This document provides guidelines for maintaining a sterile environment in an operating theatre (OT) to prevent surgical site infections. It outlines policies for OT staff dress code and conduct, including proper hand hygiene and restricting access. The OT layout separates zones by sterility. Cleaning procedures are described for daily cleaning between surgeries, deep weekly cleaning, and handling soiled equipment and laundry. Standard infection control precautions like proper disinfectant use and spills management are also covered.

1. Dr Priyadarshini Patro
Microbiologist
VY Hospital

2. Aim
 Provide a sterile field for a safe surgery
 Prevention of All HAIs ( not only SSI)
 Prevention of occupational hazards

3. Sterile Environment reduces Surgical site
infections
 SSI are the second most common cause of hospital acquired
(Nosocomial) infections.
 Leads to considerable morbidity and, when these occur deep at
the site of the procedure, can lead to mortality as high as 77%.
 The source of SSIs may be:-
 Endogenous (normal flora of the patient’s skin, mucous
membranes, or hollow viscera)
 Exogenous (surgical personnel , the operating room
environment, and tools, instruments, and materials brought to
the sterile field during an operation

4. Layout of OT
 Outer Zone:
(Main Access corridor, transfer area, supervisor office or control
station, documentation area, preoperative patient holding area(s),
the changing facilities, toilet).
 Clean/ Semi restricted zone:
( Clean corridor, sterile equipment store, anesthesia and recovery
room, rest areas)
 Restricted/ sterile zone:
(scrub sinks, operation room)

5. Policy For Theatre Staff (Including Doctors)
 All staff working in OT complex and associated with patient
care should have had a clean bath before arrival in the
hospital.
 Staff must change into theatre clothes and shoes before
entering the clean/ semi restricted area.
 Staff is expected to spend at least 1 minute at the scrub
area washing their hands & thoroughly dried.
 The operating theatre ( restricted zone) should be restricted
to just the personnel involved in the actual operation.

6. Dress code:
 A fresh mask for each operation.
 Disposable/linen caps for all staff.
 Surgical suits worn by patient caretakers comprising of
surgical team, scrubbed nurse, anaesthetist should be
clean and sterile (sterilized by autoclaving). Linen should
be changed after attending an infected case in OT.
 footwear – needs to be cleaned off blood and body fluid
after every case. They should be totally dry prior to use.
 Wristwatches and jewellery of any kind must not be worn.

7.  Protective EYE WEAR should be preferably worn for all cases.
 Wear sterile gloves after wearing the sterile gown without touching the outer
surface of the glove.
 For short visits to OT (photographer, physician, maintenance staff etc), the
person is required to change into theatre dress with facemask and head cap.
 For urgent immediate attention to a sick patient / crash situtation, the
staff need not change, but should put on disposable gowns or proper
OT dress as soon as conveniently possible.
 Theatre personnel who collect patients for OT, collect blood, deliver urgent
pathology specimen etc should wear a clean apron/gown & outside shoes
before leaving OT complex for other areas.


8. Sterile field
Do not allow sterile personnel to reach across
unsterile areas or to touch unsterile items, or
vice versa

9. Infection prevention and control
Standard Precautions:
1. Hand hygiene
2. PPE
3. Aseptic technique- Prevention of needle stick injury
4. Environmental Cleaning
5. Instruments reprocessing
6. Waste management
Universal precautions:
Blood spillage management/ blood and body fluid post
exposure management

10. General instructions
 Efforts should be made to minimize personnel traffic
during operations.
 No one should leave the O. T. wearing O. T. clothes and
slippers.
 20 – 25 degree centigrade temperature to be maintained
inside the O. T. & humidity should be 50-60%.
 Infected cases should be preferably scheduled at the end of
the list.
 Surgical suits (staff dress) should be changed after
attending such infected cases.

11. Appropriate device handling
 Handle used patient care equipment soiled with blood
and body substances in a manner that prevents skin
and mucous membrane exposures, contamination of
clothing and transfer of microorganisms to other
patients and environments.
 Reusable equipment is not used for the care of another
patient until it has been appropriately cleaned and
reprocessed.
 Single use items are properly discarded after use.

