operation theatre surveillance by dr.t.v.rao md
TRANSCRIPT
Dr.T.V.Rao MD 1
OPERATION THEATRE
SURVEILLANCEDR.T.V.RAO MD
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OPERATION THEATRE IS A PRIORITY AREAFOR SAFETY
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Establishing Operating Room •The floors and walls should be absolutely smooth and easily cleanable and should have minimum and neatly made or no joints.
•Flooring should be non porous, scratch proof, anti skid and antistatic (epoxy resin flooring) .
•The walls should also be covered with smooth material like granite with minimum joints.
•The ceilings should be painted with oil paints which give smooth finish.
•All the electrical fittings and water pipe lines in the OR must be concealed.
•The OR complex should have only one entry and all the windows should be air tight in restricted and semi-restricted area.
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Planning considerationZoning :
To ensure the aseptic condition the operating dept is divide into 4 zone :
1. Protective zone2. Clean zone3. Sterile zone4. Disposal zone
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Advantages of zoning1. Minimizes risk of hospital infection.
2. Minimizes unproductive movement of staff, supplies & patient.
3. Increases efficacy of operative team members.
4. Ensures smooth workflow.
5. Deceases hazards in operating room.
6. Ensures proper positioning of equipments.22-02-2016
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Principles of Operating Room Safety
•Avoid contamination of wound.
•Although Unpreventable.
•Chances of cross infection.
•Contamination of surgical wound is mostly from – skin / mucous membrane being incised.
•Other sources : nose, throat, hand, skin of operating team members.
•Air contamination : omnipresent problem.
• All logical precaution & preparations should be done.
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Maintaining the Operation theaters is a priority
•Stress must be laid on•Temperature•Humidity•Ventilation•Temperature : 24-270 C •Relative Humidity : 450 – 600 C for adult
• 550 – 650 C for infants22-02-2016
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VENTILATION / AIR CHANGE
•1 change / hr : contamination reduced by 60%
•2 change / hr : contamination reduced by 86%
•10 change / hr : contamination reduced by 99%
Turbulant / mixing air distribution Downward displacement piston system
Unidirectional airflow system / lamellar flow ventilation
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Prevention of Infections is Priority in Any Health Care
Areas •Prevention of airborne microbial contamination will prevent the surgical site infections. To achieve this basic strategy we should follow the certain guidelines. Which would include, proper and continuing education to staff to prevent shedding of microbes and restrict the unnecessary movements of OT staff within and outside the OT environment.
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Basic care of Operation Theatres. Reduction of Microbial counts is
important. Paying great attention to Floors
Using too many chemicals not necessary
Keep the floor Clean and Dry - with Vacuum cleaner and Wet cleaning techniques
Keep the mops dry when not in use, Frequent cleaning of Walls and Roof
is not needed Number of persons present and
Movements they make, has direct relation to increase of bacterial counts
Prompt disposal of Theatre waste out of the theatre is of top priority
Handling of Air in Operation theatre.Critical parameters for air quality include ( WHO Guidelines)(1) Maintenance / validation of efficacy of filters(2) Pressure gradient across the filter bed and in the
operation theatre(3) Air changes per hour (minimum 15 air changes per
hour)(4) Temperature and humidity should be maintained
between 20-22°C and 30-60%,• Air pressure vented to the operation theatre.• Direction of air flow should be from clean to less clean• areas.• Environmental cleaning should be twice daily• Proper design and ventilation of operating theatres(HVAC)
systems• HEPA filters indicated in operating rooms designated for
orthopaedic implant procedures
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Air Can be a Risk Factor in Health Care
•Microbiological contamination of air in the operating room is generally considered to be a risk factor for surgical site infections in clean surgery. Microbiological quality of air may be considered as mirror of the hygienic condition of the operation theatres. The quality of indoor air depends on external and internal sources, such as ventilation, cleaning procedures, the surgical team and their activity
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Surveillance means Environmental Monitoring
•Environmental monitoring means the microbiological testing of air, surfaces and equipment in order to detect changing trends of microbial counts and micro-flora22-02-2016
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Why Surgical Site infection is important
•Infection control and basic hygiene should be at the heart of good hospital management. Infection of the surgical-site is a leading complication of surgery. Microbiological contamination of air in the operating room is generally considered to be a risk factor for infections of surgical site in clean surgery
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Why We need Surveillance ln Operation Theaters
Surgical site infections (SSIs) are second to third most common site of health care associated infections. These complications of surgical procedures cause considerable morbidity, and mortality. If these occur deep at the site of the procedure, can carry mortality as high as 77 %
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Quality of Air can be sampled
•Evaluation of the quality of air in operating theatres can be performed routinely by microbiological sampling and particle counting
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Air Surveillance of Operation theatreScope- To determine air bacterial count in OT and to detect
pathogenic bacteria like staphylococcus aureus.Factors influencing: Number of persons present. Body movements, Disturbances of clothing.Methods of Air surveillance:
1 Settle plate method.2 Slit sampler method (from given volume)3 Particle counter ( non viable count ) 22-02-2016
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Why Monitoring Air quality•The survival of micro-organisms in the air is dependent on a number of interacting factors, and is not easy to predict. This is one of the main reasons why routine monitoring of airborne bacteria and fungi can be important, especially where Surgical Procedures are conducted
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STANDARD GUIDELINES AND PLANNING FOR AIR SAMPLING
•There are no universally agreed standards for any country or place regarding when to undertake microbiological sampling in the operating theatre and on the interpretation of sampling results
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Why we need the surveillance of Operation theatres
•However, there is sufficient evidence to support the undertaking of microbiological air sampling in the operation theatre as part of the vigilance & safety of an operating theatre, after any major structural replacements (not including High Efficiency Particulate (HEPA) filter changes and as deemed necessary by the hospital infection control committee. Health care workers should follow certain guidelines before air sampling.
