Version Document .No. HWP3/13, V- 1.0
Coverage
10.1 points
Proposed by
Reviewed by
Sakamma ( OT Incharge)
Dr Prakash Kini ( Group Medical Director), Dr Raghavendra Hallur (Asst Quality Manager)
Approved by
Effective date
Modifications
Dr K.P.Das (Group Advisor)
28st of April 2013
New Policy & Procedure
Operation Theatre Policies and Procedures Manual
Table of Contents 1
INTRODUCTION ........................... ........................................ ........................ ........................ ........................... ........................... ........................ ............. 4
2
Structure of the Department .......................... ........................................ ......................... ........................ .......................... ........................ ...........4
3
Functional Zoning of the Department: .......................... ....................................... ......................... ......................... .......................... .............4
4
PURPOSE ......................... ...................................... ......................... ......................... .......................... .......................... ......................... ..................... .........5
5
SCOPE ......................... ...................................... ......................... ......................... .......................... .......................... ......................... ......................... .............5
6
RESPONSIBLITY .......................... ....................................... ........................ ........................ ........................... ........................... ........................ ............. 5
7
DEPARTMENT POLICY AND PROCEDURES .......................... ........................................ ......................... ........................ .................... .......5 7.1
Policy on criteria for Staff Selection ......................... ...................................... ......................... ......................... .......................... .............5
7.2
Booking and Scheduling of surgery .......................... ........................................ ......................... ........................ ...................... .........6
7.3
Pre-operative Assessment: .......................... ....................................... ........................ ........................ ........................... .................... ......7
7.4
Policy on Pre –Anesthesia Evaluation [PAE] ......................... ...................................... ......................... ......................... .............7
7.5
Policy on obtaining Informed consent prior to Surgery/Procedure .......................... ..................................... ...........8
7.6
Preparation of patient ......................... ....................................... ......................... ........................ .......................... .......................... .............9
7.7
Policy on Surgical Site Marking.......................... ....................................... ......................... ......................... .......................... ............. 10
7.8
Transfer of Patient to Operation Theatre: ........................... ........................................ ........................ ........................ ............... 11
7.9
Receiving of patient and immediate preoperative assessment:: .......................... ....................................... ............. 11
7.10 Policy: Surgical Safety - Prevention of Wrong Procedure/Side/Site and Wrong Patient (time out procedures): ......................... ...................................... ......................... ......................... .......................... .......................... ......................... ................... ....... 12 7.11
Transportation of Patients from OT to Recovery Room / ICU / Wards ........................... ............................... .... 14
7.12
Post operative care .......................... ....................................... ......................... ......................... .......................... .......................... ............. 14
7.12.1
Definition ........................... ........................................ ........................ ......................... ........................... .......................... ..................... ........ 15
7.12.2
Purpose .......................... ....................................... ........................ ........................ ........................... ........................... ....................... .......... 15
7.13 8
Discharge from the Recovery Area: .......................... ........................................ ......................... ........................ .................... ....... 16
Quality Assurance in Operation Theatres ......................... ...................................... ......................... ......................... ...................... ......... 16 8.1
Staffing in the Operation Theatre .......................... ....................................... ........................ ......................... ........................... ............. 16
8.2
Infection control In Operation Theatre ......................... ....................................... ......................... ........................ .................. ..... 16
8.2.1
Dress Code in Operating Room .......................... ....................................... ......................... ......................... ...................... ......... 16
8.2.2
Colour code for Surgical Attire ......................... ...................................... ......................... ......................... ........................ ........... 18
8.2.3
Controlled Access ......................... ...................................... ......................... ......................... .......................... .......................... ............. 18
8.2.4
GLOVEING AND GOWNING: .......................... ....................................... ......................... ......................... .......................... ............. 20
8.2.5
Standard Precautions ......................... ....................................... ......................... ........................ .......................... ...................... ......... 21
8.2.6
Biomedical Waste Management ......................... ...................................... ......................... ......................... ...................... ......... 21
