Sterilization of Operation Theatres

Dr.T.V.Rao MD
Professor Microbiology Travancore Medical college Kollam, India

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HAND WASHING- Semmelweis

Practices, emphasizes the importance of washing hands with chlorinated water in Obstetrics to reduce maternal mortality
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Beginning of Safe Operation Theatre Practices

1867 Dr.Joseph Lister first identifies airborne bacteria and uses Carbolic acid spray in surgical areas 1880 Johnson and Johnson introduce antiseptic surgical dressings.
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Historical Aspects Changed the History

Lister era 1868 changed the concept of safe surgical procedures. Carbolic Acid in decontamination caused Reduction of Hospital associated infections Mortality reduced Morbidity reduced.

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Sterile Environment reduces Surgical site infections.

Surgical site infections SSI are the second most common cause of hospital acquired (Nosocomial) infections. These complications of surgical procedures cause considerable morbidity and, when these occur deep at the site of the procedure, can lead to mortality as high as 77%.
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Source of Surgical site Infections

The source of SSIs may be endogenous (normal flora of the patients skin, mucous membranes, or hollow viscera) or exogenous, which includes surgical personnel (especially members of the surgical team), the operating room environment (including air), and tools, instruments, and materials brought to the sterile field during an operation.
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Our efforts Make Difference

By maintaining sterile environment in operation theatre we can control major part of exogenous infections.
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What is wrong with our Practices

Disinfectants used indiscrimately, Used unnecessarily Not used when needed. Concentration not adequate Economic consideration, Business promotions. Laboratory testing X Hospital conditions may not correlate.
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Economical loss
Money wasted on unnecessary use. People concentrate on Floors, Inanimate objects, If the resources are not spend with scientific understanding the limited resources are lost in particular developing countreis. Dr.T.V.Rao MD

Basic Principles
Cleaning more Important than Disinfection and Sterilization ? However
Cleaning Removes contaminants, Dust, organic matter, Disinfection Reduces number of Dr.T.V.Rao MD microbes

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Disinfection x Sterilization
Sterilization is absolute, removes microbes and spores too. To achieve Sterilization is Expensive, not sustainable, many times not needed. An effective Disinfection reduces the infections drastically.
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Basic care of Operation Theatres.

Reduction of Microbial counts is important. Very rarely the Microbes reach the operation site, Paying great attention to Floors Using unnecessary, too many chemical not necessary Keep the floor Clean and Dry - Bacteria are reduced,
Most Important component of Bacteria is water a dry areas causes natural death except spores
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Frequent cleaning of Walls and Roof of Operation Theatre is not needed

Frequent cleaning has little effect. Do not disturb these areas unnecessarily, Floors get contaminated quickly, depend on Number of persons present in the Theatre / Movements they make, has direct relation to increase of bacterial counts
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Do not disturb the Roof

Do not disturb unnecessarily, Do not use ceiling fans they cause aerosol spread Clean only when remodeling or accumulated ,good amount of dust.
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Care of Floors
Do remember only 1 % of the microbes present on the floors are pathogenic. On many occasion S.aureus. Isolated as a prominent pathogen Floor should be decontaminated with Vacuum cleaner. and Wet cleaning techniques Keep the mops dry when not in use.
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How you care for Floors

Use only vacuum cleaners
Don't broom
As it increases the bacterial flora in the environment
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Cleaning the Floor

A simple detergent reduces flora by 80 % Addition of disinfectant reduces to 95 % In busy Hospitals counts raise in 2 hours
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Handling of Air in Operation theatre.

Negative Air pressure vented to the operation theatre. Environmental cleaning should be twice daily
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Environmental cleaning of Hospital with Chlorinated compounds.

Disinfectant Sodium hypochlorite Purpose Contaminated with Blood and body fluids

Bleaching powder 9 grams/lit

Toilets, bathrooms

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Environmental cleaning of instruments and equipment in OT Disinfectant Alcohol 70% used in cleaning Metal surfaces and Trolleys However expensive for hospitals in developing countreis
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Fumigation

a biohazard procedure ?

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What Is Formaldehyde?
Formaldehyde has the chemical elements carbon, hydrogen and oxygen in its structure. Hydrocarbons are among the most common of chemical compositions. Formaldehyde is usually sold as an aqueous or watery solution called formalin, which contains 37 to 50 percent formaldehyde by weight. It is soluble in water, but not in most organic solvents, except alcohol and ether.
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Fumigation
Formaldehyde a Age old compound. Low temp heating produce vapor Vapor phase decontaminates the air/environment. Kills vegetative bacteria / Spores ? When Formaldehyde mixed with water and exposed to elevated temperature Gaseous formaldehyde is generated Time X Temp
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Fumigation
To sterilize the operation theatre formaldehyde gas (bactericidal & sporicidal,viricidal) is widely employed as it is cheaper for sterilization of huge areas like operation theatres. Formaldehyde kills the microbes by alkylating the amino acids and sulfydral group of proteins and purine bases. In spite of the gas being hazardous continues to be used in several developing countreis
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Procedure of Fumigation
Thoroughly clean windows, doors, floor, walls and all washable equipment's with soap and water. Close windows and ventilators tightly. If any openings found seal it with cellophane tape or other material. Switch off all lights, A/C and other electrical & electronic items Calculate the room size in cubic feet (LBH) and calculate the required amount of formaldehyde as given in
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Personal care during fumigation

