Principles of Infection Control in the Operating Department
Infection control is a vital part of everyday life in Operating theatre departments across the world. It is used to ensure patient and staff safety throughout surgical procedures and patients stay in a hospital. Key issues that effect many if not all trusts across the UK include Methicillin Resistant Staphylococcus Aureus (MRSA) which is found mainly on the skin and in nasal areas of patients. This bacterium has become immune to antibiotics over the years and creates big problems in hospitals all over the world (NHS, 2009). Another infection, which has swept through our hospitals, is Clostridium Difficile (C-Diff). This is a naturally present bacteria which people hold in their gut but when a patient is given antibiotics for another symptom it can multiply the C-Diff bacteria and cause symptoms such as diarrhoea and fever (NHS, 2008). There are many more infection control issues surrounding hospitals and private healthcare trusts across the world. This essay aims to outline good practice in preventing some of these infection control issues.
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There is a set of standard precautions to adhere to when carrying out any surgical procedure. "This was originally recommended when a patient was known or to be suspected of being infected with blood pathogens" Deane (2000:39). In operating departments today every surgical procedure follows these protocols to ensure the safety of staff and others who maybe exposed during a patients stay in hospital. It is also the responsibility of the Operating Department Practitioner (ODP) to adopt any Personal Protective Equipment (PPE) supplied by the trust to prevent contamination of any kind. Deane (2000:39) suggests regular handwashing is important to prevent spread of any resident germs and also to reduce the risk of transferring any germs to patients. Ventilation is also an important aspect of surgical procedures and how it effects infection control and the prevention of spreading airborne pathogens Gilmour (2005:87).
In the majority of NHS trusts in the UK the operating department staff will commence an operating list with a cleaning procedure known as 'damp dusting' before any patient enters the theatre. "Damp dusting is the cleaning of flat surfaces (e.g. trolley tops, worksurfaces, anaesthetic machines, etc) to remove dust from the perioperative environment prior to the commencement of the operating list" (Plumridge, 2008). This is to reduce the risk of infection whilst the patient is undergoing surgery. Standard precautions recommend the use of Personal Protective Equipment for all theatre staff including aprons, masks, gloves, gowns and eye protection (Gilmour, 2005:91). Each practitioner or healthcare worker will assess the risk of contamination and the appropriate PPE will be applied. This is to ensure safe practice for all theatre staff and to keep the team free from contamination.
The control of substances hazardous to health (COSHH) regulations came into force in 1989 and requires employers to assess the risk to staff and patients alike being exposed to and handling substances hazardous to health including blood and bodily fluids (Deane, 2000:41). COSHH is maintained by performing regular audits and staff completing risk assessments when potential risks are noted.
I also personally believe that Heat Moisture Exchanging Filter (HMEFs) are invaluable to NHS trusts across the UK. These are little devices that attach to the end of the Anaesthetic machine circuits just before the facemask. It works with the heat and moisture from the patient's own respiration by changing anaesthetic vaporises from a vapour to a gas. It also heats the gas up so it does not give the patient any trauma going into the lungs cold. They also have a filter inside, which will not allow any sort of passage for bacteria or virus to get into the anaesthetic machine circuit. A new filter will be used for each new patient again avoiding cross contamination (see Appendix 1).
The ventilation system inside operating theatres offers a change of air at least fifteen times an hour (Mardell, 2009:272). This prevents microbial contamination infecting vulnerable patients and also diluting expired Anaesthetic gases. The ventilation system works by pushing clean air downwards, which in turn pushes contaminated air away from the surgical field towards the sides of the operating theatre and out of the exhaust panels. There are two main types of ventilation used in operating theatres the first one I discussed which is called 'Plenum' and is the more financially suitable to NHS trusts. The second main ventilation system used is called 'Laminar flow' this system is mainly used in Orthopaedic procedures. The reason for this is because it can offer in excess of 300 air changes per hour therefore drastically reducing any airborne organisms, which can cause postoperative infection for the patient (Technology assessment team, 2001). The ventilation system also provides the heating for the theatre. (Mardell 2009:272) claims that there is no ideal temperature that will be correct as it will depend on the type of surgery taking place. When operating on babies or children the temperature will need to be higher than if operating on adults, this is due to children and babies not being able to maintain their core temperature as well as adults. The use of patient warming devices such as 'Bair huggers' and 'Blood/Fluid warmers' should allow the air temperature to be less of a consideration for the patient and allow staff to set the temperature accordingly. Along with the temperature controls most operating theatres will also have a wall mounted control panel which also allows staff to set the atmospheric humidity. The humidity should be set at no more than 60% but no less than 30% as this minimises the potential for bacterial growth and static electricity (Mardell, 2009:273).
