OPERATING THEATRE MANAGEMENT

Prof T V Rao, Travancore Medical College

STERILISATION OF OPERATING THEATRES

Methods to replace fumigation

Despite the brief amount of time patients generally spend in an operating theatre (OT), this is an environment that plays a great role in the onset and spread of infections.

It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances, prevalent in most developing countries, people work in isolation and few facilities to make any epidemiological surveys. Many believe that routine microbiological monitoring is essential but in reality it is not practicable. Every hospital should, however, pay good attention to the proper maintenance of air conditioning and ventilator systems, and to having greater control of mechanisms and personnel involved in the disinfection and sterilisation of materials used in the theatres in operative procedures. Sterilisation means eradicating germs completely, which is not 100% possible in an operating theatre. The sources of bacterial contamination are from air and the environment, infected body fluids, patients, articles, or equipment. The following methods are practised to keep the operating theatre bacteriologically safe and below accepted levels: 1. Special air flow pattern this is such that filtered and purified air circulates and contaminated air is removed continuously. There is restriction of personnel traffic, closing of OT doors and a good ventilation system. 2. Standard cleaning, disinfection with appropriate chemical agents, good theatre practise and discipline can provide a microbiologically safe environment.

Fumigation
Fumigation is an age old process of sterilising the environment - a sick room or operating theatre, for example. It is done with Formalin fumes, which are very pungent and harmful. When a room is fumigated, it is tightly closed and sealed before fumigation. The room is opened after fumigation, 12 to 24 hours later. The room can be used again once all the fumes are out. OSHA (Occupational Health and Safety Administration) indicated that Formaldehyde should be handled in the workplace as a potential carcinogen, and set an employee exposure standard for Formaldehyde that limits an eight hour time-weighted average exposure concentration of 0.75ppm. Commercially available disinfectant Formaldehydes are the most commonly used agents for high level disinfection of the theatre environment. Formaldehyde gas is generated from liquid formalin, utilising potassium permanganate crystals. 40% formalin liquid is added to potassium permanganate crystals to generate the gas. Alternately, formalin liquid can be dispersed by a sprayer like device in the theatre environment. After a contact time of at least six to eight hours, the Formaldehyde needs to be neutralised by using ammonia, allowing at least two hours of contact time for ammonia to neutralise the Formaldehyde prior to the use of theatre.

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How fumigation was done

1. Seal the room with adhesive tapes around the edges of the doors/windows, ventilators and apertures. 2. For each 1,000 cu.ft of space place 500ml Formaldehyde (40% solution) and 1,000ml 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. Open the door and neutralise any residual Formaldehyde with ammonia by exposing 250ml of SG 880 ammonia/1L of Formaldehyde used. (Ref - Mackie and McCartney Practical Medical Microbiology 13th Edition). Fumigation is obsolete in many developed nations in view of the toxic nature of Formalin. Too frequent use and inhalation is hazardous. Several new safe chemicals are emerging but constrains of economy limit the practise of several hours of closing an operating theatre for the purposes of fumigation.

Looking at alternatives
Aldehydes are potentially carcinogenic and it is therefore recommended that other agents such as hydrogen peroxide, hydrogen peroxide with silver nitrate, peracitic acid and other chemical compounds of Formaldehyde should be used in place of the currently prevalent practise of using Formaldehyde. These agents are dispersed with the aid of a fogger-like device inside the theatre environment. The contact time is about an hour and the theatre can be used immediately after this. The following precautions have greatly reduced the rates of infection: 1. Every hospital must establish an infection control committee to monitor the events in the hospital on all matters related to the control of infections. 2. The entry of unnecessary personnel should be restricted into operation theatres as everyone potentially contributes to infection. 3. A thorough washing with warm water and good detergent can bring more of an overall improvement than solely decontamination sterilisation with other chemicals, or fumigation. 4. Frequent monitoring and training of medical and paramedical staff must carry a high priority dont merely observe mechanical and chemical methods. 5. Thorough washing and carbolisation, if done every day after the surgeries, will greatly enhance the safety standards and reduce the repeated expenditure on fumigation. Some of the emerging compounds developed for use in the sterilisation of operating theatres are more effective for environmental decontamination, have a very good cost/benefit ratio, good material compatibility, excellent cleaning properties and leave virtually no residues. One particular product available has the advantage of being a Formaldehyde-free disinfectant cleaner with low use concentration. Its active ingredients are: Glutaral 100 mg/g, benzyl-C12-18- alkyldimethylammonium chlorides 60 mg/g, didecyldimethylammonium chloride 60 mg/g.

