Sterilization of operation theaters
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Sterilization of operation theaters

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  • @undefined Thank you for the support Dr.T.V.Rao MD
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  • Dear Gautam Shah it is nice of your real time experience, one of my
    article on this topic is going to be published in ARAB Journal through the British publisher please send your e mail Dr.T.V.Rao MD
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  • Over the past 45 years, I have designed several Hospitals, Clinics and Healthcare facilities. These were often (then) in power deficient regions as well as for believers (and affording medicos) in controlled AC systems including Curtain flow isolation. I have seen few basic problems in applications.
    1 Window ACs are being replaced with Split systems. But when both of these are switched off at the end of a session, It has lot of condensate water. These water is over or close to the primary filtering grill, full of contaminants and bacteria. Next day / session when the AC is switched on initial temp, for few moments, is not cold enough to form the condensation, rather it evaporates the existing pool of earlier condesated water. These throws massive quantity of pollutants inside the theatre. It negates all the precautions of fumigation or physical scrubbing/ cleaning.
    2 Air curtain systems are intensively promoted by sophisticated equipments suppliers and also supported by published technical literature. However, in reality the system is more dysfunctional. The Air curtain and the related Air handling (supply+ evacuation) systems get disturbed by even single staff person moving in and out. Even placement of a tall Anaesthesia equipment, suction machine trolleys, or coterie just out side the demarcated curtain zone affects the flow. But it is an accepted practice (along with branding or publicity) in Hospitals. Often OTs as small as 20x20 feet have such facilities - and fail miserably due to lack of physical isolation in the space.
    3 In old style fumigation practice the surgeon often supervises the sealing / working of the fumigation equipment on previous day's visit. But on the day of operation the same surgeon or asst.insists on opening of theatre in his presence. But major problem arises how to dilute the Hydrogen Peroxide vapour ? By opening the Doors ? By bringing in large Air-circulator (Pedestal fans)? Or by running the exhaust system of the ACs. None of the options (above) are of short duration or effective. Opening the doors, pollutes the entry passage zone. Air Circulator brought from other sections are never clean. ACs exhaust system (full 100 % replacement like in Cars) is available in few Window ACs only. (commercial ACs seal the facility for greater efficiency.
    Perhaps an ideal & practical solution is to install a large exhaust fan to the exterior (24-30 inch dia. and over 1400 RPM) with a tight fitting shutter on the OT or Interior face. Such a system not only ventilates all odours, pollutants, excess moisture of floor washing and even heat.
    Are you sure you want to
    Your message goes here
    Processing…
  • Over the past 45 years, I have designed several Hospitals, Clinics and Healthcare facilities. These were often (then) in power deficient regions as well as for believers (and affording medicos) in controlled AC systems including Curtain flow isolation. I have seen few basic problems in applications.
    1 Window ACs are being replaced with Split systems. But when both of these are switched off at the end of a session, It has lot of condensate water. These water is over or close to the primary filtering grill, full of contaminants and bacteria. Next day / session when the AC is switched on initial temp, for few moments, is not cold enough to form the condensation, rather it evaporates the existing pool of earlier condesated water. These throws massive quantity of pollutants inside the theatre. It negates all the precautions of fumigation or physical scrubbing/ cleaning.
    2 Air curtain systems are intensively promoted by sophisticated equipments suppliers and also supported by published technical literature. However, in reality the system is more dysfunctional. The Air curtain and the related Air handling (supply+ evacuation) systems get disturbed by even single staff person moving in and out. Even placement of a tall Anaesthesia equipment, suction machine trolleys, or coterie just out side the demarcated curtain zone affects the flow. But it is an accepted practice (along with branding or publicity) in Hospitals. Often OTs as small as 20x20 feet have such facilities - and fail miserably due to lack of physical isolation in the space.
    3 In old style fumigation practice the surgeon often supervises the sealing / working of the fumigation equipment on previous day's visit. But on the day of operation the same surgeon or asst.insists on opening of theatre in his presence. But major problem arises how to dilute the Hydrogen Peroxide vapour ? By opening the Doors ? By bringing in large Air-circulator (Pedestal fans)? Or by running the exhaust system of the ACs. None of the options (above) are of short duration or effective. Opening the doors, pollutes the entry passage zone. Air Circulator brought from other sections are never clean. ACs exhaust system (full 100 % replacement like in Cars) is available in few Window ACs only. (commercial ACs seal the facility for greater efficiency.