8.2.7
Special Precautions for Known Infectious Cases: ......................... ....................................... ......................... .............. ... 21
8.2.8
Disinfection in Operation Theatre: ......................... ....................................... ......................... ........................ .................... ....... 22
8.2.9
OT Fogging protocol: ......................... ....................................... ......................... ........................ .......................... ...................... ......... 24
8.3
Mandatory HVAC parameters ......................... ...................................... ......................... ......................... .......................... ............... .. 27
8.4
Measuring the Quality of Services of Operation Theatre ........................... ........................................ ..................... ........ 27
9
8.4.1
Percentage of Re-scheduling of Surgeries: .......................... ....................................... ......................... ..................... ......... 27
8.4.2
Prevention of adverse events .......................... ....................................... ......................... ......................... ........................ ........... 28
8.4.3
Prophylactic Antibiotic .......................... ....................................... ........................ ........................ ........................... .................... ...... 28
8.4.4
Percentage of unplanned return to OT ........................... ........................................ ........................ ......................... .............. 28
8.4.5
Surgical Site Infection Rate: (SSI) .......................... ........................................ ......................... ........................ .................... ....... 28
HOUSE KEEPING IN THE OPERATION THEATRE ........................... ........................................ ........................ ....................... ............ 29 st
9.1
Before the start of the 1 case .......................... ....................................... ........................ ........................ ........................... .................. .... 29
9.2
Linen & gloves: ......................... ...................................... ......................... ......................... .......................... .......................... ................... ...... 29
9.3
Instruments ........................... ........................................ ........................ ......................... ........................... .......................... ..................... ........ 29
9.4
Environment .......................... ....................................... ........................ ........................ ........................... ........................... ..................... ........ 30
9.5
Weekly cleaning procedure .......................... ....................................... ........................ ........................ ........................... .................. .... 30
9.6
HVAC maintenance: ......................... ...................................... ......................... ......................... .......................... .......................... ............. 32
10
Annexure .......................... ........................................ ......................... ........................ .......................... ........................... ......................... .............. ... 33 10.1
Annexure 1: Surgical Safety Checklist: .......................... ........................................ ......................... ........................ .................. ..... 33
1
INTRODUCTION
The operation theatre also called as operating room (OR) is a very important high risk area in the hospital; It is also a high cost area which demands its proper utilization. Infection control practices and Quality Assurance activities of the OT have a vital role in the quality of services provided in the hospital.
2
Structure of the Department
Operating theatre complex is one of the important high risk areas in the hospital. The complex involves the patient receiving zone, the preoperative area, operative rooms, the dirty corridor, the clean and dirty utility rooms.
3
Functional Zoning of the De Department partment: partment:
Zoning concept should be incorporated while considering the functional criteria .the design should follow the function and not vice-versa. . 1. Protective rotectiv rote ctive e zone : these are the the areas throug through h which Protective patients are wheeled into the OT ;personnel ;p ersonnel movement ;lift ;waiting area ;change room 2. Clean zone : this includes drug store; clean utility; C lean zone staff room; doctors room; reception; 3. Sterile zone zone: this area covers the operating room/ sterile linen storage area 4. Disposal Disp osal zone: This is the the outermost outermost zone zone and and comprises of the dirty corridor around the OT complex. Soiled linen and unsterile instruments are
taken out of the operating room and the OT complex through this corridor.
4 PURPOSE P URPOSE To provide guideline instructions for Processes Related to Operation Theatre Functioning 5
SCOPE S COPE It covers the total functioning of the Operation Theatre with relation to the patient and other OT specific processes
6
RESPONSIBLITY
•
Chief Surgeon and Chief Anaesthesiologist will be responsible for the implementation of the policies and procedures in the Operation Theatre complex.
7
DEPARTMENT POLICY AND PROCEDURES
7.1
Policy on criteria for Staff Selection
Qualification of staff: staff a. Surgical care will be provided only by qualified surgeons holding Post Graduate degree area as per MCI norms and experience in the respective
b. Anaesthesia care will be provided by Anaesthesiologist holding Post Graduate degree area as per MCI norms and experience in anaesthesia c. Nursing care in the OT will be provided by qualified, experienced and registered nursing staff
7.2 Booking and Scheduling of surgery All surgeries performed in the OT complex should be scheduled unless it is an emergency Surgeries should be booked at least 2 days in prior to make necessary arrangements for it. During scheduling there should enough gap to follow the cleaning and infection control practices Priority will be given to the emergency cases in between the elective cases. The following particulars will be entered in the case posting register, •
•
•
•
Hospital MRN Number
Name, Age, Gender of the patient
Place of Admission (Room No., suite etc.)
