Theatre Infection Control Policy

Read in conjunction with Trust Infection Control Manual and Trust Infection Control policies.

Scope of policy:

Applies to all operating theatres, including day procedures and recovery

Prepared by Infection Control: SC/JT/MO

with Jim Rainer/Julie Russ
Approved by ICC January 2005

February 2005

Review date 2007

 Theatre Infection Control Policy

INDEX Page

Skin decontamination & use of antiseptic agents: 2

- Hand hygiene: surgical scrub 3

- Skin preparation and use of antiseptic agents

Infection control policies in theatre areas: 4

- Sharps use and disposal

- Clinical waste
- Blood spillage

Theatre wear and codes of practice: 5

- Theatre wear
- Visitors 6
- Dress when leaving theatre areas 7
- Movement in theatre 7
- Order of patients on operating list (dirty/clean
cases; patients with MRSA) 8
- Patients with blood-borne viruses

Environmental cleaning and decontamination 9

- Cleaning between patients 9

- Daily cleaning schedule 10
- Annual cleaning & maintenance
- General guidance: standards of cleanliness 11

Ultra Clean Ventilated (UCV) theatre (theatre 4)

12
- Codes of practice
- Air quality monitoring

Governance: roles and responsibilities

Page 1 of 14

How long the preoperative wash
or ‘surgical scrub’ should be and
what type of antiseptic should be
used is not universally agreed.
See also Trust Hand
Hygiene Policy.
Handwashing should be for
minimum of 2 minutes
(studies show this duration is
effective in reducing hand
bacterial colony counts); the
optimal duration for washing is not
known.
Alcohol gel handrubs are an
acceptable alternative to repeated
hand washing.
Skin decontamination & use of antiseptic
agents: preoperative hand hygiene
Hand decontamination is an important contributor to
reducing infections. Hands must be decontaminated by
an appropriate method.
Chlorhexidine gluconate 4% “Hibiscrub”
Povidone iodine 7.5% “Betadine”
Box 1: Recommended antiseptic agents for surgical scrub
Recommendations for pre operative surgical scrub
• Agents or methods of skin decontamination that
cause skin abrasions should not be used.
• Using a scrubbing brush on the skin is not
recommended.
• The first wash of the day should include a thorough
clean under the fingernails; a brush or orange stick
can be used.
• Nailbrushes should be single use disposable.
• An approved antiseptic agent (see box 1) should be
used for handwashing.
• ‘Surgical scrub’ handwash should be for a minimum
of 2 minutes, however, there is no evidence that
more than a two minute wash (decontamination)
using aqueous disinfectants is required.
In between cases, use of alcohol gel hand rub, applied
using correct technique, is considered adequate in the
operating theatre where the surgeon’s hands are clean
and have already been decontaminated by conventional
methods.
If skin irritation, dermatitis or sensitivity to a particular
hand cleaning product or antiseptic agent occurs seek
advice from Occupational Health and Safety.
Page 2 of 14

It is important to allow sufficient
time for alcohol based skin
preparations to dry thoroughly
after application and before
commencing the procedure to
ensure that all combustible
ingredients have evaporated.
Antiseptic ‘cocktails’ should not be
used because many antiseptics
are mutually inactivating. (If
several consecutive applications
are made to the same body site,
the same agent should be used).
Multiple-use containers are liable
to contamination each time they
are opened.
Skin preparation & use of antiseptic
agents:
Alcohol solutions are more effective than and preferable
to aqueous solutions for skin preparation (see table 1).
They should be allowed to dry thoroughly.
Box 2: Recommended antiseptic agents for skin
preparation
Chlorhexidine gluconate 0.5% w/w in spirit 70%.
Povidone iodine 7.5%.
Recommendations for use of antiseptic agents
• Gross contamination at the site of incision should be
removed before the antiseptic skin preparation.
• Apply the antiseptic skin preparation in concentric
circles moving away from the proposed incision site
to the periphery; allow sufficient prepared area to
accommodate an extension to the incision or new
incisions or drain sites to be made.
• Allow the alcohol to dry after application and before
the use of electrocautery.
• The application of the skin preparation may need to
be modified according to the condition of the skin
(e.g. burns) and the location of the incision site (e.g.
face or mucous membranes).
Ideally antiseptics should be supplied at ready-for-use
dilution in small, single-use containers with dispensers
attached where necessary. The 500ml bottles should
normally be changed at least daily.
Multi-use bottles of antiseptics - if used:
• Label with date first opened
• Use within the ‘Use by Date’ or discard once
‘use by date’ reached
• Never refill or ‘top up’; discard container and
dispenser after use or when use by date has
been reached.
Page 3 of 14