Adequate care must be taken by wearing cap, mask, foot cover, spectacle ., Formaldehyde is irritant to eye & nose; and it has been recognized as a potential carcinogen. So the fumigating employee must be provided with the personal protective equipment's.
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Creating the Formaldehyde gas

Electric Boiler Fumigation Method: For Each 1000 cu.ft of the volume of the operation theatre 500ml of formaldehyde (40% solution) added in 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door. After 45 minutes (variable depending to volume present in the boils apparatus) switch off the boiler without entering in to the room .
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Methods on Fumigation
In principle we have to generate Formaldehyde gas. Can be done by Most easier way to mix the needed quantity of Formalin to water and heating at lower temperatures at 800c 900c Can done also with addition of Formalin to potassium permanganate
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Adding Potassium Permanganate to formaldehyde..

Potassium Permanganate Method: For every 1000 cubic feet add 450gm of Potassium permanganate (KMnO4) to 500 ml of formaldehyde (40% solution). Take about 5 to 8 bowels (heat resistant; place it in various locations) with equally divided parts of formaldehyde and add equally divided KMnO4 to each bowel. This will cause auto boiling and generate fume. After the initiation of formaldehyde vapour, immediately leave the room and seal it for at least 48 hours.

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Fumigation to be neutralized
Neutralize Residual formalin gas with Ammonia by exposing 250 ml of Ammonia per liter of Formaldehyde used. Place the ammonia solution in the centre of the room and leave it for 3 hours to neutralize the formalin vapour
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An example is set as..

Operation Theatre Volume = LBH = 20 15 10 = 3000 cubic feet Formaldehyde required for fumigation = 500 ml for 1000 cubic feet = So 1500 ml of formaldehyde required Ammonia required for neutralization = 150ml of 10% ammonia for 500 ml of formaldehyde = So 450 ml of 10% ammonia require
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Need for Newer Chemical Agents in Hospital Use

1. A need for Non Aldehyde based Chemicals is growing concern 2 Need for quicker sterilization methods with ever increasing work loads. 3. Need for non toxic safe agents.
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Several Chemicals are available but the Economic Limitation are great hurdle in exploring the Utility in Developing countries

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Bacillocid rasant
Formaldehyde-free disinfectant cleaner with low use concentration very good cost/benefit ratio good material compatibility excellent cleaning properties virtually no residue
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Bacillocid rasant
Active ingredients: Glutaral 100 mg/g, benzyl-C1218-alkyldimethylammonium chlorides 60 mg/g, didecyl-dimethylammonium chloride 60 mg/g. Bacillocid rasant is suitable for the disinfectant cleaning of washable surfaces using the wet-wipeprocedure. Especially suitable for economic short-term disinfection in risk areas that are likely sources of infection
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Newer and Non Toxic compounds.

A Chemical compound VIRKON gaining importance as non Aldehyde compound. Virkon proved to be safe Virucidal Bactericidal, Fungicidal Mycobactericidal

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VIKRON is Finding Place in

As a Chemical disinfectant. Disinfects Medical devices. Disinfects Laboratory equipment. Decontaminate spillages with Blood and body fluids. Finding usefulness in replacing autoclaving and saving time.
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Care of the self and surroundings

Theatre dress (includes head cap, mask, apron, chapel, should be made available for all persons who are entering into the operation theatre (surgeons, anaesthetist, microbiologist team, nurses, theatre assistants& helper). Surroundings should be clean and free from garbage, open drainage, bushes, shrubs, wastes, Do not keep any material which are not necessary for operation theatre procedures Operation theatre should be cleaned and fumigated as the prevailing conditions of working and work load, Dr.T.V.Rao MD 38 Depends on septic cases handled in the theatre

Safety of Air conditioning and Water cooling systems

Legionnaires disease is associated with Air Conditioning system Chlorination / Heating of water may prove better alternatives.

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Between procedures in the Operation Theatres.

Clean operation tables, theatre equipment with disinfectant solution with detergent, In case of spillage of blood / body fluids decontaminate with bleaching powder/chlorine solution ( 10 % available chlorine ). Always discard wastes in prescribed plastic bags Dont accumulate biohazard waste in the operation theatres. Dont discard discarded soiled gowns in the operation theatre.
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At the End of the Day in Operation theatre.

Clean all the table tops sinks, door handles with detergent / low level of disinfectant. Clean the floors with detergents mixed with warm water, Finally mop with disinfectant like Phenol in the concentration of 1 : 10 Low concentration of Phenol serve as perfume and not as disinfectant.

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Infection control programmes

1 Monitoring of Hospital associated infections. 2 Training of Health care workers. 3 Investigations of outbreaks. 4 Any technical lapses. 5 Monitoring of staff health 6 Education on Universal Precautions 7 Advise on isolation of Infectious patients. 8 Waste disposal 9 Safe use of Antibiotics / Antibiotic

policy.