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Its advantages are: It provides complete asepsis within 30 to 60 minutes Cleaning with detergent or carbolic acid is not required Formalin fumigation is not required A shutdown of an OT for 24 hours is not required Another chemical compound which has gained importance as a non-Aldehyde compound is a multipurpose disinfectant which contains oxone (potassium peroxymonosulphate), sodium dodecylbenzenesulfonate, sulphamic acid and inorganic buffers. It is typically used for cleaning up hazardous spills, disinfecting surfaces and soaking equipment. The solution is used in many areas, including hospitals, laboratories, nursing homes, funeral homes, medical, dental and veterinary facilities, and anywhere else where control of pathogens is required. This second product has a wide spectrum of activity against viruses, some fungi, and bacteria but it is less effective against spores and fungi than some alternative disinfectants. Several other compounds are emerging in the market for safer use, however.

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. 3. Air as an infection source Bacterial counts in operating theatres are influenced by the number of individuals present, ventilation and air flow. The results should be interpreted taking this into consideration.

Surveillance of 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 multispecialty hospitals.

A breadth of considerations
Operating theatres should be built with implementation of good civil engineering standards, which encompass numerous elements. 1. Operating theatre discipline Only people absolutely needed for an assigned task should be present in the operating theatres People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres. This will greatly reduce bacterial count Airborne contamination is usually affected by the type of surgery and the quality of air, which in fact depends on the rate of air exchange All the persons, including the least cadre of employers, are partners in infection control and should be careful to comply with infection control regulations Prompt disposal of theatre waste is a 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 2. Surveillance of operating theatre The environment in the operating theatre is dynamic and subject to continuous change. Good infrastructures do not mean a safe environment, as people in fact make a greater impact by making the environment unsafe. The role of microbiological surveillance is crucial, and 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 results when applied to environmental specimens.

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There has been a sea change in the analysis of bacterial counts in the recent past, with advances in medical technologies such as 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 should we do the surveillance for air borne microbes? There is no definite answer to this question. Doing too frequent surveys is expensive and will not correlate the existing infection rate in the hospital, but can indicate the circumstance we operate which can have an effect if the safety standards fall. Surveillance for Clostridia spores may be needed. The age old tradition of detection of anaerobic spores of C.tetani, and gas gangrene producing organisms are losing ground with the onset of more awareness on theatre sterilisation. Routine testing for the anaerobes is not essential except when there are suspected cases of Tetanus or gas gangrene attributed to operating in a particular theatre. Ideally you should survey the operating theatre for anaerobes when newly constructed, or when any remodelling or structural alterations are made.

Cleaning the opertaing theatre

At the beginning of the day 1. Only remove the dust with a cloth wetted with clean water. Wipe theatre furniture lamps, sitting tables, trolley tops, operation tables, procedure tables, and Boyles apparatus. Note: You need not use chemicals/disinfectants unless contaminated with blood or body fluids. Between the procedures Clean operating 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. Discard all waste in plastic bags (do not accumulate around surgical sites). 3. Do not discard soiled linen and gowns on the operating 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 one in ten (low concentrations of phenol will not serve the purpose). 4. Keep the operating theatre dry for the next day's work

General management instructions

For the sterlisation and disinfection of operating theatres, and critical care areas, there are certain protocols which should be followed. These include: 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 equipment. 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. Cleaning alone followed by drying will considerably reduce bacterial population. 4. Walls 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 only clean when dirty.

Training paramedical staff

The short solution to controlling infection lies with trained staff. The principle and control of infection to all newcomers and junior staff should be an important goal for any good institution. Formulate a guidelines update as per the any changing situations in the control of infection. Institutes should formulate their ideas on infection control based on varying circumstances, as there are no fixed control guidelines or formulae to suit all occasions. Simple, repeated hand washing is the most cost effective method of reducing several infections in hospitals in particular in operating theatres.