See ‘Sharps use, sharps injury
and contamination incident
Policy’ in Infection Control
Manual
Treat all sharps with care and
avoid practices such as passing
‘sharps’ from person to person
Report any sharps
inoculation injury
promptly according
to Trust policy.
Surface contamination by blood or
body fluids should be dealt with
promptly and removed as soon as
possible.
Chlorine solution may damage
equipment and some metal
surfaces so it is important to rinse
surfaces well after cleaning
splashes or blood spillage.
Infection control policies: theatre areas
Sharps use and disposal
• Ensure removable blades can be easily detached
using an appropriate device.
• Use an appropriate size and type of ‘sharps’ bin/box
for the area and anticipated volume of usage
• Do not place ‘sharps’ bins/boxes in areas where
there may be an obstacle to environmental cleaning.
• Avoid overfilling: the sharps containers must be
closed securely when three-quarters full.
• Used needles must not be resheathed.
Clinical waste
As per Trust Waste disposal policy.
Blood spillage
• Larger spills: sprinkle with chlorine releasing granules
(NaDCC as ‘PreSept’ or approved brand) until the
fluid is absorbed.
• Small blood splashes or drops: wipe up using fresh
hypochlorite solution 10,000 ppm available chlorine
(as per manufacturer’s instructions on container:
‘PreSept’ or approved brand); apply solution using
disposable paper towels.
• Leave the granules to solidify or paper towels with
hypochlorite solution for a contact time of 2-5 minutes
• Clear up using scoop (granules) or with disposable
paper towels and dispose of as clinical waste. Wipe
the area clean using hypochlorite solution.
• Rinse well using detergent and hot water
(hypochlorite is corrosive). Dry using paper towels.
See also ‘Blood spillage’ in section 5 of
the Infection Control Manual.
Page 4 of 14

Gloves have a dual role:
- as a barrier for personal
protection from patients’ blood
and exudates
- to protect bacteria from the
surgeons hands entering the
surgical site.
Surgical gloves must conform to
BS EN 455-2
There is insignificant evidence to
support the continued wearing of
masks to prevent wound
infection1.
Risk assessment should be
undertaken and if necessary
masks should be worn for the
protection of the wearer.
Staff need to be protected from
inhalation of surgical smoke and
laser plumes
Theatre wear and codes of practice
Theatre wear
Gloves
• Scrub team members should wear sterile surgical
gloves donned after the sterile gown.
• A fresh pair of sterile gloves should be worn for
each procedure.
Wearing double gloves at surgical procedures helps to
reduce hand contamination and protect the wearer from
viral transmission. However double gloving may be
uncomfortable and reduce manual dexterity and tactile
sensitivity.
Puncture of a glove is not necessarily an indication to
change gloves (there is no evidence that perforated
gloves increase the incidence of infection). It may be
preferable to don a second pair of gloves to protect the
operating surgeon or individual undertaking the
procedure.1 If glove punctured: change gloves or put a
second pair over the first pair.
Face Masks
The use of masks to reduce post-operative wound
infections is questionable; studies have shown no
increase in infection rate when masks were not worn for
general surgery.1 Masks do however provide a barrier for
airborne organisms and also protection for the wearer
against blood and body fluid splashes.
• A mask (with a filter size <1.1 microns) may be worn
over the mouth and nose by all members of the
‘scrub’ team; a visor or goggles should also be worn
for added protection where risk of aerosol.
• If worn, a fresh mask should be worn for each
operation.
• The mask should be changed if deemed to have
become contaminated or saturated.
• Although there is no evidence on which to base the
recommendation it would seem reasonable that
surgeons with beards should wear a facemask.
• Masks should not be worn outside theatre area or
left tied around the neck. After surgery, the mask
should be removed and disposed of.
• In vertical laminar flow theatres a mask should be
worn during prosthetic implant surgery.
Page 5 of 14