    Perhaps an ideal & practical solution is to install a large exhaust fan to the exterior (24-30 inch dia. and over 1400 RPM) with a tight fitting shutter on the OT or Interior face. Such a system not only ventilates all odours, pollutants, excess moisture of floor washing and even heat.
    Are you sure you want to
    Your message goes here
    Processing…
  • excellent ppt
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    Sterilization of operation theaters Sterilization of operation theaters Document Transcript

    • Sterilization  of  Operation  Theatres  Methods to Replace FumigationDr.T.V.Rao  MD                                    In  spite  of  brief  stay  of  patients  in  the  operation  theatre,  the  environment  of  operation  theatre  plays  a  great  role  in  the  onset  and  spread  of  infections,  because  of  a  multifactor  causation  of  infections.  It  is  usually  necessary  to  study  the  epidemiology  of  infection  as  a  multidisciplinary  approach.  In  resource  poor  circumstances  as  in  most  developing  countries,  people  work  in  isolation  and  few  facilities  to  make  any  epidemiological  surveys.  Many  believe  that  routine  Microbiological  monitoring  is  most  essential  but  in  reality  it  is  not  practicable.  But  every  hospital  should  pay  good  attention  in  proper  maintenance  of  air  conditioning  plants,  ventilator  systems,  and  to  have  greater  control  on  mechanisms  and  personnel  involved  in  disinfection  and  sterilization  of  materials  used  in  the  theatres  in  operative  procedures.  Sterilisation  means  eradicating  germs  completely,  which  is  not  100%  possible  in  an  operation  theatre.  The  sources  of  bacterial  contamination  are  from  air  and  the  environment,  infected  body  fluids,  patients,  articles,  equipment  etc.  The  following  methods  are  practiced  to  keep  the  operation  theatre  (OT)  bacteriologically  safe  and  below  accepted  levels:                                                                                                                                                                                    1.  Special  air  flow  pattern  (the  air  flow  pattern  is  such  that  filtered  and  purified  air  circulates  and  contaminated  air  is  removed  continuously).  There  is  restriction  of  personnel  traffic,  closing  of  OT  doors  and  a  good  ventilation  system.                                                                                                                                                                                                              2.  Standard  cleaning,  disinfection  with  appropriate  chemical  agents,  good  theatre  practice,  discipline,  can  provide  a  microbiologically  safe  environment.    Fumigation                                                                                                                                                                                                                                                                                                                  Fumigation  is  an  age  old  process  of  sterilisation,  of  the  environment,  may  be  a  sick  room  or  Operation  theatres.    It  is  done  with  formalin  fumes.  Formalin  fumes  are  very  pungent  and  harmful.  So  when  a  room  is  fumigated,  it  is  tightly  closed  and  sealed  before  fumigation.  The  room  is  opened  after  fumigation  (12  -­‐  24  hours).  The  room  can  be  used  once  all  fumes  are  out.  OSHA  indicated  that  Formaldehyde  should  be  handled  in  the  workplace  as  potential  carcinogen  and  set  an  employee  exposure  standard  for  Formaldehyde  that  limits  an  8-­‐hour  time-­‐  weighted  average  exposure  concentration  of  0.75ppm.  Commercially  available  disinfectant  Formaldehydes  are  the  most  commonly  used  agents  for  high  level  disinfection  of  the  theatre  environment.  Formaldehyde  is  the  commonly  used  agent.  Formaldehyde  gas  is  generated  from  liquid  formalin  utilizing  potassium  permanganate  crystals.  40%  formalin  liquid  is  added  to  potassium  permanganate  crystals  to  generate  gas.  Alternately,  formalin  liquid  can  be  dispersed  by  a  sprayer  like  device  in  the  theatre  environment.  After  a  contact  time  of  at  least  6-­‐8  hours,  the  formaldehyde  needs  to  be  neutralized  by  using  ammonia,  
    • allowing  at  least  2  hours  contact  time  for  ammonia  to  neutralize  the  formaldehyde  prior  to  the  use  of  theatre.                                                                                                                                                                                                                                                                                                                                                              How  the  Fumigation  was  done    1  Seal  the  room  with  adhesive  tapes  round  the  edges  of  the  doors  /  windows  and  ventilators  and  apertures.  2  For  Each  1000  cu.ft  of  space  place  500ml  formaldehyde  (40%  solution)  and  1000ml  of  water  in  an  electric  boiler.  Switch  on  the  boiler,  leave  the  room  and  seal  the  door.  3.  Seal  the  room  for  24  hrs.    4.  Then  open  the  door  and  neutralize  any  residual  formaldehyde  with  ammonia  by  exposing  250ml  of  S.G  880  ammonia/  1Lt  of  formaldehyde  used.  (Ref  -­‐  Mackie  and  McCartney  Practical  Medical  Microbiology  13th  Edition)    5.  Fumigation  is  obsolete  in  many  developed  nations  in  view  of  toxic  nature  of  Formalin.  Too  frequent  use  and  inhalation  is  hazardous    6  Several  new  safe  chemicals  are  emerging  but  constrains  of  economy  limit  the  use  and  several  hours  of  closure  of  operation  theatres  can  be  curtailed  as  with  Fumigation.  Aldehydes  are  potentially  carcinogenic  and  it  is  therefore  recommended  that  other  agents  such  as  hydrogen  peroxide,  hydrogen  peroxide  with  silver  nitrate,  peracitic  acid  and  other  chemical  compounds  of  formaldehyde  should  be  used  in  place  of  the  currently  prevalent  practice  of  using  formaldehyde.  These  agents  are  dispersed  with  the  aid  of  a  fogger-­‐like  device  inside  the  theatre  environment.  The  contact  time  is  about  an  hour  and  the  theatre  can  be  used  immediately  after  the  contact  time.  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  everyone  contributes  to  Infection.  3.  A  thorough  washing  with  warm  water  and  good  detergent  can  bring  overall  improvement  than  mere  decontamination  sterilization  with  other  Chemicals  or  fumigation.    4.  Frequent  monitoring  and  training  of  medical  and  paramedical  staff  must  carry  high  priority  than  mere  mechanical  and  chemical  methods.  
    • 5.  Thorough  washing  and  carbolisation  if  done  every  day  after  the  surgeries  will  greatly  enhance  the  safety  standards  and  economize  the  repeated  expenditure  on  fumigation  Emerging  Compounds  in  use  for  Sterilization  of  Operation  theatres  Bacillocid  rasant  A  newer  and  effective  compound  in  environmental  decontamination  with  very  good  cost/benefit  ratio,  good  material  compatibility,  excellent  cleaning  properties  and  virtually  no  residues.  It  has  the  advantage  of  being  a  Formaldehyde-­‐free  disinfectant  cleaner  with  low  use  concentration.  Active  ingredients:  Glutaral  100  mg/g,  benzyl-­‐C12-­‐18-­‐  alkyldimethylammonium  chlorides  60  mg/  g,  didecyldimethylammonium  chloride  60  mg/g.  Advantages  -­‐  Provides  complete  asepsis  within  30  to  60  minutes.  -­‐  Cleaning  with  detergent  or  carbolic  acid  not  required.  -­‐  Formalin  fumigation  not  required.  -­‐  Shutdown  of  O.T.  for  24  hrs.  not  required.  :  Provides  complete  asepsis  within  30  to  60  mts.    Cleaning  with  detergent  or  carbolic  acid  not  required  ®  Formalin  fumigation  not  required  ®  Shutdown  of  O.T.  for  24  hours  not  required  with  Bacillocid  ®  Other  Newer  and  Non  Toxic  compounds.    A  Chemical  compound  VIRKON  gaining  importance  as  non-­‐Aldehyde  compound.  Virkon  proved  to  be  safe  Virucidal  Bactericidal,  Fungicidal  Mycobactericidal  Newer  and  Non  Toxic  compounds.  Virkon  is  a  multi-­‐purpose  disinfectant.  It  contains  oxone  (potassium  peroxymonosulphate),  sodium  dodecylbenzenesulfonate,  sulphamic  acid;  and  inorganic  buffers.  It  is  typically  used  for  cleaning  up  hazardous  spills,  disinfecting  surfaces  and  soaking  equipment.  The  solution  is  used  in  many  areas,  including  hospitals,  laboratories,  nursing  homes,  funeral  homes,  medical,  dental  and  veterinary  facilities,  and  anywhere  else  where  control  of  pathogens  is  required.  Virkon  has  a  wide  spectrum  of  activity  against  viruses,  some  fungi,  and  bacteria.  However,  it  is  less  effective  against  spores  and  fungi  than  some  alternative  disinfectants.  Several  other  compounds  are  emerging  in  the  Market  for  safer  use,  may  need  better  resources  for  utility  and  implementation.    Operation  theatres  should  be  built  with  implementation  of  good  civil  Engineering  standards.  OPERATION  THEATRE  -­‐  DISCIPLINE  1.  Only  people  absolutely  needed  for  an  assigned  work  should  be  present  in  the  Operation  Theatres  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.  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  SURVEILLANCE  OF  OPERATION  THEATRE  Role  of  Microbiological  Surveillance  The  environments  in  the  operation  theatre  are  dynamic  and  subject  to  continuous  change.  Good  infrastructures  do  not  mean  a  safe  environment  as  human  make  a  greater  difference  in  making  the  environment  unsafe.  Microbiologists  should  be  aware  of  organisms,  sites  and  populations  as  surveillance  cultures  should  be  chosen  carefully  to  allow  meaningful  interpretation  of  results.  Microbiologists  should  be  familiar  with  the  clinical  techniques  as  those  normally  used  for  culturing  clinical  specimens  may  not  yield  correct  result  when  applied  to  environmental  specimens.  Sites  and  cultured  reports  should  not  be  chosen  as  etiological  sources  in  the  present  infections.  Culturing  unnecessary  surface  areas  causes  confusion  and  meaningful  interpretation  is  lost.  AIR  IS  THE  IMPORTANT  SOURCE  OF  INFECTION  Bacterial  counts  in  operation  theatres  are  influenced  by  the  number  of  individuals  present,  ventilation  and  air  flow,  the  results  should  be  interpreted  taking  the  above  facts  into  consideration.  Surveillance  for  Air  bore  Pathogens:  In  resource  poor  Hospitals  settle  plates  with  blood  agar  are  used  and  can  detect  pathogens,  commensals  and  saprophytic  bacteria.  Multiple  plates  are  kept  and  results  are  based  on  overall  assessment  rather  than  on  a  single  plate  study  in  the  room.  Microbiologists  will  clarify  the  acceptable  counts  at  the  different  physical  locations  in  multispecialty  hospitals.  There  is  a  sea  change  in  analysis  of  bacterial  counts  in  recent  past  with  advances  in  medical  technologies  like  Joint  replacement  surgeries  dealing  with  critical  patients.  Slit  sampler  and  Air  centrifuge  equipment  for  bacterial  counts  are  replacing  settle  plates,  the  safe  level  of  colony  counts  can  be  calculated  as  per  the  standards  created  with  peer  reviewed  studies  by  the  manufacturers.    How  frequently  we  can  do  the  Surveillance  for  Air  borne  Microbes?  Yet  there  is  no  definite  answer  to  this  question  
    • Doing  too  frequent  surveys  are  expensive  and  will  not  correlate  the  existing  infection  rate  in  the  Hospital.  But  can  indicate  the  circumstance  we  operate  which  can  have  bearing  effect  if  the  safety  standards  fall  Surveillance  for  Clostridia  spores  may  be  needed  The  age  old  tradition  of  detection  of  anaerobic  spores  of  C.tetani,  and  Gas  gangrene  producing  organisms  are  losing  ground  with  onset  of  more  awareness  on  theatre  sterilization.  Routine  testing  for  the  Anaerobes  are  not  essential  except  when  there  were  suspected  cases  of  Tetanus  or  Gas  gangrene  attributed  to  operating  in  a  particular  Operation  theatre.  But  it  is  ideal  to  survey  the  Operation  theatres  for  anaerobes  when  newly  constructed  or  any  remodelling  or  structural  alterations  are  done.  In  such  situations  which  will  have  trust  worthy  safety  of  the  theatre.  STERILISATION  AND  DISINFECTION  OF  OPERATION  THEATRES  AND  CRITICAL  CARE  AREAS  GENERAL  INSTRUCTIONS  1.  