SURGICAL THEATER SAFETY - CHECK LIST

1.
In
the
recent
past
there
is
growing
awareness
on
Infectious
safety
asepsis
and
Hygiene
of
the
patients
in
operation
theatres,
as
we
have
greater
accountability
than
a
patient
in
Inpatient
care.
Surgical care has been an essential
component of health care worldwide for over a century. As the incidences of
traumatic injuries, cancers and cardiovascular disease continue to rise; the impact
of surgical intervention on public health systems will grow. The focus of the
Challenge is the WHO Safe Surgery Checklist. The checklist identifies three
phases of an operation, each corresponding to a specific period in the normal
flow of work: Before the induction of anesthesia (“sign in”), before the incision of
the skin (“time out”) and before the patient leaves the operating room (“sign out”).
In each phase, a checklist coordinator must confirm that the surgery team has
completed the listed tasks before it proceeds with the operation. Surgery is often the
only therapy that can alleviate disabilities and reduce the risk of death from common conditions.
Every year, many millions of people undergo surgical treatment, and surgical interventions
account for an estimated 13% of the world’s total disability-adjusted life years
WHO and surgical safety
WHO has undertaken a number of global and regional initiatives to address surgical safety?
Much of this work has stemmed from the WHO Second Global Patient Safety Challenge “Safe
Surgery Saves Lives”. Safe Surgery Saves Lives set about to improve the safety of
surgical care around the world by defining a core set of safety standards that could be applied
in all WHO Member States.
Surgical site infections (A great Concern and Increasing Accountability)
An infection that occurs in surgical patients at the site of operation is procedures in the
superficial or deep layers of the incision or in the organ or space that was manipulated or
traumatized, such as the peritoneal space, pleural space, mediastinum or joint space. These
problems are serious and costly, and are associated with increased morbidity and mortality as
well as with prolonged hospitalization. Recently, their prevalence has been used as a marker
for the quality of surgeons and hospitals. Infections and about 37% of the hospital-acquired
infections of surgical patients. Two thirds of surgical site infections are incisional and one third
confined to the organ space. In western countries, the frequency of such infections is 15–20%
of all cases, infections lead to an average increase in the length of hospital stay of
Role of Microbiological Surveillance
( Adpoted from Dr.T.V.Rao’s Articles on World wide web )
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.

2. 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 Airborne 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.
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 should Surveillance be done for Airborne 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 may be needed. The age old tradition of detection of
anaerobic spores ofC.tetani, and Gas gangrene producing organisms are losing
ground with onset of more awareness on theatre sterilization. Routine testing
for the anaerobes are 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 remodelling or structural alterations are done. In such
situations which will have trust worthy safety of the theatre.
General Instructions for sterilization and disinfection of Operation theatres
• Keep the floor dry when in use.
• Use only vacuum cleaners (booming to be forbidden, as it will dispense
the infected material all around and on the equipment’s.

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.
• 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
• Only remove the dust with cloth wet with clean water. (Mop theatre furniture
lamps, sitting tables, trolley tops, operation tables, procedure tables, and
Boyle’s
apparatus). Note:
Chemicals/disinfectants need not be used unless contaminated with blood or
body fluids.
Between the procedures
• Clean operation tables or contaminated surfaces with disinfectant
solutions.
• In case of spillages of blood/ body fluids decontaminate with bleach
solution/ chlorine solution (10% available chlorine)
• Discard all waste in color coded plastic bags (do not accumulate around
surgical sites)
• Do not discard soiled linen and gowns in the operation theatre floor.
At the end of the day
• Clean all the tabletops, sinks, door handles with detergent followed by
low level disinfectant.
• Clean the floors with detergents mixed with warm water.
• Finally mop with disinfectant like phenol in the concentration of 1 in 10
(low concentrations of phenol will not serve the purpose).
• Keep the operation theatre dry for the next day's work.
Operation Theatre Discipline:
• Only people absolutely needed for an assigned work should be present in
the Operation Theatres
• People present in theatre should make minimal movements and curtail
unnecessary movements in and out of theatres, which will greatly reduce
bacterial count.

4. • 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.
• Prompt disposal of Theatre waste out of the theatre is of top priority.
Any spillage of body fluids on the floors is highly hazardous and prompts
the rapid multiplication of nosocomial pathogens.
Microbiological contamination of air in the operating room is generally considered to be a risk factor for
surgical site infections in clean surgery. According to Pasquarella et al 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. 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.
In spite many developments the personal care of the Health care workers and protecting the environment in
the operation theaters greatly reduces the many infections arising out of Operation Theater as a source of
Infection However our hands can play greater role than any physical objects in the operation theaters
HAND WASING
Hand washing is therefore an important, cheap and a simple way of preventing nosocomial
infections. Hand antisepsis reduces the incidence of health-care-associated infections.
If you find more incidences of Surgical site Infection we should improve the good hygiene practices than
doing controversial and yet not perfected Operation theater surveillance
We in many developing countries lack coordination the system, lack resources to do effective surveillance
and misuse of Antibiotics masks the reason to identify the Infections arising in the operation theatres
HOWEVER an accountability can be initiated with a simple practicable check list
• Data collected on surgical procedures performed in the designated theatres.
• Checklist introduced in the theaters.
• Data collected on a similar cohort of surgeries.
Measures:
• Patient safety processes such at correct confirmation of patient identity, administration of timely
prophylactic antibiotics etc.
• Post operative complications
• Length of hospital stay
Ref 1
SAFE SURGERY SAVES LIVES SECOND GLOBAL PATIENT SAFETY CHALLENGE (WHO
safety manual)
2 Pasquarella C, Masia MD, Nnanga N, Sansebastiano GE, Savino A, Signorelli C, Veronesi L
Microbial air monitoring in operating theatre: active and passive samplings] Ann Ig. 2004; 16 (1-2): 375-
86.
3 Parker MT. In Hospital Associated Infections, Guidelines to laboratory methods. WHO, Regional
Office for Europe, Copenhagen. 1978; 28-32.