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Passive monitoringby Settle plates
•Passive monitoring typically employs ‘settle plates’ – petri dishes containing appropriate culture media, which are opened and exposed for a given time and then incubated to allow visible bacterial and fungal colonies to develop and be counted. Settle plates are only capable of monitoring those viable biological particles that sediment out of the air and settle onto a surface over the time of exposure. They will not detect smaller particles or droplets that remain suspended in the air and they cannot sample specific volumes of air, so the results can only be considered semi-quantitative at best.
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Follow the Standard Operating procedures
•Prior to air sampling, obtain the suitable air sampling equipment from a laboratory, establish laboratory time-lines for sample collection, processing and provision of results and should not ignore to consult the hospital microbiologist or infection control unit.22-02-2016
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Bacterial Counts vary as per the existing circumstances
Bacterial counts in operation theaters are influenced by the number of individuals present, ventilation and air flow methods.
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When to do Air Sampling •Air sampling should be done after the all new or replacement work has completed. The ventilation system should run continuously for 24 hours before sampling and the theatre surfaces and fixed equipment, ducting and air diffuser plates have to be cleaned.
•However many do for frequently monitoring the
operation theaters 22-02-2016
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RECOMMENDED METHODSSURVEILLANCE
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RECOMMENDED METHOD FOR AIR SAMPLINGA single or multiple samples should be
collected from each operating theatre.The air sampler should be checked for cleanliness before use by following the manufacturer’s instructions.The theatre being sampled should have been left vacant for a minimum of 15 minutes, preferably one hour. To avoid false-positive results the theatre doors must be kept closed prior to and during the sampling period.
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Standard protocols of collecting the specimens
•Air sampling was performed with settle plates methods. Petri dishes containing blood and/ or / MacConkey agar were transported to operation theatres in sealed plastic bags. The plates were labelled with sample number, site within theatre, time and date of sample collection22-02-2016
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Placements and Processing the specimens
The plates were placed at four chosen places in the operation theatre at about 1 metre above the ground, and exposed for 30 minutes to 1 hour minutes. After this exposure, the plates were covered with their lids and taken to laboratory in sealed plastic bags and incubated at 37°C for 24 hours.
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RECOMMENDED METHOD FOR AIR
SAMPLING A single sample should be collected from each operating theatre.•The air sampler should be checked for cleanliness before use by following the manufacturer’s instructions.
•The theatre being sampled should have been left vacant for a minimum of 15 minutes, preferably one hour. To avoid false-positive results the theatre doors must be kept closed prior to and during the sampling period.
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Settle plate Method
• Using blood agar, It is being practiced in basic hospitals to detect pathogenic bacteria major isolate being Staphylococcus aureus bacteria in hospital air. Settle plate method with blood agar where the plates have to be kept at 1 meter height on the four corners of room and results are obtained based on the mean colony number on the all culture plates after a prescribed time
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RESULTS AND INTERPRETATION:
Culture plates should be incubated under optimum conditions in the microbiology laboratory. Early culture reports hardly available until after 24 hours of incubation. Aerobic cultures on non-selective medium (preferably Blood agar) should not exceed 35 colony – forming units of bacteria and fungi per cubic meter of air for a conventional theatre and 1cfu for an ultra clean theatre to perform joint replacement and cardiac surgeries [1]. 22-02-2016
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Are there any Rigid or Absolute Guidelines in
Bacteriology Laboratory No •These counts are not
rigid standards and are intended as a guideline only. Even though the swabs are taken for OT surveillance to isolate and identify the clostridia spores, air sampling is must to measure the safer load of microbes
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Pros and Cons of Swabbing the environment and
Culturing •In some of the hospitals OT sampling is done by swabbing and plating on the blood agar and results are being announced after 24-48 hours of aerobic incubation. By the above mentioned method quantitative estimation of the microbial load is not possible. Literature which is supporting for this kind of practice is not available from various sources. Moreover, this type of cultures on non-selective medium will create unnecessary confusion while detecting OT sterilization status and which should be abandoned
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PROCESSING OF SAMPLES •Swabs taken from different articles were streaked in Blood and MacConkey agar .These culture plates along with those exposed in air were incubated at 37°C under aerobic conditions for 24 hrs. After incubation the colonies were counted and identification of isolates was performed. Concentration of airborne bacteria was expressed as colony forming units per cubic meter cube (cfu/m3).