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The surgical field has to be set up sterile and maintain sterility throughout the procedure. This is usually an invisible box approximately 1 metre square surrounding the operating table which consists of the patient, surgeon and scrub practitioner, and must contain as little equipment as possible to avoid de-sterilising anything or anyone in that area. The surgical field is maintained by people only entering when necessary and to announce to the surgical team when doing so to avoid accidental contamination (Beck, 2009). The sterile field is designed to reduce any risk of infection to a patient or to any staff member involved with the procedure. It is achieved by performing a number of safe practices: staff dress and preparation, patient preparation, utilisation of sterile equipment and theatre etiquette during surgery (Parker, 2004:108).
Aseptic Non Touch Technique (ANTT) is a form of rigorous handwashing that frees your hands and arms from living pathogenic micro-organisms (Hart, 2007:43). This is a vital part in preparing for a surgical procedure for the safety of your patient. If any member of the surgical team have a poor asepsis technique this could result in a Healthcare Acquired Infection (HCAI) for the patient. Unfortunately nosocomial infections are not a thing of the past and still effect nearly all of our NHS trusts across the UK. (Heritage, 2006) quotes "Hospitals are places where sick people go with the expectation that they will get better. Unfortunately, however, there is a risk that hospital patients may become infected because of their stay in hospital". (Nazarko, 2008) quotes "Every two minutes a patient acquires a Healthcare Associated Infection (HCAI). Every two hours a patient dies because of a HCAI". These are very scary figures and should make healthcare workers more aware of regular handwashing between patients.
You can achieve full asepsis by using sterile equipment and ensuring none of your sterile equipment or indeed yourself come into contact with anything non-sterile. "Whilst it is impossible to sterilise your hands the surgical scrub serves to minimise the number of pathogens on your hands" (Pirie, 2005). A normal hand wash is considered to be inadequate, as it does not remove enough micro-organisms from your skin. Scrubbing up on the other hand is considered to reduce the amount of micro-organisms on your skin dramatically. Scrubbing up is a longer process and is performed more intensively by going from the hands up to just below the elbow. The difference in the two procedures is simply that scrubbing up actively reduces more micro-organisms on your hands and arms than a normal hand washing procedure, which reduces the spread of infection to your patients (Collins & Hampton, 2005).
Other types of bacteria that are found in operating theatres are called Spores. These differ from normal forms of bacteria in a way that they are much harder to remove from surfaces as they have a hard shell protecting them. "The original cell replicates its genetic material, and one copy of this becomes surrounded by a tough coating. The outer cell then disintegrates, releasing the spore which is now well protected against a variety of trauma, including extremes of heat and cold, radiation, and an absence of nutrients, water, or air" (Darling, 2009). These can be an extreme problem in operating theatres as some types of spores are released into the air becoming airborne pathogens which can then travel and settle into surgical wounds causing infection in a patient (Wilson, 2006).
Waste materials in operating departments are divided into two main categories. One is Domestic waste, which compromises of non-clinical waste, which has not been in direct contact with any blood or body fluids such as paper, equipment packaging and food remains. This waste is usually placed into a black bin liner and disposed of accordingly. The other is Clinical waste which covers all other waste products that has had direct patient contact such as drapes, surgical gowns, gloves and disposable equipment. Swabs should not go into a clinical waste bag until the end of the procedure when they have been checked and accounted for by the practitioner. This waste is usually placed into orange or yellow bin liners and disposed of by incineration. Sharps on the other hand go into there own special bin provided and
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must never be disposed of in a bin bag in case of an accidental sharps injury to anybody.
Infection control is vital in maintaining patient and staff safety alike. It is the responsibility of healthcare professionals as individuals but also working together as a team to carry out the standard precautions set by their trust. Simple things like handwashing between patients and wiping down monitoring leads can hugely reduce the amount of hospital acquired infections for patients. Always check if the equipment you are using is disposable or reusable laryngoscope blades, laryngeal mask airways etc and after usage dispose of them accordingly. When commencing an operating list always carry out your standard precautions for every patient this will help protect you as a member of staff but more importantly it will keep a patient safe. When disposing of waste especially clinical waste ensure there are no tears in the bag and the bin liners have been zip tied at the top to avoid any spillage's, which could result in somebody becoming contaminated with any blood or body fluids. Remember only to open the hatch at the end of the procedure avoiding any contaminated air being let into the theatre whilst the patient is still undergoing the procedure. This could result again in an infection to the surgical site and cause severe discomfort to the patient post operatively. So always remember the standard precautions are there to protect staff and patients alike. They should be abided by at all times and hopefully we can reduce the rate of infection control dramatically.
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