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Bibliography
1. Principles and Practice of Disinfection, Preservation and Sterilization, 3rd edn. AD Russell, WB Hugo, GAJ Ayliffe, Eds. Blackwell Scientific Ltd, Oxford, 1999. ISBN 063 2041 43. 2. Disinfection, sterilization and operation theater guidelines for dermatosurgical practitioners in India Narendra Patwardhan1, Uday Kelkar2 Year : 2011 | Volume : 77 | Issue : 1 | Page : 83-93. 3. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, William A. Rutala, PhD, M.P.H.1,2, David J Weber, MD, MPH1,2, and the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 (CDC 2008). 4. Assessment of in-vitro efficacy of 1% Virkon against bacteria, fungi, viruses and spores by means of AFNOR guidelines. Herndez A, Martr E, Matas L, Martn M, Ausina V. PMID 11073729 [PubMed - indexed for MEDLINE]. 5. Evaluation of in vitro efficacy of the disinfectant Virkon. Gasparini R, Pozzi T, Magnelli R, Fatighenti D, Giotti E, Poliseno G, Pratelli M, Severini R, Bonanni P, De Feo Eur J Epidemiol. 1995 Apr; 11(2):193-7.

2. Bacteraemia in a tertiary care urban hospital in South India The Indian Journal of Pathology and Microbiology July, 1999. 3. Bio informatics in future medicine, Drug Development and role of Doctor Voice of Medico July, 2001. In addition, publications in the last five years include: 1. Evaluation of different phenotypic methods for detection of Methicillin Resistant Staphylococcus aureues in a tertiary care hospital - Journal of the Academy of clinical microbiologists 2007, Vol 9, No 2 (original articles). 2. Salmonella Typhimuruim septicaemia manifesting as mono arthritis The journal of academy of clinical microbiologists 2007, Vol 9 No 2 (Case Study). 3. Estimation of antibodies to Hbs Ag in vaccinated health care workers, Indian Journal of medical microbiology, 2008, Vol 26 Issue (Correspondence). 4. Prevalence of Rubella immunity in health care students, The Internet Journal of Infectious Diseases, 2009, Vol 7 (original article). 5. A case of snake bite complicated by Morganella morganii subspecies, morganii Bio group 1 infection, The Internet Journal of Infectious Diseases 2008, Vol 6, No 2. 6. Onchomycosis due to Fusarium oxysoprum, The Internet Journal of Infectious Diseases, 2009, Vol 7, No 2. Dr T V Rao is also a content provider on Medical Microbiology and Infectious Diseases for numerous international websites. M: +919961785124, +918281669524 E: [email protected] W: www.medmicrobes

Author
Dr T V Rao is a Professor and Head of the Department of Microbiology at Travancore Medical College in Kollam, India. His work covers a wealth of areas, with research and audit experience: 1. Associated with HIV/AIDS screening and research work at Andhra Medical College, Visakhapatnam, 1990 91. 2. Associated with Dr TN Naik, PhD, Head of Virology National Institute of Cholera and Enteric Diseases Calcutta (ICMR) on study of Rotavirus with technology developed at NICED Calcutta 1991. 3. Isolated 0 139 Vibrio cholera at Sri Venkateswarara Institute of Medical Sciences, Tirupati (AP). The strain was named as Tirupati strain by National Institute of Cholera and Enteric Diseases Calcutta India (Under ICMR) 1994. 4. Trained at Institute of Immuno Haematology at Indian Council of Medical Research, Bombay on HLA; typing for establishing HLA Laboratory for benefit of the patient undergoing renal and bone marrow Transplantation. Papers published by Dr T V Rao include the following: 1. Emphysematous Pyelonephritis in diabetic keto acidosis Indian experience The Indian Practitioner January, 1997.

About Travancore Medical College, Kollam, India

Our Department of Microbiology caters for the basic needs of the multispecialty hospital, apart from teaching medical students attached to it. Our main work includes bacteriology, and processing of clinical samples for detection of infectious agents. We document the results in WHONET software, and periodically analyse the Antibiograms. We do hospital surveillance for environmental biosafety and several tests in virology to cater to the immediate needs of both inpatients and outpatients. We train several postgraduates in Diagnostic Microbiology on dissertations and thesis work. I am supported in the department by Dr Mary Mathews MD Professor; Mrs Deepa Babin MSc, Assistant Professor; Mr Sreenath MSc, Lecturer; and Mrs Nusaifa and Mrs Muniba and Mrs Magitha with technical assistance.

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