The document provides guidelines for operating theatre practices to prevent surgical site infections. Some key points: 1) Proper infection control practices like preoperative patient shower, nasal decolonization for certain surgeries, appropriate hair removal and antiseptic skin preparation can reduce infection risks. 2) Strict adherence to attire, behavioral and environmental standards like proper scrub suits, caps, masks, surgical hand scrubbing and gloving techniques are important for the surgical team. 3) Maintaining optimal temperature, airflow, humidity and air changes in the operating theatre helps control infections. Proper draping and limiting exposure of the surgical site are also recommended.

1. BASIC Operation Theatre GUIDELINES
Prof Dr Y Thamma Reddy
Prof & HOD, Department of Orthopaedics
Osmania Medical College, Hyderabad
Get the Basics Right to Prevent SSI

2. • REQUIRED FOR
• INFECTION CONTROL
• PATIENT SAFETY
• AVOID WRONG SITE IDENTIFICATION
OT GUIDLINES

3. ❑High global epidemiological burden
SURGICAL SITE INFECTION - SSI
• A concern that can be prevented

4. Definition :
Microorganisms enter through the
surgical skin incision
Examples :
Entrance points of external fixator,
infected surgical wound, etc.
SSI - SURGICAL SITE INFECTION

5. 1/3rd of hospital-acquired infections in surgical
patients are SSI.
40–60 % of SSI are preventable
2–5% of operated patients will develop SSI
SSI increases length of stay in hospital by ~ 7 dayS
FACTS ON SSI :

6. •Exogenous:
•Contamination of wound through bacteria from
environment:
–Surgical team
–Operating room environment
–Instruments, material
•Endogenous:
•Contamination of wound through the patient’s own
bacterial skin flora
SOURCE OF INFECTION :

7. What are the guidelines so far to
prevent SSI ? ? ? ? ? ? ? ? ? ? ?

8. SUCCESSFUL GUIDELINES FOLLOWED SO FAR to
prevent SSI
• NICE - UK NHS
• SHEA/IDSA- USA
• CDC - USA
• GDG - Europe
• WHO global guidelines 2016

9. • WHO GLOBAL GUIDELINES FOR PREVENTION OF SSI 2016
• Widely followed as they are
• Meticulous
• Metaanalysis and RCT`s
• LATEST EVIDENCE
• WORLD WIDE REPRESENTATION

10. Patient Preparation to prevent SSI

11. • PRE-OPERATIVE SHOWER OR BATH FOR PATIENTS
• It is good clinical practice for patients to
bath or shower prior to surgery.
• Either plain soap or an antiseptic soap
may be used for this purpose.
• Rationale : Decreases the microbial load
significantly ~ ( NICE 2008/2016; WHO 2016)
• # No recommendation on CHG or antiseptic soap and CHG gowns
to reduce SSI - WHO guidelines 2016

12. Patients undergoing cardiothoracic and orthopaedic
surgery with known nasal carriage of S. aureus
should receive perioperative intranasal
applications of Mupirocin 2% ointment with or
without a combination of CHG body wash.
Mupirocin 2% - twice a day for 5 days
is used for eradication of both
MRSA and MSSA.
Staphylococcous aureus - Nasal carriers :
Decolenisation

13. Strong recommendation :
Cardiothoracic and Orthopaedic
Conditional recommendation with moderate
evidence : Other surgeries as well
especially high risk surgeries
A common practise to reduce Hospital
acquired infections in ICU`s.
is now a guideline to prevent SSI -
Nasal Decolenisation

14. • Common surgical site preparation practices followed :
• Shaving
• Depilation creams
• Clippers (Trimming)
Pre-operative Hair Removal

15. • Not recommended
• Has high role of developing SSI
• Rationale : Causes multiple skin micro abrasions which can
contaminate the surgical site
SHAVING the surgical sites

16. • Costly
• Can be allergic to
many , that can
predispose SSI
• Not recommended.
Depilation creams for removal of hair -
Surgical Sites

17. • Place : OUTSIDE Operation theatre.
• Simple , Inexpensive technique.
• Single patient Clippers to be used to prevent SSI. Catridge can
be changed while the motor can be same.
Clipping of hair - Surgical Site

18. • WHO Guidelines 2016 :
•STRONG RECOMMENDATION :
AVOID HAIR REMOVAL
• If absolutely necessary, when hair interferes with surgery like
neurosurgery, pubic region - It should be only clipped.
Newer evidence - Hair removal

19. Preoperative oral antibiotics combined with
mechanical bowel preparation (MBP) should be used
to reduce the risk of SSI in adult patients undergoing
elective colorectal surgery.
MBP - without oral antibiotic had higher rates of
SSI.
MECHANICAL BOWEL
PREPARATION

20. • MBP - Polyethylene glycol or sodium phosphate were the agents of
choice for MBP in most studies.
• Not proven for paediatric surgeries in the RCT.
• Antibiotics :
• Oral Aminoglycosides (exclusively used for gut preparation) or
IV aminoglysides
• Metronidazole (anaerobic coverage) was used in most studies
basing on which guidelines were issued.
MBP + ANTIBIOTIC

21. • SCRUB SUITES
• Surgical attire fabric should be
free of lint, provide comfort and
allow for “breathability” (allow
the escape of body heat) while
containing the shedding of skin
squames.
• Scrub suits are made of 100%
spunbound polypropylene in
order to decrease the shedding of
skin squames in to the
environment.
Surgical attire - Health care personnel in OT

22. • Attire to be worn in semi-restricted and restricted areas.
• Cotton fabrics typically have large pores and are not tightly
woven allowing the dispersal of skin squames into the
environment .
• They can be machine laundered - Inhouse or commercial. Have to
be laundered daily after use.
• Placing attire in designated receptacle after use to prevent
contamination
Scrub Suites

23. • HOODED Head caps vs Normal head caps
Surgical Suites - HEAD CAPS
CDC Standards for PPE - Personal protective equipment
To be donned first before wearing scrub suites to prevent contamination
Head caps should
be available in
changing rooms

24. • Hooded caps - covers the entire facial hair
• Surgical team washing for a case should wear them .
• Rest of the OR personnel can wear non hooded cap.
Cap once worn can
be used all day long
unless
contaminated with
fluids or spilled
with water

25. • EYE Shielding masks - Protective
to scrubbed health care personnel
particularly when irrigating the
wounds or chances of spillage is
more.
• A new one have to be used for each
case to prevent contamination.
Surgical MASK
CDC Standards for PPE - Personal protective equipment

26. It is recommended that a new mask be used for each procedure
or at the minimum, changed frequently and if it becomes wet
and or contaminated by blood and body fluids.
Hand wash should be done as the mask is being removed to
prevent contamination of hands and thereby spreading germs.
• Regular disposable mask - should cover NOSE and MOUTH

27. Overhanging of mask on neck while
not in Operating rooms is strongly
not recommended - as used masks
harbor multiple microbes that can
be transferred to the scrub suit and
dispersed into the healthcare facility
environment.

28. • A mask should never be touched this
way while removing.
• It harbours loads of organisms filtered
at the time of wear.
• Instead it should be taken off the
strings and disposed in waste disposal.
• A receptacle should be placed
seperately at the exit of OT or changing
rooms for collection of these used
Masks and head caps.

34. Scrubbing - Health care individuals

35. • No Rings , NO Bracelets, NO ornaments
to wrist and hand
• No Sacred threads !!!
• The fingernails should be kept clean, should
not extend beyond the fingertips and
artificial nails should not be worn.
• The subungual area has been identified as
harboring the majority of microorganisms.
Debris should be removed from the
subungual area
• Cuticles around finger tips and nail tips
should be intact
PRE-SCRUB

36. • Nail polish, if worn, should be freshly applied and free of chips.

37. The skin of the hands and forearms
should be intact with no burns,
lesions, abrasions, and cuts
present.
Minor injuries have to be covered in
a sterile way with a
TEGADERM Sterile bandage
after scrubbing & before
gloving
Integrity of SKIN of Scrubbing Personnel

38. LEVEL of SCRUBBING -
Fingertips up to 2’’ above elbow

39. • Time duration of scrub :
• Different for different scrubbing
solutions used.
• First scrub vs Subsequent Scrubs - No
evidential guidelines / consensus
• Research - Meta analysis : No role of
shorter subsequent scrubs.
SURGICAL HAND PREPARATION

40. The hands of the surgical team should be clean upon entering
the OR by washing with a non- medicated soap for 1 minute.
• 5 minutes ideal time of scrub with antimicrobial and water.
• 2 minutes with ABHR (Alcohol based hand rub)
• Every scrub after contamination needs prior one minute of
scrubbing with antiseptic solution.
• Once in the operating area, repeating hand rubbing or
scrubbing without an additional prior handwash is
recommended before switching to the next procedure.
• Association of Professionals of Infection
control (APIC) recommends :

41. • Common practices : 5 Minutes
• Betadine scrub solution ( PVP-1) in aqueous solution
• Povidone-iodine is a chemical complex of
povidone, hydrogen iodide, and elemental iodine.
• Chlorhexidine scrub solution
• washed with RO treated water - to prevent micro organism
contamination.
• Alcohol based hand Rub : 2 Minutes
• 2% Chlorhexidine in 70 % Alcohol
SCRUB SOLUTION -

42. • USE RO treated tap water with optimum temperature.
• Prewash the hands and forearms with non-
antimicrobial soap.
• The scrub should begin at the finger tips and end 2”
above the elbows .
• Spread the scrub from hand to forearm on each side
and start scrubbing from hand above without returning
to a clean area.
Surgical Scrubbing Technique

43. • The fingers, hands and forearms should be visualized as
having four sides (planes) that must be thoroughly scrubbed,
including the web space between each digit.

45. • Hold hands higher than the elbows so that water runs from the
finger tips toward the elbows.
• Additionally, keep the hands and arms away from the scrub
attire, while keeping the elbows in a flexed position to avoid
water from wetting the scrub suit.
• The surgical team member, after entering the OR, should
thoroughly dry hands and arms using aseptic technique prior to
wearing the sterile gown to prevent strike-through
contamination.

46. Performing the surgical scrub without a brush or
sponge is acceptable and has no role in preventing
SSI.
A STERILE cloth or STERILE paper towels or air
dryer - to dry wet hands and forearm are used.
All methods have been proven to further reduce the
microbial count.

47. • After ensuing hands are dried and
Sterilium/ ABHR is air dried, a sterile
gown - either disposable one or a
woven reusable one is worn.
GOWNING of the scrubbed person

48. • Lift the folded gown upwards from the table
trolley by touching only edges of the inner
aspect of gown.
• If a gowned person is already available, he can
open the gown and stretch it so that hands can
be donned in to the sleeves of the gown.
• Step back in to an unobstructable area.
GOWNING TECHNIQUE :

49. Let the gown unfold while keeping inside of the
gown towards the body without touch the
sterile exterior with bare hands.
If the gown doesn’t unfold, the circulating OR
personnel can pull down by touching only
inside of the gown
GOWNING TECHNIQUE :

50. GOWNING TECHNIQUE :
Hold in to the hands of the gown while an assistant pull over through the upper limbs

51. • Circulating OR personnel
can Pull over the gown by
touching the inside of the
gown only and tie at the
back.
• Later the surgeon turns
around and ties the fabric to
front covering all around
without exposing any bare
area.

52. • Prevention of SSI - Disposable non woven gowns & Reusable
woven gowns both are allowed.
• Disposable - Better. In view of cost constraint and no
available stronger evidence both can be used.
• Standards :
• Proper Size covered until lower third legs and sleeves covered
up to half the hand.
• Completely wrapped in without exposing any bare area over
front of chest and back
• Woven reusable gowns have to be avoided with spillage of
water or fluids to prevent contamination.
GOWNS - Material and standards

53. GLOVING TECHNIQUE
• 2 layered gloves - strongly recommended.
• To prevent contamination of the surgical field that
may occur in the event of glove perforation.
• Change of gloves @ contamination or @
Perforation recomended.
• No Reuse at all
• No role of decontamination of glove using alcohol
based solutions ( Sterilium )
• No role of coloured glove or Perforator indicator to
prevent SSI
•

54. • CLOSED TECHNIQUE
• OPEN TECHNIQUE
• ASSISTED TECHNIQUE
GLOVING TECHNIQUES

55. • TOUCH ONLY GLOVE CUFF WITH BARE HAND
CLOSED TECHNIQUE :
When no assistant available. MUST TO FOLLOW FOR FIRST GLOVE

56. CLOSED GLOVE TECHNIQUE

57. CLOSED GLOVE TECHNIQUE

58. • OPEN GLOVE
TECHNIQUE :
• If first glove is intact,
subsequent gloves could
be worn by touching the
sterile glove anywhere
fastly.
• ASSISTED GLOVING
TECHNIQUE :
• When a scrubbed assistant
is available, the first glove
is donned by stretching it
and donning the hands in
to the glove directly.

59. As microbiological contamination rates of gloves increase with
duration of surgery, glove changes are recommended at least once
per hour.
Furthermore, gloves should be changed after draping, before
handling implants and if visible perforation is seen to reduce
contamination.
CHANGE OF GLOVES

60. • Sterile manner - Donning
sterile gloves
• Can take help of assistant in
case of limb preparation
• Starting from the surgical
site to the entire planned area
which is exposed after
draping has to be scrubbed.
Surgical Site preparation - Scrubbing

61. •Common Practises :
• Povidone Iodine is used for scrubbing the patient
• PAINTING THE SURGICAL SITE after SCRUBBING :
• Povidone Iodine Solution
• CHG based alcohol solution ( CHG 2% in isopropyl 70% alcohol)
Scrub Solution

62. based alcohol preparation to prevent SSI in all
surgeries.
Do not wipe or blot the
surgical preparation.
It should air dry

63. Possible harms associated with the use of alcohol-based solutions
Not to be used in neonates
Not to be used in contact with mucosa or eyes or genital tract
Not to be used in clean wounds, contaminated wounds and
dirty wounds as it is cytotoxic and caused further damage.
Highly flammable. Excess solution pooled on table @
preparation time should be removed otherwise can cause burns
due to cautery use.
Chlorhexidine based alcohol solution

64. • Both disposable non woven drapes and Woven reusable drapes
cane used.
• DRAPING has to limit exposure of surgical area as minimum as
possible. However keeping in plan of extension of exposure
should be planned at the time of draping.
• Drapes once put in place should never be removed or pulled
back. Once draped underneath surface is considered unsterile.
• When using reusable woven drapes, the first layer has to be
sterile fluid repellent sheet to prevent contamination through the
drapes to unsterile table top.
• Towel clips once placed should never be removed.
DRAPING

65. • Commercially available skin
sealants are applied on skin after
draping. They form a film on skin
that need not be peeled off, and
helps in restricting organisms in to
surgical field.
Antimocrobial SKIN SEALANTS

66. • WHO 2016 guidelines
• No benefit
• Need not be used
• Level of evidence : Strong
Antimicrobial Skin sealants

67. • No recommendations in
WHO Guidelines
• Other guidelines
recommend it to seal of
the exposed area after
draping.
• Evidence : No significant
difference between plain
and iodine impregnated
films
STERIDRAPE / IOBAN

68. • Golden Rule : only front part of
chest and upper limbs are
assumed to be sterile.
• BACK of the scrubbed person is
always considered unsterile even
if not touched by anyone.
• Always move such a way that
your back faces the standing
persons back in this way
Moving around near surgical site

69. •Minimum total air changes should be 30.
•The fresh air component of the air change
is required to be minimum 5 air changes out of
total minimum 30 air changes.
MODULAR OT - HEPA FILTERS

70. •The airflow needs to be
unidirectional and downwards on
the OT table.
•The air velocity recommended is

71. GENERAL OTs
•21 +/- 3 Deg C
SPECIALTY OTs
•18 deg C +0 -2 deg C.
Relative humidity between 40 to 60%.
IDEAL OT TEMPERATURE

72. • Never pass between two scrubbed people !!
• If some one is keen on watching the surgery, easier way is to scrub and assist !! to prevent SSI
• GOLDEN RULE : STAY ONE METRE AWAY from scrubbed people and instrument table
or trolleys
• Circulating staff have to be keen observers and inform if any of the scrubbed people gets
unsterile and they may have to redo scrubbing.
• INFECTION COSTS a LOT, not just money !!!! Avoiding it is easier
Circulating people in OR

73. • TOO MANY PEOPLE IN OT
LIKE THIS -
• WILL CREATE CHANGE IN
AIR FLOW VELOCITY AND
CONTAMINATIONS AND
NOTHING LIKE EVEN HEPA
FILTERS WORK.
• THAT IT SELF IS THE SOURCE
OF INFECTION
OPERATING ROOM - RESTRICTED
NUMBER

74. • THIS IS A SMALL PROCEDURE DONE START AND END OF
EVERY SURGERY AND IT HAS PRONOUCEDLY SEEN
REDUCING MORBIDITY, MORTALITY AND WRONG SIDE
SURGERIES IN OT.
WHO PATIENT SAFETY CHECKLIST

76. References
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Safety Communication - FDA Requests Label
Changes and Single-Use Packaging to Decrease Risk
of Infection. US Food and Drug Administration.
http://www.fda.gov/Safety/MedWatch/SafetyInformat
ion/SafetyAlertsforHumanMedicalProducts/ucm37489
2.htm. Accessed February 11, 2015.
• Guideline for a safe environment of care, part 1. In:
Guidelines for Perioperative Practice. Denver, CO:
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• Gottardi W. The influence of the chemical behaviour
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• National and state healthcare-associated infections
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Emerging and Zoonotic Infectious Diseases, Centers
for Disease Control and Prevention; 2016
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Emori TG, Munn VP, et al. The efficacy of infection
surveillance and control programs
in preventing nosocomial infections in US hospitals.
Am J Epidemiol. 1985;121(2): 182-205.
• Naderi N, Maw K, Thomas M, Boyce DE, Shokrollahi
K. A quick and effective method of limb preparation
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Surg Engl. 2012;94(2):83-86. [IIB]
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http://www.who.int/gpsc/global-guidelines-web.pdf

77. Thank you