NOSOCOMIAL NOTES TWO.pdf

OPERATING THEATRE An operating theatre, operating room, surgery suite or a surgery center is a room within a hospital within which surgical operations are carried out.  Classification of theatres 1. According to type of surgery-major or minor theatre 2. According to specialty- genera...

OPERATING THEATRE An operating theatre, operating room, surgery suite or a surgery center is a room within a hospital within which surgical operations are carried out.  Classification of theatres 1. According to type of surgery-major or minor theatre 2. According to specialty- general surgery theater, maternity theatre, ENT, neurosurgery theatre, pediatric theatre, cardiothoracic, orthopedic theater, urology, ophthalmic, laparascopy 3. According to urgency-emergency theatre, elective theatre 4. According to sterility- a. Sterile b. ultra –sterile(more sterile) for transplant c. Septic theatre to do septic operation like debridement 5. According to structure a. Modular-. Modern. Can be fixed equipment's like gas port, have fittings like laminar flow b. Non modular/convectional-traditional  Factors to consider when designing a theater Size –to accommodate the equipment’s Number of specialties Work load-number of surgical beds/patients Geographical Location –proximity to other department Zoning Emergency exit Ventilation Drainage  Rooms in a theatre Changing room Receiving area Induction room-for induction of anesthesia Post Anesthesia care unit(PACU)-recovery post surgery Sterile preparation room Operating room Scrub room Store Decontamination room Rest room  OPERATING THEATRE ZONES The OR(operating room) department is divided into four zones based on varying degrees of cleanliness, in which the bacteriological count progressively diminishes from the outer to the inner zones. The four zones in a theatre Unrestricted zone or clean area. Semi restricted zone or sub sterile area Restricted zone or sterile area Disposal zone or dirty area  1. Unrestricted/ Clean zone or outer zone This is the area where hospital personnel, OT personnel, patient's & their attendants can move about in street clothes. Connects to semi restricted zone.it is the entrance. ✓Stores & cleaner room ✓Equipment store room ✓Maintenance workshop ✓Kitchen (pantry) ✓Firefighting device room ✓Emergency exits ✓TV control area  2. Semi restricted/sub sterile areas/ protective zone 1. Nurses station or counter – 8. Rest rooms- sleeping area for 2. Pre-operative check area surgeon on call (reception) or receiving area 9. Seminar room Changing room 10. Theatre consumables and 3. Holding area equipment store 4. Staff room 11. Visitors waiting room 5. Post anesthetic care units 12. visitors gallery (PACU) or recovery room 6. Sanitary facility for staff- 7. Offices for in charges ,surgeon and anaestheologist  3.Restricted/Aseptic zone or sterile area This is a place where staff & 4. Gowning and Gloving room patients in street clothes & shoes 5. Sterile preparation room where are not allowed to enter. setting up the sterile Scrubbed personnel wear sterile instruments takes place. The gowns & gloves & get ready for surgical trolleys and mayo stand operation procedure. (Operating should be properly disinfected. room attire is required) 6. Sterile store –where sterile This zone has six rooms : packs are kept 1. Anesthesia Induction room 2. Operation room where operations are done 3. Scrub room –where theatre personnel scrub  4. Disposal zone or dirty utilility area Also called sluice room, Dirty utility area or Disposal corridor Contaminated instruments with blood, articles, gloves are received following surgical procedures. Here all these are cleaned, washed & wiped dry & then wrapped, stored & sent for sterilization in the CSSD. OT attire mandatory in this area. Protective gear must also be worn due to splashing when cleaning instruments. Advantages of zoning 1. 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 equipment's.  QUALITIES OF DIFFERENT AREAS OPERATING ROOM The number & size can be as per the requirement. The standard OT should be rectangular or square in shape It should be spacious enough to allow free movement of personnel, trolleys, stretchers, wheel chairs, monitoring devices, portable x-ray machines etc. Cardiac or neurosurgery OT should be bigger in size of 20x30x10 feet with 600 sq. feet floor space. OT for endoscopy or minor surgery can be of small size of 18x18x10 feet with a floor space of 324 sq. feet.  2.DOORS Main door to the OT suite has to be of adequate width (1.2 to 1.5 m). The doors of each OT should be spring loaded flap type, but sliding doors are preferred as no air currents are generated. Doors should be flush type and made of steel-easy to wipe Flap type  SURFACE / FLOORING The surface / flooring must be slip resistant, Strong with minimum joints so that they do not permits adherence of bacteria or dust particles containing microorganism. It should be easily washable It should be able to withstand repeated washing with germicidal agents. It should be able to absorb sound. The color of the flooring should be such that if a needle is dropped on the floor it is visible.  4. WALLS The walls should be made of hard fire resistant, smooth, non-porous material. It should be light in color (light blue or green) and washable paint should be ideal. Color of paint should allow reflection of light and yet soothing to eyes. Adequate electric points should be available on the wall at < 1.5 m height from the floor. Red power oulets/plugs for all theatre equipment's connected to the generator to continue the operation in case of power shortage while Regular white outlet can be plugged in equipment not directly involved in patient care like your music system or phone charger.  