Name of the Surgeon
Name of proposed surgery
Operation Theatre Number to be booked for the case
Date and time of proposed surgery
Special requirements in terms of equipment (if any)
7.3 Pre-operative Assessment:
All patients undergoing surgery are assessed pre-operatively and a provisional diagnosis is made which is documented prior to surgery. This is applicable for both for routine and emergency cases.
Patients requiring surgical intervention will have to undergo a full check-up by the concerned surgeon which includes the following:
a. Through clinical Examination of the Patient b. Vitals c. Examination of the chest. d. Investigation such as scan , ECG and Blood reports as required required The patient’s preoperative check up findings is to be documented in the Assessment format in the patient’s case sheet and signed by the concerned doctor.
7.4 Policy on Pre –Anesthesia Evaluation [PAE]
Patients for Anaesthesia should undergo a Pre-Anaesthesia Evaluation [PAE] by a Qualified Anaesthesiologist The PAE should be done before the patient p atient is wheeled into the OT complex both in routine and emergency cases. The PAE may be even carried c arried out prior to admission in case ca se of elective surgeries. The consultant anaesthesiologist will undertake the pre-aesthesia check up of the patient which includes the following: •
Medical
History
such
as
HT/DM/
asthma/allergy etc. •
Surgical and Anaesthesia history if any
Chest
Pain/IHD/B.
•
.General Examination such as Pulse ,BP,RR etc
•
Airway assessment
•
Systemic Examinations etc
•
All pre-aesthesia check up findings is documented in the specified format attached with the patients file.
The Pre Anaesthesia Assessment should result in formulation of Anaesthesia Plan which should be documented in the patient’s medical record.
The Anaesthesia plan should mention the Premedications, type of anaesthesia, the drugs to be used for induction, and the drugs to be used for maintenance. It should also mention about other concomitant medications and IV fluids, special monitoring requirements where appropriate and anticipated post anaesthesia care.
7.5 Policy on obtaining Informed consent prior to Surgery/Procedure Informed consent should be obtained by the surgeon performing the Procedure from the patient or the relatives. The person performing the surgery will be responsible for the entire consent process. Informed consent should be taken after giving the information regarding 1. The requirement and nature of procedure, 2. Risks involved 3. Benefits of the procedure 4. Alternatives available and 5. Who will be performing the requisite procedure in the language that patient and relatives understand.
The consent is obtained from the patient and or the attendees as per the hospital’s Informed Consent policy prior to the surgery. Details pertaining to the proxy consent could be sought in the Informed consent Policy. No te: There should be high risk risk consent for high risk cases. And the consent Note: should be taken for Sterilization and MTP procedures as per the law of land.
7.6 Preparation of patient Before the patient is shifted to the OT the following points should be checked for:
Patient should be identified properly Name, age, Patient UHID and medical records Proper Informed consent is taken by the concerned c oncerned surgeon from the patient of the concerned attendees. Preparedness by the Operation theatre should be checked by the concerned ward staff with the OT complex staff. OT staff should be informed about infected cases (HIV, HBsAg, MRSA or any other know infectious patients) prior to surgery.
All the Jewellery should be removed r emoved and handed over to the patient attendees.
Pre medication if any should be given to the patient as prescribed. Patient Part preparation if any such a clipping of hairs should be done a day prior to surgery unless an emergency.
If any diagnostic investigations results are awaited they should be followed up, collected and informed to the concerned if required.
Bowel Preparation if required should be done as per the orders.
Bladder emptying or catherization should be followed done as ordered.
Dentures if any should be removed prior to transfer to OT complex.
Patient should be identified once again before shifting the patient to the OT complex.
Anaesthesia trolley checked for all the drugs and by anaesthesia technicians.
Anaesthesia machines, ventilators, central gas supply and cylinders checked by the OT technicians
All sutures needed for surgery listed and taken from Pharmacy in the previous evening – OT nurse.