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Role of Microbiology Departments.

Identifies the pathogens Monitoring of Antibiotic therapy,

Education on specimen collection and transportation,

Information on common Antibiogram patterns Data on Hospital Infection Surveillance of the Hospital environment Counseling of the Infected Hospital Staff.
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Settle plates for bacterial counts are used by Microbiologists

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Recent advances in Air Sampling

There is a sea change in analysis of bacterial counts recent past with advances in medical technologies as in Joint replacement surgeries dealing with critical patients, Slit sampler and Air centrifuge equipment for bacterial counts are replacing settle plates. The safe levels of colony counts can calculated as per the standards created with peer reviewed studies by microbiologists and manufacturers.

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Slit Sampler
Very Effective / Highly sensitive Fixed volume of air is sucked and bacterial counts are made
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Surveillance of Operation theatre Examination of Air

Estimations are done for detection of bacteria carrying particles in Air. Factors influence Number of persons present. Body movements, Disturbances of clothing.
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Methods of Air surveillance

1 2 Settle plate method. Slit sampler method (from given volume) 3 Counts vary from one to many Settle plates method Record position Time Duration Plates with media as Blood agar exposed for specified period and incubated in the incubator for 24 hours at 37 c

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How many bacteria are pathogenic

Counts vary On number of personal present in the given area. Behavior of the persons. Depend on nature of procedures, type of operations. Varying ranges But remember only 1 % are pathogenic Presence of S. aureus makes difference
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Surveillance for Anaerobic spores

The age old tradition of detection of anaerobic spores of Cl.tetani and other gas gangrence producing spores in the operation theatre and closing the theatres is losing relevance with changing understaning and newer concepts Routine and regular testing for Anerobic spores is not essential except when there was suspected case of Tetanus or Gas Gangrene attributed to operting in a particular operation theatre
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Ideal to Survey for Anaerobes

It is ideal to survey the operation theatres for anaerobes when operating in newly constructed or after remodelling and structural alterations are done In these circustances survelaance will increase safety of the theatres.

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Do we need surveillance regularly

Bacteriological surveillance testing at regular internals is not warranted, But warranted when modification of operation theaters are done, In any unforeseen increase of incidence of infection form any particular operation theatre.
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Factors which influence Safety in Hospital Environment

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OPERATION THEATRE - DISCIPLINE

1. Only people absolutely needed for an assigned work should be present. 2. People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres, which will greatly reduce bacterial count. 3. Air borne contamination is usually affected by type of surgery, quality of air which in fact depends on rate of air exchange.
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Every body Partners in Infection Control

All the persons including the least cadre of employers are partners in infection control and should be aware to comply with infection control regulations 4 Prompt disposal of Theatre waste out of the theatre is of top priority. Any spillage of Body fluids including Blood on the floors is highly hazardous and prompts the rapid multiplication of Nosocomial pathogens in particular Pseudomonas spp
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Good Hand Washing Practices Save many Lives

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Choice of Soap
Simple soap routinely used. Medicated Soap warranted in specific circumstances Soap advertisement claims are they real? To frequent use of medicated soaps are injurious to skin and cause allergic dermatitis

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Which hand wash solution is best ?

1 Alcohol with Chlorhexidine. 2.Alchool without Chlorhexidine. 3 Chlorhexidine 2 % 4 Chlorhexidine 4 % 5 Povidone with Iodine 7.5 % 6 Triclosan 1 % Or Anything NEW
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BEST HAND WASH IS

Which suits the Circumstances. Availability of Resources. Economical. Safe to you. Some chemical containing compounds can cause sensitization and Allergic reactions.
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Confused with promotions of commercial interests ?.

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Use your Wisdom

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Who/What is Important in prevention of Infections

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Remember we are More important than many Chemicals

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THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED THE RATES OF INFECTION 1. Every Hospital must constitute Infection control committee to monitor the events in the Hospital, on all matters related to control of Infections. 2. The entry of unnecessary personnel to be restricted into operation theatres as every one contributes to Infection. 3. A thorough washing with warm water and good detergent and carbonization can bring overall improvement than mere fumigation
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 Frequent monitoring and training of medical and paramedical staff must carry high priority than mere mechanical and chemical methods. 5. Thorough washing and carbonization if done every day after the surgeries will greatly enhance the safety standards and economize the repeated expenditure on fumigation.
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Sterilization and Disinfection policies.

Create you own Infection control team which suits your Hospital, Infection control team decides the policies. Educate the staff on Methods and policies in Hospital safety and Hygiene Educate the staff on few useful option, many theoretical ideas confuse. To many Chemicals Costly, need not be effective.
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Importance of Staff Education

Specify the staff for duties and responsibilities. Education is a matter of continuity Train under the seniors observation. Train the staff with scientific goals
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Operation Theatre Safety is Responsibility Of

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Everyone

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Frequent Washing of Hands saves several Lives Universally

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