5.SCRUB STATION 1. Types: Stainless/ Granite/Marble/ Cement 2. Gradient of basin forward and downwards 3. Gradient towards outlet 4. Hot water mixing: automatic or manual 5. Non splashing taps 6. Taps able to change direction 7. Elbow/ Foot or Infra-Red operated taps 8. Should have soap dispenser which is Manual/automatic 9. Should be planned to accommodate for at least for 2-3 persons in each OT. HEAT ,VENTILATION, AIR CONDITIONING SYTEM (HVAC) Heating, ventilation, and air conditioning (HVAC) is the used to control the temperature, humidity, and purity of the air in an enclosed space. Types of HVAC systems 1. The circulating system takes some or all of the air from the inside, adjusts the temperature and circulates air back to the room. 2. Non-recirculating systems- heat / cool the air from outside as desired and convey it into the operating room with ideally 20-air exchange per hour. Air is then exhausted to outside.  LAMINAR FLOW SYSTEM Definition :Laminar flow is a system that relies on the use of ventilator systems that use fans to generate a positive air pressure in the roof of the theatre. The fans are connected to high efficiency particulate air (HEPA) filters to remove bacteria and other debris. Laminar flow theatres aim to reduce the number of infective organisms in the theatre air by generating a continuous flow of bacteria free air. In laminar flow theatres air may be 'changed' in theatre more than 300 times per hour The filters are 90% efficient in removing particles more than 0.5mm. Only up to 80% of air is recirculated back to prevent build-up of anesthetic and other gases  Laminar system also maintains the operating theatre at a positive pressure of 5 cm H2O from ceiling of OT downwards and outwards, to push out air from OT and ot dirty air inside the theatre. It also Keeps the temperature of the operating theatre between 20°C and 23°C and relative humidity at 50- 60%. That is which comfortable to both patient and staff. TYPES of laminar flow 1. Vertical-positioned on the roof. Air movement is from the roof where the hepa filters are fitted the air travelled to the OR then back to the filters via vents or return girdle through false walls and ceilings 2. Horizontal-positioned on the walls. Air movement is from the walls where the HEPA filters are fitted to the OR then back to the filters via vents of an opposite lower return grille  Importance of laminar flow Provide high volume laminar stream of clean air. Minimizing the risk of surgical site infection. Maintain a comfortable environment Control odours Control the particulate(dust, dirt) using high efficiency filters. Reduces entrapment of air within the operating theatre from waste anesthetic gases. Eradicate the chance of plenum(heater, ventilation, and air- conditioning ) contamination using air tight construction.  Obstacles or factors that interrupt laminar flow Spotlights over the field Ceiling beams with surgical machinery and equipment Mayo stands over the patient Microscopes, articulated laser arm, and C-arm Personnel and patient thermal plume(human heat exchange) Opening and closing the OR door Personnel moving about the room Blocked exhaust vents which remove airborne microorganisms to help control infection  Ways to maintain sterility in theatre keeping doors and windows closed keeping personnel to a minimum during a procedure and restrict personnel once the operation has started (unless it is absolutely essential Minimizing talking or moving Locate operating theatre away from areas in the healthcare facility that are heavily travelled by staff and patients. Ensure no windows to keep away insects, dust etc. PREVENTING NOSOCOMIAL INFECTIONS  HAND HYGEINE Effective hand hygiene is the cornerstone of standard precautions and is the single most important measure in the prevention of hospital acquired infections and anti- microbial resistance. The most common mode of transmission of any infectious agents is via the hands of staff and patients.  Flora: these are Micro – organisms found on the human body. They are of two types – 1. Resident( normal) Flora(endogenous): Micro – organisms that are always present, usually without altering patient’s health, they can’t be removed with only hand washing with soap, but friction does; 2. Transient flora/exogenous bacteria: They are episodic, attaching to the skin for a brief period of time but do not continually live there, acquired through direct contact with organism or environmental surfaces, easily removed on hand washing Where normal flora is found  Function of normal flora Act as a protective barrier in resisting the establishment of pathogenic microorganisms. This defence mechanism is called ‘ colonization resistance ’. Note that The classical example is that when an antibiotic is prescribed to an individual, it kills and disturbs the normal healthy microflora of the gut which acts as a protective ‘wall paper’.  THE FIVE MOMENTS FOR HAND HYGIENE DEVELOPED BY THE WORLD HEALTH ORGANIZATION 1. Before clean/aseptic procedure 2. Before touching a patient 3. After body fluid exposure 4. After touching patient 5. After touching patient surroundings THE BASIC COMPONETS/ELEMENTS OF HAND WASHING 1. Soap. 2. Running water-warm water of 100F(37.8 degree Celsius) 3. Friction. 4. Time -40 to 60 seconds 5. Drying-proper drying by use of disposable paper towels to avoid re-contamination. 6. Surfaces-avoid touching surfaces There are three types of hand washing 1. social or routine handwashing; 2. Antiseptic or clinical handwashing 3. surgical hand washing  Social/routine handwash Social hand wash is done mainly to clean hands off dirt or debris if hands are visibly dirty and to remove transient micro-organisms from the surface of the skin. Social hand hygiene prevent spread of infection in the society /community.It is done using warm water and antibacterial soap or by use of alcohol based hand rub if hands are clean. Hands must first be washed with liquid soap and water when: a. They are visibly dirty or soiled with blood and bodily fluids; or b. Exposure to potential spore-forming pathogens is strongly suspected or proven Social hand hygiene is done: Before eating After visiting the toilet Before preparing food After coming in contact with someone else  Hand hygiene technique The steps below should be followed when performing hand hygiene with either soap and 1. Ensure that the jewelry has been removed. Short nails (