Drugs needed for a surgery should be listed out by OT In-charge
OT staff should be informed by concerned person about cancellation of the cases so that they can schedule the OT for other case
7.7 Policy on Surgical Site Marking 7.1.1
Making the Mark
1.1.1. The patient’s surgical site is to be marked before the patient is moved to the location where the procedure will be performed. The patient should be involved, awake and aware; preferably before any prescribed pre-medication is administered 1.1.2. The mark is to be an arrow pointing to the site of the operative procedure, as close as possible to the incision site 1.1.3. The mark is to be made with an indelible, permanent black marker pen and should be sufficient to remain visible after skin preparation and draping; if practicable 1.1.4. The site for all procedures that involve incisions, percutaneous punctures, or insertion of instruments must be marked taking into consideration
•
•
Surface, spine level, specific digit or lesion to be operated on Laterality. For procedures involving laterality of organs, but where the decision or approach may be from the mid-line or natural orifice, the site must be marked and a note made of the laterality
1.1.5. All site markings must be made in conjunction with checks made on the patient’s diagnostic imaging results i.e. X-rays, scans, electronic imaging or other appropriate test results, ensuring these match the patient’s medical notes and identity band.
7.8
Transfer of Patient to Operation Theatre: a. Prior to the transfer of the patient the ward nurse informs the OT nurse about the patient details and confirms the scheduled sc heduled time for surgery forty five minutes prior to the scheduled time of surgery. b. The ward nurse prior to the transfer of the patient ensures that the nurse’s preoperative checklist is dully filled and all the patient details as required by the surgeons are arranged in the proper order. c. The patient is identified by at least two identification parameters. d. The patient is transferred to the OT as per the hospital’s transfer policy.
7.9 Receiving of patient and immediate preoperative assessment:: a. The patient is received in the preoperative patient holding area of the theatre. b. The patient is identified at the entry of the OT complex by the OT staff nurse c. The OT nurse evaluates the patient’s details and checks the preoperative nursing checklist filled by the ward nurse to ensure the patients preparedness and confirms the patient’s identity by orally confirming with patient and checking the ID bands and the medical records.
d. The patient is transferred to the Pre operative room where the concerned surgeon and anaesthetist undertake immediate preoperative evaluation. 7.10 Policy: Surgical Safety - Prevention of Wrong Procedure/Side/Site and Wrong Patient (time out procedures):
The prevention of wrong site/side/procedure and patient begins with proper identification of patient and the preoperative evaluation of the patient.
This involves the following activities such as marking of the surgical side, verification of patient prior to the shifting of the patient from the ward to the OT, at the time of patient’s entrance to the OT suite and prior to the initiation of the procedure inside the theatres ,etc
To ensure eliminate the risks endangering the lives and well being of the surgical patients the WHO surgical Safety checklist has to be followed to ensure that the team follows a few critical steps for its effectiveness.
The format of the WHO surgical safety checklist: As per Annexure 1.
The circulating nurse will be responsible to run the surgical safety checklist.
All steps should be checked verbally with the appropriate team member to ensure that the key actions have been performed.
Before induction of anaesthesia, the person coordinating the Checklist should verbally review with the anaesthetist and patient (when
possible) that patient identity has been confirmed, that the procedure and site are correct and that consent for surgery has been given.
The coordinator should visualize and verbally confirm that the operative site has been marked (if appropriate) and should review with the anaesthetist the patient’s risk of blood loss, airway difficulty and allergic reaction and whether an anaesthesia machine and medication safety check has been completed.
Ideally the surgeon should be present during this phase as the surgeon may have a clearer idea of anticipated blood loss, allergies, or other complicating patient factors
Before skin incision, each team member should introduce himself or herself by name and role. If already partway through the operative day together, the team can simply confirm that everyone in the room is known to each other.
The team should confirm out loud that they are performing the correct operation on the correct patient and site and then verbally review with one another, in turn, the critical elements of their plans for the operation, using the Checklist for guidance.
The team should also confirm that prophylactic antibiotics have been administered within the previous 60 minutes and that essential imaging is displayed, as appropriate.
Before leaving the operating room, the team should review the operation that was performed, completion of sponge and instrument counts and the labeling of any surgical specimens obtained. It should
also review any equipment malfunctions or issues that need to be addressed.
Finally, the team should discuss key plans and concerns regarding postoperative management and recovery before moving the patient from the operating room.
7.11 Transportation of Patients from OT to Recovery Room / ICU / Wards
1.
Circulating nurse/OT technician should inform recovery room nurse that patient is to be shifted from OT to post surgical unit
2.