Disposable headgear is worn by
all theatre staff in most UK
operating departments; different
colours are frequently used to
indicate seniority or identify
students.
Theatre footwear should be
cleaned regularly.
False fingernails have been
shown to harbour pathogens (the
longer they are worn the more
likely it was that a pathogen would
be isolated).
Visitors do not need special
clothing unless entering the
operating theatre itself.
Theatre Caps
• Scrubbed staff should wear disposable headgear
because of their proximity to the operating field,
particularly in a laminar flow field.
• Hats must be worn in laminar flow theatre during
prosthetic implant operations.
• After use dispose of headgear and do not wear
outside theatre.
In terms of infection risk, non-scrubbed staff members of
the operating team do not need to wear disposable
headgear, since effective theatre ventilation probably
counteracts any possible increase in bacterial shedding.
However it is Trust policy for headgear to be worn in
theatre by all staff likely to be near the operation field and
this includes non-scrubbed staff; common sense also
dictates that hair should be kept clean and out of the way.
Theatre footwear
• Special well-fitting footwear with impervious soles
should be worn in the operating department.
• Footwear should be regularly cleaned to remove
splashes of blood and body fluid.
• All footwear should be cleaned after every use, and
procedures should be in place to ensure that this is
undertaken at the end of every session.
Jewellery and accessories
• Necklaces, ear-rings and rings with stones should
be removed;
• Wedding rings may continue to be worn by ‘scrub’
and non-scrub’ staff although surgeons may be
advised to remove these, particularly if working with
metal prostheses.
• Staff in the operating theatre should not wear false
fingernails.
Visitors
Visitors attending the anaesthetic room do not need to
wear special protective wear or footwear and may wear
ordinary outdoor clothes.
If a visitor is to enter any of the main operating theatres,
then they should change into theatre suits.
Page 6 of 14

