protection where risk of aerosol.

• If worn, a fresh mask should be worn for each


Staff need to be protected from operation.
inhalation of surgical smoke and
laser plumes • The mask should be changed if deemed to have
become contaminated or saturated.

• Although there is no evidence on which to base the


recommendation it would seem reasonable that
surgeons with beards should wear a facemask.

• Masks should not be worn outside theatre area or


left tied around the neck. After surgery, the mask
should be removed and disposed of.

• In vertical laminar flow theatres a mask should be


worn during prosthetic implant surgery.

Page 5 of 14
Theatre Caps

• Scrubbed staff should wear disposable headgear


because of their proximity to the operating field,
Disposable headgear is worn by particularly in a laminar flow field.
all theatre staff in most UK
operating departments; different • Hats must be worn in laminar flow theatre during
colours are frequently used to prosthetic implant operations.
indicate seniority or identify
students. • After use dispose of headgear and do not wear
outside theatre.

In terms of infection risk, non-scrubbed staff members of


the operating team do not need to wear disposable
headgear, since effective theatre ventilation probably
counteracts any possible increase in bacterial shedding.
However it is Trust policy for headgear to be worn in
theatre by all staff likely to be near the operation field and
this includes non-scrubbed staff; common sense also
dictates that hair should be kept clean and out of the way.

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


Theatre footwear should be
cleaned regularly. 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;

False fingernails have been • Wedding rings may continue to be worn by ‘scrub’
shown to harbour pathogens (the and non-scrub’ staff although surgeons may be
longer they are worn the more advised to remove these, particularly if working with
likely it was that a pathogen would metal prostheses.
be isolated).
• Staff in the operating theatre should not wear false
fingernails.

Visitors
Visitors do not need special Visitors attending the anaesthetic room do not need to
clothing unless entering the wear special protective wear or footwear and may wear
operating theatre itself. ordinary outdoor clothes.

If a visitor is to enter any of the main operating theatres,


then they should change into theatre suits.

Page 6 of 14
Dress when leaving theatre

There is little or no research-based evidence to show that


wearing surgical ‘greens’ outside theatre without changing
Perceptions from staff, visitors and into clean theatre suits increases surgical wound infection
the public concerning ‘theatre rates. However, wearing greens outside theatre and in
discipline’ suggest that theatre public areas can give the impression that discipline is lax.
personnel should wear a fastened, Although there is insufficient evidence to support the
cover gown/coat over theatre suits wearing of cover gowns over surgical attire to prevent
before leaving the department. infection when theatre staff leave the theatre area
temporarily, the practice is desirable aesthetically1.

Recommendations:

• Theatre staff should wear a clean white coat


over theatre suit, if leaving the department and
Masks and hats should not be especially in public areas.
worn outside theatre & recovery
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 patient’s skin, from the
surgeon’s hand or by airborne microbes setting into the
wound or onto instruments that will be used in the wound.

Operating room doors need to be Most microbes in theatre air are from staff and few from
kept closed during procedures to the patient; microbial dispersion increases with
optimise the efficacy of the movement. Control of movement in, and entry into, the
ventilation system1,2 theatre environment is important in reducing the airborne
contamination routes.

Recommendations:
A conventionally ventilated theatre
• Keep operating room doors closed in order to
should have an air change rate of
around 20 air changes/hr (1 air optimise the efficiency of the ventilating system.
change every 3 minutes) 2. Each air
change will, assuming perfect mixing, • Keep ‘traffic’ in and out of the operating room to a
reduce airborne contamination to 37% minimum during surgical procedures.
of its former level.