Level of consciousness and vital signs to be monitored in recovery room by staff nurse every 15 mins or earlier as instructed.
3.
When the patient is fully conscious and follows the command, the patient is shifted to the concerned ward, with written order of the anaesthesiologist in the recovery room vitals chart
4.
When the patient is deemed fit for discharge from the recovery room, the recovery nurse should confirm with the ward nurse for the bed and start shifting of patient.
7.12 Post operative care Policy: After the surgery/procedure the patient should be monitored in the recovery room until the patient is found to be fit for discharge from the recovery room.
Post-operative plan of care -The operating surgeon should document the post operative plan of care. This plan should include advice on IV fluid, medication, care of wound, nursing care, observing for any complication. The plan could be written in collaboration with the anesthesiologist.
7.12.1 Definition Postoperative care is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating operating room roomand post anesthesia care unit (PACU), as well as during the days following surgery.
7.12.2 Purpose In the immediate postoperative period the patient is nursed in a recovery area using one-to-one nursing and continuous monitoring. The role of the recovery nurse is to ensure that the patient is protecting pr otecting their airway, breathing freely and perfusing adequately ( airway, breathing and c irculation). irculation). The recovery nurse should also monitor the patient’s pain as the anaesthetic wears off and ensure that there are no early complications developing, such as bleeding from the wound or loss of distal circulation and/or sensation. Blood pressure, pulse and oxygen saturation are therefore monitored regularly and the results charted. Trends seen on these charts reassure the recovery nurse that the patient is recovering well or warn that a complication is developing
The goal of postoperative care is
to prevent complications immediately after surgery due to anesthesia, To monitor bleeding or any other such complication after surgery.
7.13 Discharge from the Recovery Area: The recovery unit nurse should apply defined criteria c riteria to assess the fitness of the patient to be discharged from the recovery area. Post Sedation/Anesthesia recovery score sheet should be used to ascertain the fitness for discharge. The important criteria to be monitored before discharge are: consciousness, respiratory activity, circulatory efficiency, and motor activity. 8
Quality Assurance in Operation Theatres
8.1
Staffing in the Operation Theatre The staffing of OT should be as per policy on criteria for staff selection contained in Para 7.1 All the staff Posted to work in the Operation theatre will be credentialed and privileged as to review the qualification and expertise in the area Also only those who have adequate qualification and experience would be posted in the OT for non clinical work( Housekeeping etc).
8.2 Infection control In Operation Theatre
8.2.1 Dress Code in Operating Room a. Purpose: Purpose Surgical attire provides a barrier between personnel and patient and patient and personnel, through which which contamination contamination may pass. Surgical
attire also provides protection for personnel against exposure to infectious micro-organisms and hazardous materials. b. Policy i.
All personnel entering the clean zone of the OT complex should be in operating room attire.
ii. iii.
Attire which is soiled or wet shall be changed. All reusable attire shall be laundered after each use, by a laundry facility approved and monitored by Hospital.
iv.
OT attire shall be stored in an enclosed cupboard. All head and facial hair is to be covered while in the restricted areas of the surgical suite.
v.
The surgical cap or hood is to be clean, free of lint and confine the hair. The surgical cap or hood should be changed daily. .
vi.
Dedicated slippers should be worn in the restricted areas
vii.
Shoe covers shall be worn if it is anticipated that splashes or spills will occur.
viii.
Masks shall be worn at all times in the surgical suites and other areas where open sterile supplies or scrubbed personnel personnel are located. Masks shall cover the nose and mouth and shall be discarded whenever removed.
ix.
Personal jewellery worn in the surgical suites shall be limited to the following: •
Necklace - One small single chain
•
Earrings - Small studs.
All other other earrings worn worn are to be
contained within a cap at all times. •
No rings will be allowed.
x.
All jewellery (rings and watches) is to be removed prior to hand washing. All other jewellery shall shall be totally confined confined within scrub attire attire or removed.
xi.
Fingernails shall be kept short and trimmed
8.2.2 Colour code for Surgical Attire
For doctor’s green suite.
For staff’s blue suite.
For housekeeping’s grey suite.
OT linen for using surgery is green linen.