Perceptions from staff, visitors and
the public concerning ‘theatre
discipline’ suggest that theatre
personnel should wear a fastened,
cover gown/coat over theatre suits
before leaving the department.
Masks and hats should not be
worn outside theatre & recovery
areas.
Operating room doors need to be
kept closed during procedures to
optimise the efficacy of the
ventilation system1,2
A conventionally ventilated theatre
should have an air change rate of
around 20 air changes/hr (1 air
change every 3 minutes) 2. Each air
change will, assuming perfect mixing,
reduce airborne contamination to 37%
of its former level.
Dress when leaving theatre
There is little or no research-based evidence to show that
wearing surgical ‘greens’ outside theatre without changing
into clean theatre suits increases surgical wound infection
rates. However, wearing greens outside theatre and in
public areas can give the impression that discipline is lax.
Although there is insufficient evidence to support the
wearing of cover gowns over surgical attire to prevent
infection when theatre staff leave the theatre area
temporarily, the practice is desirable aesthetically1.
Recommendations:
• Theatre staff should wear a clean white coat
over theatre suit, if leaving the department and
especially in public areas.
• Surgical masks must be removed before
leaving theatre; masks should never be left
tied around neck.
• Hats must be removed when leaving theatre.
Theatre: codes of practice
Movement in Theatre
The main routes of microbial entry into an open clean
surgical wound are from the patient’s skin, from the
surgeon’s hand or by airborne microbes setting into the
wound or onto instruments that will be used in the wound.
Most microbes in theatre air are from staff and few from
the patient; microbial dispersion increases with
movement. Control of movement in, and entry into, the
theatre environment is important in reducing the airborne
contamination routes.
Recommendations:
• Keep operating room doors closed in order to
optimise the efficiency of the ventilating system.
• Keep ‘traffic’ in and out of the operating room to a
minimum during surgical procedures.
Page 7 of 14
The two most probable routes of
infection transmission between
successive or sequential surgical
patients are via air or from
environmental surfaces.
If theatre ventilation is effective,
air should not be a source of
infection transmission between
sequential patients. This means
that surface contamination is more
likely to pose infection risk.
Surfaces and equipment in direct
contact with the patient should be
cleaned carefully before the next
patient. What is important is that
this should is carried out
effectively after the procedure, not
whether or not the patient is last
on the list.
See MRSA policy “Operating
Theatres and Recovery”
It is unlikely that operating
department staff will always be
aware of whether a patient has
MRSA hence care should be
applied to routine cleaning of
surfaces in direct contact with
patients (see page 9).
Order of patients on operating list: dirty/clean cases
Most microbes in theatre air are from staff and few from the
patient. If theatre ventilation is effective air should not be a
source of infection transmission between patients, regardless
of whether the procedure is “dirty” or clean.
Surface contamination is more likely to pose risk of
transmission of infection than air: surfaces such as operating
tables and other furniture, and instruments that make direct
contact with more than one patient have potential for
transmission of infection between ‘dirty’ and subsequent
cases. The only practical way of reduction of microbes is by
cleaning and disinfection of the relevant environmental
surfaces.
Recommendations:
• The operating table, surfaces & items of
equipment in direct contact with the patient should
be cleaned* between patients.
• Putting patients last on the list may facilitate
cleaning but is not always necessary if cleaning
between patients is adequate.
(*See ‘cleaning between patients’ on page 9).
Traditionally “dirty” cases are put last on the list; however it is
not always necessary to put the “dirty” case last on list
provided the cleaning of relevant surfaces can be done
adequately before the next patient. If it is judged that these
processes can be carried out adequately during a list, there
should be no extra hazard.
If “dirty” cases (i.e. patients likely to disperse microbes of
particular risk to other patients) are placed last on a list, this
may facilitate the process of adequate cleaning/
decontamination of the relevant surfaces.
A conventionally ventilated operating theatre does not
need to lie fallow for more than 15 minutes before a clean
procedure is performed following a dirty operation.
Vertical laminar flow theatres need only 5 minutes to
replace the full volume of air in the theatre.
Patients with MRSA
Treat as above (see box). Provided there are routine high
standards of cleaning between patients, it is not necessary to
put patients with MRSA last on list unless they meet the
specific risk criteria below:
Put last on list:
• Patient has extensive eczema or other exfoliative skin
disorder colonised with MRSA
• Patient with MRSA is undergoing orthopaedic or joint
replacement surgery
• Patient has tissue infection with MRSA and/or where
aerosol-dispersing power tools are used on infected tissue.
Page 8 of 14

Patients with other infections
Follow recommendations on page
8. Seek advice from Infection
Control where necessary.
If the patient has an infection that
may be transmitted by respiratory
droplet or secretion (e.g. TB or
VZV/chickenpox):
Seek advice from the Infection
Control Nurse or Doctor (Refer
also to Infection Control Isolation
policy).
After the patient has left and
before the next patient, surfaces
such as the operating table and
any equipment in direct contact
with the patient should be cleaned
with detergent.
Surfaces that do not have direct
patient contact (e.g. floor, wall and
light) do not become more
contaminated after dirty than after
clean operations.
Patients with blood-borne virus: Hepatitis B, C or HIV
• Treat in the same way as any other patient, with
universal blood precautions.
• Take due care with sharps and ensure that all
measures are in place to minimise risk of needlestick
injury or contamination with blood: the
operating/scrub team should be experienced and the
procedure should be unhurried; the scrub team may
wish to double-glove; risk assessment should
determine whether water impermeable gowns should
be worn.
• Scrub team should know the correct procedure to
follow in the event of an inoculation or ‘sharps’
incident if there has been exposure to HIV.
Environmental cleaning and
decontamination
Cleaning between patients
Surfaces such as the operating table and any equipment
that has been in direct contact with the patient:
• Clean carefully after the patient has left, using an
approved detergent (e.g. ‘Hospec’) and hot water
using a disposable cloth OR using a disposable
detergent wipe. Wipe the area thoroughly and allow
to dry.
• It is not necessary to use disinfectants in addition,
unless there has been contamination with blood/body
fluid spillage or aerosol (see “blood spillage” on page
4).
• After cleaning, the surface should be dry before the
next patient;
• 15 minutes is sufficient for conventionally ventilated
theatres (1-3) to lie fallow after “dirty” cases and
before the next case; 5 minutes for theatre 4 (UCV).
Page 9 of 14

Box 3: recommendations for use of
mops
Mops should be colour coded:
each theatre area should have a
separate colour code, with mops
kept for one theatre.
After use mops should be
decontaminated by hot wash:
return to laundry daily.
Store mops in a designated area:
store upright with mop heads in
air and kept dry.
Mop buckets should be emptied,
cleaned and dried after each
use. Store inverted
See also table 1 “General
guidance: standards of
cleanliness” on page 12
Environmental Cleaning
Cleaning at end of session:
Daily schedule for recommendations
Operating theatre floors
• Operating theatre floors should be cleaned using an
approved detergent (e.g. ‘Hospec’) and hot water.
Floor scrubbing machines, where used, should have
detergent reservoirs that can be cleaned.
• Use mops according to recommendations in table 3
• The whole of the floor including corners and edges
must be cleaned
Horizontal surfaces and fixed equipment
• Damp dust horizontal surfaces using a disposable
cloth (lint free) for all operating theatre cleaning.
• Clean all fixtures and any equipment in theatre by
wiping with an approved detergent (e.g. ‘Hospec’),
hot water and disposable cloth.
Overhead lights and canopy
• Damp dust lights and fittings using an approved
detergent (e.g. ‘Hospec’), hot water & disposable
cloth.
• Check for splashes and contamination. Clean using
an approved detergent (e.g. ‘Hospec’), hot water and
disposable cloth. Where there may have been
spillage or contamination with blood/body fluids wipe
surface with dilute hypochlorite solution 1,000 ppm
available chlorine (1 ‘PreSept’ NaDCC table/litre
water), then rinse well (wipe with cloth and water);
allow to dry.
Anaesthetic room, prep room/other areas
• Clean floor using an approved detergent (e.g.
‘Hospec’) and hot water. Follow recommendations in
table 3; use different colour code mops to those used
to clean operating room.
• Ensure no visible dust/dirt on floor
• Damp dust horizontal surfaces and fittings. Wipe
clean ventilator grills.
Page 10 of 14

Theatre trolleys need to be kept
clean.
Trolleys going into UCV theatre
should be designated for use in
that theatre only.
Recommendations for Theatre trolleys
• Wipe over daily using an approved detergent
(e.g. ‘Hospec’) and hot water on disposable
cloth or paper towel
• Ensure any visible splashes or visible dirt is
removed and the trolleys are clean

• Regularly check fabric of trolleys used in theatre

to see if torn or any defects; if any defects are
identified, the trolley should be repaired or
replaced.

Environmental Cleaning

Annual cleaning and maintenance:

Annual maintenance & cleaning of
Schedule
operating theatres should take
There should be a planned schedule for thorough
place at least twice per annum
cleaning of walls, doors and ceilings at least once every 6
and requires planned downtime.
months.
Arrangements should be made for this. At the same time
any defects, repairs and planned maintenance work
should be undertaken.

Recommendations:

Walls, doors and ceilings:

• Washing is recommended twice a year or
sooner if visibly dirty or contaminated

General fabric of furnishings fittings and décor:

• An annual down time for inspection, repairs,
decorating and planned maintenance must be
allowed for.

Page 11 of 14
General guidance: table showing
standards for environmental cleanliness

• The operating room must be kept free of

unnecessary equipment and clutter.

• The anaesthetic room/other areas should be free of

clutter and unnecessary equipment to facilitate
cleaning.

• The theatres should be visibly clean and free from

dust.

• Items and equipment must not be stored directly on

floor. Floor areas must be kept free. Storage
areas: items should be stored in racks above floor
height.

• Ventilated grilles in doors should not be occluded or

obstructed by equipment.

• Storage of supplies and consumables in

preparation/ rooms off operating room should be
kept to minimum, with appropriate stock rotation to
ensure no build up of dust or bio-burden on items
stored.