12. Appropriate handling of laundry
 Clean and used linen should be transported and stored separately.
 Used linen should be put in trolly at the point of generation. Linen
trolly should not be overfilled. Overfilling will prevent closure and
increase the risk of rupture in transit.
 Staff should ensure sharps and other objects are not discarded
into linen trolly.
 Linen soiled with blood or body substances should be packed and
transported to laundry .

13. What is wrong with our Practices
 Disinfectants used
indiscrimately,
 Used unnecessarily
 Not used when needed.
 Concentration not
adequate
 Economic consideration,
 Business promotions.

14. Basic Principles
 Cleaning more
Important than
Disinfection and
Sterilization ?
 However
Cleaning
Removes contaminants,
Dust, organic matter,
Disinfection
Reduces number of
microbes

15. 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 chemicals is not
necessary.
 Keep the floor Clean and Dry -
Bacteria are reduced.
 Most Important component of
Bacteria is water & dry areas
causes natural death except
spores.

16. Frequent cleaning of Walls and Roof of
Operation Theatre is not needed
 Frequent cleaning has little
effect.
 Do not disturb these areas
unnecessarily.
 Do not use ceiling fans they
cause aerosol spread .
 Clean only when remodeling or
accumulated good amount of
dust.

17. Cleaning the Floor
 Floors get contaminated quickly,
depend on
Number of persons present in the
Theatre / Movements they make,
has direct relation to increase of
bacterial counts.
 Floor should be decontaminated with
Vacuum cleaner and Wet cleaning
techniques .
 A simple detergent reduces flora by 80 %
 Addition of disinfectant reduces to 95 %
 In busy Hospitals counts raise in 2 hours

18. Cleaning in Operation theatres -
 Frequency of cleaning :
Operation rooms – daily
Entire theatre complex – once a week
 Schedule for cleaning of the OTs –
Before first case i.e. beginning of the day
 During a Surgery
 Between Surgeries
End of the day
Weekly/ Monthly

19.  Prior to First Case:
 Wipe all furniture, equipment, lights, suction points, OT
table, slabs, etc with a detergent/soap and water
Complete at least one hour before start of Surgery .
 During surgery:
Spills/ Blood Splashes in the vicinity of the sterile field -
absorbed with a cloth & covered with freshly prepared
sodium hypocholorite for at least 30 mins
Clean the area with soap and water.

20.  In Between Surgeries:
 Gather all soiled linens in the receptacles 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.
 Used instruments –
Disinfect – Wash in adjacent room by scrubbing with brush, liquid
soap and vim – Send for sterilisation.
 In septic theatres – autoclave first – then clean manually – pack
and reautoclave.
 Furniture, Operating Lights, Suction Cannisters and other
equipment used - Wiped with a detergent.
 Patient transport vehicles are wiped.
 Floor – mop 3-4 feet area of the floor around the table

21.  Days End:
Repeat Same procedure as earlier.
 Wipe over head lights, cabinets, waste receptacles,
equipment, furniture with soap/detergent and water.
Wash floor with soap and water followed by disinfectant
solution (0.1% hypochlorite solution/ 1% Bacillocid solution/
7% Lysol).
Disinfect the operating room, scrub utility, corridor,
furnishings and equipment.

22. Weekly (Deep cleaning )
 Staff undertaking cleaning must wear appropriate Personal Protective
Equipment (PPE).
 The patient(s) must be vacated from the area to be cleaned.
 Pre cleaning culture swabs must be taken by ICN.
 Disposable/opened items must be discarded; the area is cleared of all
personal effects, equipment (once cleaned), linen and biomedical waste.
 Remove the curtains prior to cleaning and send for laundering.
 Housekeeping services are responsible for cleaning the entire
environment including en-suite facilities/patient lockers/tables/underside
of bed frame with Bacillocid 1% .

23.  Clean the wall and ceiling with Bacillocid 1 %.
 AC ducts/vents should be cleaned.
 Mop the beds and mattress with Bacillocid 1 %. Mopping should be done for
air beds unless contraindicated by manufacturer‘s instructions .
 Floor should be scrubbed with water and detergent (R2) and then mopped
with Bacillocid 1% from inside to outside .
 Suction jars and Humidifiers should be cleaned with soap and water,
Korsolex and dipped in Sodium Hypochlorite 1 % for 45 minutes or send for
ETO.
 All equipments clinical and nonclinical are mopped with disinfectant.
 Biomedical staff is responsible for cleaning of all electronic equipment with
Bacillol 25.