8.2.3 Controlled Access
The access to the OT complex should always be controlled, only concerned persons should be allowed to enter the OT complex. Any new persons entering the OT complex should take permission from the OT in charge c harge and enter the unit only after changing to the OT suits. Visitors, Family member and friends will be restricted in the OT
8.2.3.1 Steps before Starting Surgical hand preparation
Keep nails short and pay attention to them when washing your hands – most microbes on hands come from beneath b eneath the fingernails. Do not wear artificial nails or nail polish. Remove all jewellery (rings, watches, bracelets) b racelets) before entering the operating room suite.
Wash hands and arms up to elbows with a non-medicated soap before entering the operating room area or if if hands are visibly soiled. Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of cells. Nailbrushes, if used, must be sterile and used only once.
8.2.3.2 Steps for surgical hand preparation
Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes. Proceed to scrub the arms, keeping the hand higher than the arm at all times. this helps to avoid recontamination r econtamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands. Wash each side of the arm from wrist to the elbow for one minute. Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches touches anything except the the brush at any time, the scrub must be lengthened by one minute for the area that has been contaminated. Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water. Proceed to the operating room suite holding hands above elbows. At all times during the scrub procedure, care should be taken not to splash water onto surgical attire. Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique before putting on gown and gloves.
8.2.4 GLOVEING AND GOWNING:
Gowning Technique (For sterile gowns) Sterile gowns are always folded inside out to avoid contamination. As it is impossible to render the hands sterile, they must not come in contact with the outside of the gown or gloves. Procedure: Hands must be washed thoroughly before gowning Pick up the gown holding it well away from the trolley and your own body. Hold the neck band and unroll until the sleeves sleev es are seen. Slide both hands and arms into the sleeves at the same time. The floor nurse / assistant slides s lides her hands under the gown at the shoulder and pulls out and fastens all the back tapes. Cover the back with the back flap with the help of the scrub nurse. Remember: Do not keep the hands lower than the waist line. Do not keep the hands near ones neck or shoulder. Do not touch the back of the gown. g own. Removal of Gown at the end of the Procedure The circulating nurse will unfasten the gown. The gown is carefully removed by the scrub nurse leaving the gloves on. The gown with the inside folded out is placed in the appropriate bin. The gloves are then removed by holding the inside of the cuff and placed in appropriate container • •
• • •
•
• • •
• •
• •
8.2.5 Standard Precautions To be followed as per Infection Control Manual.
8.2.6 Biomedical Waste Management
To be followed as per Infection Control Manual.
8.2.7 Special Precautions for Known Infectious Cases: The following are the cases to be considered as infectious1. 2. 3. 4. 5. 6. 7. 8.
HIV Hepatitis B Hepatitis C MRSA VRSA VRE Gas Gangrene Any Multi Drug Resistant Pathogen
Infectious cases should be posted at the end of the day after all surgeries For infected cases universal precautions should be taken Before procedure minimize the things present inside, keep the things and trolley outside if it is not necessary. Use disposal packs and gowns. g owns. Use goggles to protect the eyes. Shoe cover to avoid dripping of body fluids and blood. Double gloves should be used Needles should be handled very cautiously. After the case the OT should be carbolized and Fogged as per the protocol.
For Air Borne Precautions:
For H1N1, chicken pox, pulmonary tuberculosis any other active cases require air borne/ droplet precautions patient and the attending staff should wear N95 masks. Also during the transfer of patients. Handling of Linen: All the infected linens should be put in a separate yellow colour bag and be labelled as Infectious
8.2.8 Disinfection in Operation Theatre:
8.2.8.1 At the beginning of the day:
no Equipment 1 OT table
Disinfectant 70 % Isopropyl alcohol
Anaesthesia machine
70 % Isopropyl alcohol
Frequency At the start of the day&Between every case Before induction
Monitor accessories
with 70 % Isopropyl alcohol
Every case
Drug trolley
70 % Isopropyl alcohol
Beginning of the day
Suction machines
70 % Isopropyl alcohol
Beginning of the day
Suction bottles Defibrillator
2%bacillocid 70 % Isopropyl alcohol
Every case Beginning of the day and if used in between patients
8.2.8.2 After the end of all cases:
Collect all instruments and send to CSSD Collect all linen and place in double bags and tie. Label and send to to laundry Put disposable linen in yellow bags Collect other waste in appropriate coloured bags and send Wipe all furniture including lights trolleys iv stands etc with friction and disinfection as per table above Wipe the walls with 2% Bacillocid Bac illocid solution Mop floor with soap and water followed by 2%bacillocid. 2%bac illocid.