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Slit Sampler and Air centrifuge
•Because of recent advances in certain surgical procedures and bacterial counts settle plate method is replaced with Slit sampler and Air centrifuge equipment through which we can calculate the safe levels of colony counts
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Slit Sampler and Air centrifuge •There are several
different types of air samplers available and the manufacturer’s instructions for use must be followed. If affordable, the preferred method is to use a sampler with timer and remote control
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Slit sampler and Air centrifuge
Determine the Results •The sampling equipment will determine the volume of air sampled. Sampling volume needs to be more than 0.25 m3 (250 L) and optimally around 1m3 (1000 L).
•Once sampling is completed, remove the test strips/agar plate aseptically and label it clearly and send it the processing environment.22-02-2016
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Placement of Air Sampler •The air sampler should be placed in the middle of the theatre table at the height of 1 meter and to be secured on a trolley.
•The air sampler should then be switched on either by remote control or manually, before leaving the room.
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What the Scientific Studies Say
•A number of studies have been carried out in operation theatres to determine relationship between total bacterial air count in OT and risk of infection. It has been observed that counts in the range of 700-1800/m3 were related to significant risk of infection and the risk was slight when they were below 180/m3.14
• Ref Parker MT. In Hospital Associated Infections, Guidelines to laboratory methods. WHO, Regional Office for Europe, Copenhagen. 1978; 28-32.
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WHAT ABOUT ANAEROBES •Even today most of the surgeons are worrying about the OT associated infections with anaerobes like clostridium tetani in most of the instances. Infections with Cl. tetani are associated with very bad surgical procedures which includes the over jealous manipulations of the tissues of surgical site and leaving the dead tissue in the surgical site at the end of the procedure and also heavy dust in the operation theatre environment.
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WHAT ABOUT ANAEROBES •Surveillance for clostridia spores is an age old concept of OT surveillance and lost its importance with the available and applicable OT sterilization and disinfection awareness Programme and practices. Today we rarely encounter a infection with C.tetani
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When to Test for Clostridia spp
Routine testing for clostridia spores is not mandatory except during certain situations like new constructions or structural alterations are made to the theatre
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Use your Rationalism in establishing and making decisions of Operation
Theaters • Routine sampling of floor, walls or furniture which are not in direct contact with patients are not the sources of infection. They do not contribute in the prevention of nosocomial infection, unless there is an epidemic.
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However many factors play a role in Infections
•A large body of information is available which indicates that prevention of post operative infection is dependent on several factors including effective theatre design, sterilization and disinfection procedures, good surgical technique, bacterial contamination of theatre air, discipline which includes restricting the movement of staff [2].
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What are our achievable goals
•So prevention of airborne microbial contamination will prevent the surgical site infections. To achieve this basic strategy we should follow the certain guidelines. Which would include, proper and continuing education to staff to prevent shedding of microbes and restrict the unnecessary movements of OT staff within and outside the OT environment.
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Good Hand Washing Practices Save many Lives
Alcohol with Chlorhexidine.2.Alchool without
Chlorhexidine.3 Chlorhexidine 2 %4 Chlorhexidine 4 %5 Povidone with Iodine 7.5 %6 Triclosan 1 % Or Anything NEW
BEST HAND WASH IS
WORD OF CAUTION ON SURVEILLANCE
•There are no absolute measures universally agreed on Operation Theatre
surveillance the protocols vary from circumstances of working , work load of patients and critical care procedures
•I wish professionals should follow the updated information
• Dr.T.V.Rao M D 47
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REFERENCES:•1Davis N., Curry A, Gambhir AK, Panigrahi H, Walker CR, Wilkins EG, Worsley MA and Kay PR Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br 1999; 81-B:8869.
•2.Colquun J, Partridge L. Computational Fluid Dynamics Applications in Hospital Ventilation Design. The Australian Hospital Engineer 2003; 26 (1) 35-40.
•3. Guidelines to standards for operating rooms. Located at. http://www.health.wa.gov.22-02-2016
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REFERENCES:• . 4Geeta Mehta. Microbiological surveillance of operation theatre – 2005.
• http://www.orthoteers.org. •5. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp infect 2002; 51(2) 79-84.
•6. Department of Health, Western Australia. Private Hospital Guidelines, 3rd edition. 1998. http://www.health.wa.gov.
•7 Updates on Operation theatre surveillance •
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