Keep  the  floor  dry  when  in  use.  2.  Use  only  vacuum  cleaners  (booming  to  be  forbidden  as  it  will  dispense  the  infected  material  all  around  and  on  the  equipment’s.    3.  Chemical  disinfection  of  an  operation  room  floor  is  probably  unnecessary.  The  bacteria  carrying  particles  already  on  the  floor  are  unlikely  to  reach  an  open  wound  in  sufficient  numbers  to  cause  an  infection  Cleaning  alone  followed  by  drying  will  considerably  reduce  bacterial  population.  4.  Wall  and  Ceilings-­‐  Wall  and  ceiling  are  rarely  contaminated.  The  numbers  of  bacteria  do  not  appear  to  increase  even  if  walls  are  not  cleaned.  Frequent  cleaning  is  not  necessary  and  has  little  influence  on  bacterial  counts.  Routine  disinfection  is  therefore  unnecessary,  but  only  cleaned  when  dirty.    ENVIRONMENTAL  CLEANING  OF  OPERATION  THEATRES  At  the  Beginning  of  the  Day  1.  Only  remove  the  dust  with  cloth  wetted  with  clean  water.  (Mop  theatre  furniture  lamps,  sitting  tables,  trolley  tops,  operation  tables,  procedure  tables,  and  Boyle’s  apparatus)  Note:  Need  not  use  chemicals/disinfectants  unless  contaminated  with  blood  or  body  fluids  Between  the  procedures  Clean  operation  tables  or  contaminated  surfaces  with  disinfectant  solutions.  1.  In  case  of  spillages  of  blood/  body  fluids  decontaminate  with  bleaching  solution/  chlorine  solution  (10%  available  chlorine)  2.  All  discard  waste  in  plastic  bags  (do  not  accumulate  around  surgical  sites)    
    • 3.  Do  not  discard  soiled  linen  and  gowns  in  the  operation  theatre  floor.    At  the  end  of  the  day  1  .Clean  all  the  table  tops,  sinks,  door  handles  with  detergent  followed  by  low  level  disinfectant.  2  .Clean  the  floors  with  detergents  mixed  with  warm  water.  3.  Finally  mop  with  disinfectant  like  phenol  in  the  concentration  of  1  in  10  (low  concentrations  of  phenol  will  not  serve  the  purpose).  4.  Keep  the  operation  theatre  dry  for  the  next  days  work  TRAINING  OF  PARAMEDICAL  STAFF/  RESIDENTS  1.  The  short  solution  to  control  infection  lies  with  trained  staff.  2.  The  principal  and  control  of  infection  to  all  new  comers  and  junior  staff  should  be  a  goal  of  any  good  Institution.  3.  Formulate  guidelines  update  as  per  the  changing  situation  in  control  the  infection.  4.  Institute  should  formulate  ideas  on  infection  control  to  the  need  of  circumstances,  as  there  are  no  fixed  guidelines  or  formulae  to  control  to  suit  all  occasional.  5.  Simple  repeated  hygienic  hand  wash  is  most  cost  effective  method  to  reduce  several  infections  in  Hospitals,  in  particular  operation  theatres  Dr.T.V.Rao  MD  Professor  of  Microbiology    Bibliography    1  Principles  and  Practice  of  Disinfection,  Preservation  and  Sterilization,  3rd  edn.  A.  D.  Russell,  W.  B.  Hugo,  G.  A.  J.  Ayliffe,  Eds.  Blackwell  Scientific  Ltd.,  Oxford,  1999.  ISBN  063  2041  43,  2  Disinfection,  sterilization  and  operation  theater  guidelines  for  dermatosurgical  practitioners  in  India  Narendra  Patwardhan1,  Uday  Kelkar2  Year  :  2011    |    Volume  :  77    |    Issue  :  1    |    Page  :  83-­‐93  3  Guideline  for  Disinfection  and  Sterilization  in  Healthcare  Facilities,  2008,  William  A.  Rutala,  Ph.D.,  M.P.H.1,2,  David  J.  Weber,  M.D.,  M.P.H.1,2,  and  the  Healthcare  Infection  Control  Practices  Advisory  Committee  (HICPAC)3  (CDC  2008)  4  Assessment  of  in-­‐vitro  efficacy  of  1%  Virkon  against  bacteria,  fungi,  viruses  and  spores  by  means  of  AFNOR  guidelines.  Herńndez  A,  Martró  E,  Matas  L,  Martín  M,  Ausina  V.  PMID    11073729    [PubMed  -­‐  indexed  for  MEDLINE]  5  Evaluation  of  in  vitro  efficacy  of  the  disinfectant  Virkon.  Gasparini  R,  Pozzi  T,  Magnelli  R,  Fatighenti  D,  Giotti  E,  Poliseno  G,  Pratelli  M,  Severini  R,  Bonanni  P,  De  Feo  Eur  J  Epidemiol.  1995  Apr;  11(2):193-­‐7.      
    • Correspondence      Dr.T.V.Rao  MD  Professor  of  Microbiology  Travancore  Medical  College  Kollam  Kerala  Email  doctortvrao@gmail.com