NOTE: Disinfect spills if any on any surface with 1%hypochlorite before proceeding with cleaning
8.2.8.3 Terminal Cleaning
Housekeeping staff to take all standard precautions
Linen to be stripped meticulously taking care not to raise many aerosols. Fold the linen away from the person p erson and fold into a bundle
Pack the linen into double yellow bags and label as infected and sent to the laundry.
Wash bed pans with detergent and water dry then wipe with 1% bacillocid and air dry.
Wipe all IV poles, suction machines, beds, pillows, cots, switch boards, door
handles, trolleys,telephone trolleys,telephone handles etc with 2% bacillocid
Wash the toilets and hand wash sinks with soap and water
Mop the floor with detergent and water followed by bacillocid special at 2%dilution.
8.2.9 OT Fogging protocol:
8.2.9.1 Schedule :
Fogging will be done every week preferably at the end of all cases on Saturday. The OT should be thoroughly scrubbed before fogging.
8.2.9.2 Disinfectant
Fogging will be done with Aerox/ecoshield
8.2.9.3 Dilution:
o o
Aer Aerox Ae rox: ox:: 250ml
in 750 of water per 1000cu ft Ecoshield : 200 ml in 800ml of water per 1000cuft
8.2.9.4 Procedure:
Scrubbing: o Send all linen for washing o Wipe OT table, mattress,telephones ,ac grills, lights, monitors with 2%bacillocid o Wash (clean) and dry all furniture and equipment suction holders, foot & sitting stools, Mayo stands, IV poles, basin stands, X-ray view boxes, hamper stands, all tables in the room, holes to oxygen tank, kick buckets and holder, and wall cupboards).
o
o o o o
Wipe the doors and window panels with damp and dry cloth to remove dust Scrub the floor with a hard brush Wipe the walls with 2% bacillocid bac illocid solution. Mop the floor with 2% bacillocid solution. HVAC pre filters should cleaned by the people arranged by maintenance
8.2.9.5 Fogging: o
o o o o o
Fill the disinfectant into the fogger machine as per the dimensions of the Ot Seal all areas to prevent escape of fog Keep the machine in the centre of the room Switch the machine on for 30 min Keep the door closed for one hour Send air samples and swabs to microbiology laboratory as per protocol.
8.2.9.6 Swabbing: o o o
o o o
Collect immediately after opening the room Don sterile mask and gloves Moisten the swab with sterile water .take care to prevent cross contamination Wipe the surface to be sampled with vertical S strokes Place the swab in sterile container c ontainer and cap immediately. Culture swabs will be sent in the following order:
1. Two from the floor/walls 2. Two from the Equipments as listed below on alternate alte rnate basis. •
Surface of OT table
•
Overhead Lights
•
Monitor Screen
•
A/C Grill
•
Warmer
•
Humidifier Water
•
Any other area if suspected
8.2.9.7 Air sampling of a working OT is done by the settle plate method method 1. Two Blood Agar plates should be kept exposed for 1Hour, One at the centre of the room and the other at any one corner of the room.
2. After Exposure the lid should be closed and sealed with micropore and sent to Microbiology Lab
8.2.9.8 Document: The following documentation of the swabs and air culture is mandatory Name of the centre, OT no, Sample location, time and date of collection .name of person collecting the sample.
8.3 Mandatory HVAC parameters
The Air supplied to the OT should be filtered by HEPA filters through a dedicated AHU
All the OT should be adhering a dhering to the following are the parameters: Efficiency of the HEPA should be 99.97%- air is to be filtered up to 0.3 microns Number of Air changes- 25 Total Air changes Fresh Air Component- 6 out of total 25 air changes Pressure- Positive Pressure of 15 Pascals between be tween the adjoining areas Air quality- should be of Class 1000/ ISO 6 Temperature- 21 +/- 3 deg Celsius Relative humidity- 40-60 %
8.4 Measuring the Quality of Services of Operation Theatre The following Indicator values will be calculated every month to measure the quality of service in the Operation theatre:
8.4.1 Percentage of Re-scheduling of Surgeries: Re-scheduling of patients included cancellation and postponement of cases beyond four hours of surgery.