• The fabric in theatre should be kept in good state of

repair. Any chipped tiles, defects in floor or fabric
of area should be replaced or repaired.

• Wall seals should be intact and clean.

• Theatre trolleys must be free of dust and without

dirt or spillage; the fabric of the trolley should be in
good condition.

Page 12 of 14

Restriction of traffic and
unnecessary opening of operating
room doors are particularly
important in a plenum-ventilated
theatre to ensure optimal
efficiency.
Annual testing of UCV air quality
should be undertaken to coincide
with planned cleaning and
maintenance.
Theatre manager should initiate
request for testing in conjunction
with Estates Manager
(Engineering) and Consultant
Microbiologist/ICD.
Ultra Clean Ventilated (UCV) theatre 4
Codes of practice: recommendations
• Keep operating room doors closed in order to
optimise the efficiency of the ventilating system.
• Keep ‘traffic’ in and out of the operating room to a
minimum during surgical procedures.
• Trolleys entering theatre should be designated for
use in that theatre only and cleaned after each
patient.
• Personal protective wear/hoods used in orthopaedic
theatres should be hung on a designated wall hanger
in theatre 4 area.
Air quality monitoring
Recommendations:
• Report any malfunction or abnormal readings to
Estates without delay (theatre co-ordinator should
also inform the Consultant Microbiologist/ICD).
• In event of any major work being done on HEPA
filters, theatre co-ordinator should also inform
Consultant Microbiologist /ICD (Estates Manager -
Engineering should also inform ICD).
• Testing of UCV theatre air quality must be performed
annually. Arrangements must be made with Estates
Manager - Engineering and ICD for appropriate
testing to be performed.
• Planned downtime and appropriate arrangements
should be made in conjunction with theatre/clinical
teams/Caregroup managers to support downtime
(24-72hrs) for air quality testing. This should
wherever possible coincide with annual planned
maintenance & cleaning: see also page 11.
• Reports of annual UCV air quality monitoring should
be sent to theatre manager and to the Consultant
Microbiologist (ICD).
Page 13 of 14

Monitoring of standards and
corporate governance:
Systems must be in place to
ensure standards are monitored
and complied with.
Responsibilities
It is the responsibility of all theatre and clinical staff to
ensure standards in this guidance are complied with.
It is the responsibility of theatre co-ordinators to ensure
standards of cleanliness are met or to initiate appropriate
action if standards are not met. (Theatre operational
managers should also perform regular audits of theatre
standards of cleanliness and keep written record of this).
The Infection Control team (ICD or ICNs) will perform
periodic audits of theatre standards (theatre Infection
Control policy/practice) and include findings in annual
report (DIPC). A summary of the roles and
responsibilities is included in the table below.

Table showing summary of standards and responsibilities

STANDARD RESPONSIBILITY

Daily cleaning

(1) Cleaning between patients/end of lists Theatre staff

(2) Monitoring of cleanliness standards; Theatre co-ordinators or deputy

documentation of checks

(3) Periodic audit of standards; inclusion in ICT (ICD (DIPC) and/or ICN)
DIPC annual report

Annual cleaning and maintenance

(1) Arranging downtime for work to take Theatre Co-ordinators in association with
place (twice per year) Associate Director & Patient Planning.

(2) Arranging Estates/other providers to do Theatre operational managers in conjunction

any necessary work during downtime with Associate Director and Estates/ICT.

Air quality monitoring (UCV theatre)

(1) Ensuring Annual testing of air quality (in Theatre co-ordinator to initiate request for
conjunction with (2) above) is performed testing to Estates Manager – Engineering;
responsible for commissioning air quality
testing, in conjunction with ICD (DIPC).

(2) Provision of air quality test report (HTM Estates in conjunction with DIPC
2030) annually to ICC/RMSG.

References

1. “Behaviours and rituals in the Operating Theatre” report from the HIS working group on
Infection Control in the Operating Theatres”

2. “Microbiological Commissioning and monitoring of operating theatre suites” a report of a

working party of the Hospital Infection Society.

Page 14 of 14