Page 7 of 14
The two most probable routes of Order of patients on operating list: dirty/clean cases
infection transmission between
successive or sequential surgical Most microbes in theatre air are from staff and few from the
patients are via air or from patient. If theatre ventilation is effective air should not be a
environmental surfaces. source of infection transmission between patients, regardless
of whether the procedure is “dirty” or clean.
If theatre ventilation is effective, Surface contamination is more likely to pose risk of
air should not be a source of transmission of infection than air: surfaces such as operating
infection transmission between tables and other furniture, and instruments that make direct
sequential patients. This means contact with more than one patient have potential for
that surface contamination is more transmission of infection between ‘dirty’ and subsequent
likely to pose infection risk. cases. The only practical way of reduction of microbes is by
cleaning and disinfection of the relevant environmental
surfaces.
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.
(*See ‘cleaning between patients’ on page 9).

Traditionally “dirty” cases are put last on the list; however it is


Surfaces and equipment in direct
not always necessary to put the “dirty” case last on list
contact with the patient should be
provided the cleaning of relevant surfaces can be done
cleaned carefully before the next
adequately before the next patient. If it is judged that these
patient. What is important is that
processes can be carried out adequately during a list, there
this should is carried out
should be no extra hazard.
effectively after the procedure, not
If “dirty” cases (i.e. patients likely to disperse microbes of
whether or not the patient is last
particular risk to other patients) are placed last on a list, this
on the list.
may facilitate the process of adequate cleaning/
decontamination of the relevant surfaces.

A conventionally ventilated operating theatre does not


need to lie fallow for more than 15 minutes before a clean
procedure is performed following a dirty operation.
Vertical laminar flow theatres need only 5 minutes to
replace the full volume of air in the theatre.

See MRSA policy “Operating Patients with MRSA


Theatres and Recovery” Treat as above (see box). Provided there are routine high
standards of cleaning between patients, it is not necessary to
put patients with MRSA last on list unless they meet the
It is unlikely that operating specific risk criteria below:
department staff will always be
aware of whether a patient has Put last on list:
MRSA hence care should be • Patient has extensive eczema or other exfoliative skin
applied to routine cleaning of disorder colonised with MRSA
surfaces in direct contact with • Patient with MRSA is undergoing orthopaedic or joint
patients (see page 9). replacement surgery
• Patient has tissue infection with MRSA and/or where
aerosol-dispersing power tools are used on infected tissue.

Page 8 of 14
Patients with blood-borne virus: Hepatitis B, C or HIV

• Treat in the same way as any other patient, with


universal blood precautions.
Patients with other infections
Follow recommendations on page • Take due care with sharps and ensure that all
8. Seek advice from Infection measures are in place to minimise risk of needlestick
Control where necessary. injury or contamination with blood: the
operating/scrub team should be experienced and the
If the patient has an infection that procedure should be unhurried; the scrub team may
may be transmitted by respiratory wish to double-glove; risk assessment should
droplet or secretion (e.g. TB or determine whether water impermeable gowns should
VZV/chickenpox):
be worn.
Seek advice from the Infection
Control Nurse or Doctor (Refer
also to Infection Control Isolation • Scrub team should know the correct procedure to
policy). follow in the event of an inoculation or ‘sharps’
incident if there has been exposure to HIV.

Environmental cleaning and


decontamination

Cleaning between patients

Surfaces such as the operating table and any equipment


that has been in direct contact with the patient:
After the patient has left and
before the next patient, surfaces
• Clean carefully after the patient has left, using an
such as the operating table and
approved detergent (e.g. ‘Hospec’) and hot water
any equipment in direct contact
using a disposable cloth OR using a disposable
with the patient should be cleaned
detergent wipe. Wipe the area thoroughly and allow
with detergent.
to dry.

• It is not necessary to use disinfectants in addition,


Surfaces that do not have direct unless there has been contamination with blood/body
patient contact (e.g. floor, wall and fluid spillage or aerosol (see “blood spillage” on page
light) do not become more 4).
contaminated after dirty than after
clean operations. • After cleaning, the surface should be dry before the
next patient;

• 15 minutes is sufficient for conventionally ventilated


theatres (1-3) to lie fallow after “dirty” cases and
before the next case; 5 minutes for theatre 4 (UCV).

Page 9 of 14
Environmental Cleaning

Cleaning at end of session:


Daily schedule for recommendations
Operating theatre floors
Box 3: recommendations for use of
• Operating theatre floors should be cleaned using an
mops
approved detergent (e.g. ‘Hospec’) and hot water.
Mops should be colour coded: Floor scrubbing machines, where used, should have
each theatre area should have a detergent reservoirs that can be cleaned.
separate colour code, with mops
kept for one theatre. • Use mops according to recommendations in table 3

After use mops should be • The whole of the floor including corners and edges
decontaminated by hot wash: must be cleaned
return to laundry daily.

Store mops in a designated area:


store upright with mop heads in Horizontal surfaces and fixed equipment
air and kept dry. • Damp dust horizontal surfaces using a disposable
cloth (lint free) for all operating theatre cleaning.
Mop buckets should be emptied,
cleaned and dried after each • Clean all fixtures and any equipment in theatre by
use. Store inverted wiping with an approved detergent (e.g. ‘Hospec’),
hot water and disposable cloth.

Overhead lights and canopy


• Damp dust lights and fittings using an approved
detergent (e.g. ‘Hospec’), hot water & disposable
cloth.
• Check for splashes and contamination. Clean using
an approved detergent (e.g. ‘Hospec’), hot water and
disposable cloth. Where there may have been
spillage or contamination with blood/body fluids wipe
surface with dilute hypochlorite solution 1,000 ppm
available chlorine (1 ‘PreSept’ NaDCC table/litre
water), then rinse well (wipe with cloth and water);
allow to dry.

Anaesthetic room, prep room/other areas


See also table 1 “General • Clean floor using an approved detergent (e.g.
guidance: standards of ‘Hospec’) and hot water. Follow recommendations in
cleanliness” on page 12 table 3; use different colour code mops to those used
to clean operating room.
• Ensure no visible dust/dirt on floor
• Damp dust horizontal surfaces and fittings. Wipe
clean ventilator grills.

Page 10 of 14
Recommendations for Theatre trolleys
Theatre trolleys need to be kept
• Wipe over daily using an approved detergent
clean.
(e.g. ‘Hospec’) and hot water on disposable
Trolleys going into UCV theatre cloth or paper towel
should be designated for use in
that theatre only. • Ensure any visible splashes or visible dirt is
removed and the trolleys are clean

• Regularly check fabric of trolleys used in theatre


to see if torn or any defects; if any defects are
identified, the trolley should be repaired or
replaced.

Environmental Cleaning

Annual cleaning and maintenance:


Annual maintenance & cleaning of
Schedule
operating theatres should take
There should be a planned schedule for thorough
place at least twice per annum
cleaning of walls, doors and ceilings at least once every 6
and requires planned downtime.
months.
Arrangements should be made for this. At the same time
any defects, repairs and planned maintenance work
should be undertaken.

Recommendations:

Walls, doors and ceilings:


• Washing is recommended twice a year or
sooner if visibly dirty or contaminated

General fabric of furnishings fittings and décor:


• An annual down time for inspection, repairs,
decorating and planned maintenance must be
allowed for.

Page 11 of 14
General guidance: table showing
standards for environmental cleanliness

• The operating room must be kept free of


unnecessary equipment and clutter.

• The anaesthetic room/other areas should be free of


clutter and unnecessary equipment to facilitate
cleaning.

• The theatres should be visibly clean and free from


dust.

• Items and equipment must not be stored directly on


floor. Floor areas must be kept free. Storage
areas: items should be stored in racks above floor
height.

• Ventilated grilles in doors should not be occluded or


obstructed by equipment.

• Storage of supplies and consumables in


preparation/ rooms off operating room should be
kept to minimum, with appropriate stock rotation to
ensure no build up of dust or bio-burden on items
stored.

• The fabric in theatre should be kept in good state of


repair. Any chipped tiles, defects in floor or fabric
of area should be replaced or repaired.

• Wall seals should be intact and clean.

• Theatre trolleys must be free of dust and without


dirt or spillage; the fabric of the trolley should be in
good condition.

Page 12 of 14
Ultra Clean Ventilated (UCV) theatre 4

Codes of practice: recommendations


Restriction of traffic and • Keep operating room doors closed in order to
unnecessary opening of operating optimise the efficiency of the ventilating system.
room doors are particularly
important in a plenum-ventilated • Keep ‘traffic’ in and out of the operating room to a
theatre to ensure optimal minimum during surgical procedures.
efficiency.
• Trolleys entering theatre should be designated for
use in that theatre only and cleaned after each
patient.

• Personal protective wear/hoods used in orthopaedic


theatres should be hung on a designated wall hanger
in theatre 4 area.

Air quality monitoring

Recommendations:

• Report any malfunction or abnormal readings to


Annual testing of UCV air quality Estates without delay (theatre co-ordinator should
should be undertaken to coincide also inform the Consultant Microbiologist/ICD).
with planned cleaning and
maintenance. • In event of any major work being done on HEPA
filters, theatre co-ordinator should also inform
Consultant Microbiologist /ICD (Estates Manager -
Engineering should also inform ICD).
Theatre manager should initiate
request for testing in conjunction • Testing of UCV theatre air quality must be performed
with Estates Manager annually. Arrangements must be made with Estates
(Engineering) and Consultant Manager - Engineering and ICD for appropriate
Microbiologist/ICD. testing to be performed.

• Planned downtime and appropriate arrangements


should be made in conjunction with theatre/clinical
teams/Caregroup managers to support downtime
(24-72hrs) for air quality testing. This should
wherever possible coincide with annual planned
maintenance & cleaning: see also page 11.

• Reports of annual UCV air quality monitoring should


be sent to theatre manager and to the Consultant
Microbiologist (ICD).

Page 13 of 14
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
Monitoring of standards and standards of cleanliness are met or to initiate appropriate
corporate governance: action if standards are not met. (Theatre operational
managers should also perform regular audits of theatre
Systems must be in place to standards of cleanliness and keep written record of this).
ensure standards are monitored
and complied with. The Infection Control team (ICD or ICNs) will perform
periodic audits of theatre standards (theatre Infection
Control policy/practice) and include findings in annual
report (DIPC). A summary of the roles and
responsibilities is included in the table below.

Table showing summary of standards and responsibilities


STANDARD RESPONSIBILITY

Daily cleaning

(1) Cleaning between patients/end of lists Theatre staff

(2) Monitoring of cleanliness standards; Theatre co-ordinators or deputy


documentation of checks

(3) Periodic audit of standards; inclusion in ICT (ICD (DIPC) and/or ICN)
DIPC annual report

Annual cleaning and maintenance

(1) Arranging downtime for work to take Theatre Co-ordinators in association with
place (twice per year) Associate Director & Patient Planning.

(2) Arranging Estates/other providers to do Theatre operational managers in conjunction


any necessary work during downtime with Associate Director and Estates/ICT.

Air quality monitoring (UCV theatre)

(1) Ensuring Annual testing of air quality (in Theatre co-ordinator to initiate request for
conjunction with (2) above) is performed testing to Estates Manager – Engineering;
responsible for commissioning air quality
testing, in conjunction with ICD (DIPC).

(2) Provision of air quality test report (HTM Estates in conjunction with DIPC
2030) annually to ICC/RMSG.

References

1. “Behaviours and rituals in the Operating Theatre” report from the HIS working group on
Infection Control in the Operating Theatres”

2. “Microbiological Commissioning and monitoring of operating theatre suites” a report of a


working party of the Hospital Infection Society.

Page 14 of 14