Formula: Number of cases Rescheduled/Number of surgeries performed X Formula: 100
8.4.2 Prevention of adverse events Percentage of cases where the organization’s procedure to prevent adverse events like wrong patient and wrong surgery have been adhered to. Formula: Number of cases where the procedure was followed/ Number of Formula: surgeries performed X 100
8.4.3 Prophylactic Antibiotic
Percentage of cases who received prophylactic antibiotics within the specified time Formul For mula: a: Number of patients who did receive prophylactic antibiotic(s)/ Formula: Number of surgeries performed X 100
8.4.4 Percentage of unplanned return to OT FormulaFormula- Number of unplanned return to OT/ Number of surgeries performed X 100
8.4.5 Surgical Site Infection Rate: (SSI) Formula: rmula: Number of surgical site Infections in a given month/ Number Fo rmula: of surgeries performed in that month X 100 For Details on SSI Refer to Infection Control Manual
9
HOUSE KEEPING IN THE OPERATION THEATRE
Theatre complex should be absolutely clean at all items. Dust should not accumulate at any region in the theatre. Soap solution is recommended for cleaning floors and other surfaces. Operating rooms are cleaned daily and the entire theatre complex is cleaned thoroughly once a week. 9.1
Before the start of the 1st case
Wipe all equipment, furniture, room lights, suction points, OT table, surgical light reflectors, other light fittings, slabs etc with soap solution. This should be completed at least one hour before the start of surgery. 9.2 Linen & gloves: Gather all soiled linen and towels in the receptacles provided. Take them to the service corridor (behind the theatre) and place them in trolleys to be taken for sorting. The dirty linen is then sent to the laundry. Use gloves while handling dirty linen.
9.3 Instruments Used instruments are cleaned immediately by the scrub nurse and the attender. Reusable sharps are decontaminated in Lysol / hypochlorite.They are then sent for sterilization in the CSSD. The instruments are sent in the
instrument tray for autoclaving. They are then packed and re-autoclaved before use. 9.4 Environment Wipe used equipment, furniture, OR table etc., with detergent and water. If there is a blood b lood spill, disinfect with 1 % sodium hypochlorite before wiping. Empty and clean suction bottles and tubing with disinfectant. After the last case: case : The same procedures as mentioned above are followed and in addition the following are carried out. •
Wipe over head lights, cabinets, waste receptables, equipment, equipment, furniture
with 2 % bacillocid •
Wash floor and wet mop with liquid soap and then remove water and wet
mop with 2 % bacillocid solution. 9.5 Weekly cleaning procedure Remove all portable equipment. •
•
Damp wipe lights and other fixtures with detergent.
•
Clean doors, hinges, facings, glass inserts and rinse with a cloth moistened with detergent.
•
Wipe down walls with clean cloth mop with detergent.
•
Scrub floor using detergent and water .
•
Stainless steel surfaces – clean with detergent, rinse & clean with warm water.
•
Replace portable equipment: Clean wheel castors by rolling across toweling saturated with detergent.
•
Wash (clean) and dry all furniture and equipment (OT table, suction holders, foot & sitting stools, Mayo stands, IV poles, basin stands, X-ray view boxes, hamper stands, all tables in the room, holes to oxygen tank, kick buckets and holder, and wall cupboards).
•
After the above measures are undertaken
Bacillocid spray is done using the bacillocid fogger with 2% bacillocid solution Before spraying the area is swept and the area is mopped with clean water. Evenly does the spray close the room and allow it to dry for 1 hour. After 1 hour mop the floor with plain water with a clean mop cloth.
9.6 HVAC maintenance: HVAC pre filters should cleaned by the people arranged by maintenance once in a week regularly and a nd whenever needed. Maintenance and Repairs •
Machinery and equipment should be checked, cleaned and repaired routinely
•
Urgent repairs should be carried out at the end of the days list
•
Air conditioners and suction points should be checked, cleaned and repaired on a weekly basis.
•
Preventive maintenance on all theatre equipment to be carried out weekly and major work to be done at least once every year.
10 Annexure
10.1 Annexure 1: Surgical Safety Checklist:
