Infection Prevention in the Operating Room:Defining the World Health Organisation’s 5th Moment for Hand Hygiene

Authors Fiona Smith1, Karen Lee2

Eleanor Binnie-McLeod3

Mark Higgins3

Liz Irvine3

Angela Henderson3

Ann Orr3

Fiona Clark3

Joanne Spence3.

1 NHS Grampian Infection Prevention and Control Nurse2 University of Dundee3 NHS Grampian Operating Theatre DepartmentsContact details: fionasmith14@nhs.net.

INTRODUCTIONThe World Health Organisation’s fifth moment for hand hygiene was designed to interrupt microbial transmission between equipment in the patient zone, which is in a narrow geographical area dedicated to the patient and equipment in the healthcare zone which is not dedicated to that patient (Sax et al., 2007). Equipment included in the patient zone is cleaned between patients to complement hand hygiene in disruption of microbial transmission between the patient zone and healthcare zone (World Health Organisation, 2009).

Reliance on understanding the geographical zones presents a challenge (Sax and Clack 2015). Where confusion exists around equipment included in the patient zone, both hand hygiene at ‘moment 5’ and cleaning equipment between patients may be missed, thus increasing risk of healthcare associated infection (HAI) (Hopf, 2015). HAI has been linked to non-sterile surfaces in the operating room (OR) and to non-scrubbed perioperative hands (Loftus et al., 2008).

In the OR content of the patient zone is not defined. The search for unpublished literature included a study tour to Professor Hugo Sax’s University Hospital Zurich ORs (NHS Education for Scotland, 2017).

AIMProvide an evidence base for application of the 5th moment for hand hygiene and equipment cleaning in the OR by defining the patient zone.

METHODOne Infection Prevention and Control Nurse (IPCN) used direct overt structured observation during full length surgical operations. In a range of specialties surgical cases were selected using non-random judgement sampling. Non-sterile objects in direct contact with the patient and touched by non-scrubbed staff immediately after touching the patient (hand contact events) were listed and tallied. Expert opinion of an IPCN and the senior perioperative nursing team were used to categorise non-sterile objects to either the patient or healthcare zone.

Num

ber o

f han

d co

ntac

t eve

nts

50

40

30

20

10

0

Storage trolley top

IV bag/line

OR table control

Door plate

Suction canister/tubes

IV Pole

Anaesthetic work station

Patient position supports

Ward bed upper surface

Olympus stack

Patient notes

Bedding/gown

Breathing circuit

Anaesthetic work station IV tray

Operating table top

Moving and handling board/sheet

Oxygen mask/tubing

ECG cables

Oxygen cylinder

Moving/handling machine

Non-sterile objects

RESULTS

Figure 1. The 20 most frequently touched objects by non-scrubbed staff in the operating room during 11 full length (12 hours 50 minutes) surgical operations.

Figure 2. Non-sterile objects included in the patient zone.The photograph shows an operating room set up to include all 57 non-sterile objects touched during all 11 observation sessions. Green dots show the 37 non-sterile objects included in the patient zone.

Figure 3. Non-sterile objects included in the healthcare zone. The photograph shows an operating room set up to include all 57 non-sterile objects touched during all 11 observation sessions. Red dots show the 20 non-sterile objects included in the healthcare zone.

DISCUSSION This novel research has contributed to the evidence base and guides application of the 5th moment for hand hygiene and equipment cleaning in the OR. Using overt observation may have introduced bias to this small study. Collaboration with perioperative staff throughout has helped the final product (Figure 4) become a useful resource to guide hand hygiene and equipment cleaning.

ReferencesHopf, H.W. (2015) ‘Bacterial reservoirs in the operating room’, Anesthesia and Analgesia, 120(4), pp. 700-702.Loftus, R.W. et al. (2008) ‘Transmission of pathogenic bacterial organisms in the anesthesia work area’, Anesthesiology, 109(3), pp. 399-407.NHS Education for Scotland. (2017) Sharing stories: Defining the patient zone in the operating room. Study tour to the University Hospital Zurich 2016. Available at: http://www.nes.scot.nhs.uk/education-and-training/by-discipline/nursing-and-midwifery/information-for-practitioners/general-nursing-council.aspx. Accessed: 3rd June 2017Sax, H. and Clack, L. (2015) ‘Mental models: a basic concept for human factors design in infection prevention’, Journal of Hospital Infection, 89(4), pp. 335-339. Sax, H. et al. (2007) ‘My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene’, Journal of Hospital Infection, 67(1), pp. 9-21. World Health Organisation (2016) Reproducing, adapting and translating WHO hand hygiene illustrations. Available at: http://www.who.int/gpsc/copyright/en/ (Accessed: 21 October 2016)World Health Organisation (2009) WHO guidelines on hand hygiene in health care. Available at: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf (Accessed: 16 September 2015).

Declaration of Interest. None to declare.

AcknowledgementsStaff of NHS Grampian Operating RoomsInfection Prevention and Control Team (IPCT), NHS GrampianMedical Illustration, Aberdeen University, for producing the poster.Prof Hugo Sax and the University Hospital Zurich IPCT.General Nursing Council for Scotland (Education) Fund for funding the study tour to Zurich.

Figure 4. ‘My 5 moments for hand hygiene’ in the operating room.The photograph shows the non-sterile objects included in the patient zone in an operating room.

1 BEFORE TOUCHING A PATIENT

3 AFTER BODY FLUID EXPOSURE RISK

2BEFORE CLEAN/ASEPTIC PROCEDURE

4 AFTER TOUCHING A PATIENT

5 AFTER TOUCHING PATIENT SURROUNDINGS

Based on the ‘My 5 moments for Hand Hygiene’, URL: http://www.who.int/gpsc/5may/background/5moments/en/index.html © World Health Organization 2009. All rights reserved.

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