24.  All equipment in the area must be decontaminated
prior to transferring to a clean area.
 Post cleaning culture swabs to be taken by ICN.
 The ward/area can resume its normal activities after
taking the culture swabs.

25. 3 bucket system
For mopping of floors 3 bucket system should be preferred.
 1st Bucket with water:
Dirty mop is rinsed
 2nd Bucket with fresh water for rinsing:
Mop rinsed again in this water
 3rd Bucket with low level disinfectant :
Mop is immersed in the solution and the floor mopped liberally.
Wash the used mop with disinfectant after use and dry thoroughly before
reuse .

26. Fogging in patient care areas
 CDC and HICPAC have recommendations in both 2003
Guidelines for Environmental Infection Control in Health-
Care Facilities and the 2008 Guideline for Disinfection and
Sterilization in Healthcare Facilities that state that the
CDC does not support disinfectant fogging.

27.  Fogging is indicated in following situations:
1. If there is a case of anthrax, gas gangrene, tetanus or an
open septic wound with laboratory evidence of
Clostridium tetani in any area where surgical procedures
are carried out.
2. Before functioning of a newly constructed or renovated or
repaired operation room/ intensive care unit.
3. When routine environmental surveillance reveals C.tetani
or any pathogenic spore former.
4. As a part of terminal cleaning once in a week.
5. Daily in operation theatres where surgeries are performed
with window ACs.

28.  Procedure:
1. Measure the area of room to be fogged in cubic feets.
2. Seal the room including windows and ventilators air tight.
Use adhesive tapes to close the gaps.
3. Switch off the fans and ACs.
4. For each 1000 cu.ft.(28.3 cu.mt.) space, use one litre of
0.5% Baciliocid extra solution/ 20% Ecoshield
solution
5. Pour this solution to fogging machine
6. Switch on the machine
7. Keep it for 60 minutes

29. Microbiological surveillance after Fogging
 Recommended only in case of fogging done after new construction/
renovation/ repair work or after procedures done on septic cases.
 Not indicated in case of fogging being done as a part of terminal cleaning. In
such case the area/room can be used immediately after fogging.
 Surveillance cultures in the form of air sampling by open plate cultures
(settle plates) and swabs for isolation of aerobic and anaerobic bacteria
should be taken by infection control nurse.
 Information regarding the same should be provided to infection control
team prior to fogging.
 The area/room where fogging was performed should not be used until
the microbiological surveillance cultures are reported as negative.

30. Action plan in case of positive microbiological surveillance
report:
 The area/site should be cleaned and scrubbed thoroughly
with soap/detergent and water followed by cleaning with
disinfectant (phenolic agents/ hypochlorites). This should
be followed by repeat fogging and repeat microbiological
testing.
 OT/room/area can be used only after microbiological
surveillance cultures are reported as negative.

31. CDC recommendation for prevention of SSI
Category IA : Strongly recommended for implementation and
supported by well-designed experimental, clinical, or
epidemiological studies.
Category IB :Strongly recommended for implementation and
supported by some experimental, clinical, or epidemiological
studies and strong theoretical rationale.
Category II : Suggested for implementation and supported by
suggestive clinical or epidemiological studies or theoretical
rationale.
No recommendation; unresolved issue. Practices for which
insufficient evidence or no consensus regarding efficacy exists.

32. Preoperative
 Preparation of patient
 Hand antisepsis for surgical team members
 Management of infected or colonized surgical personnel
 Antimicrobial prophylaxis

33. Preparation of the patient
o Identify and treat all infections remote to surgical site before elective
operations (IA).
o Do not remove hair preoperatively unless it will interfere with the operation(
IA).
o If needed, remove hair immediately before the operation preferably with
electric clippers instead of razor (IA)
o 4 % chlorhexidine showers/bath is mandatory for all elective surgical patients
after shaving is complete.
o If this is not feasible (e.g. sick bedridden patients), chlorhexidine, 4%
povidone iodine lotion is to be sponged on to the patient in bed.
Patient scalp hair needs to be capped by a disposable cap before shifting to OT.

34. Hand/forearm antisepsis for
surgical team
 Keep nails short and do not wear artificial nails IB
 Perform preoperative surgical scrub for at least 2 to 5
minutes using an appropriate antiseptic IB
 Dry hands with sterile towels and don a sterile gowns
and gloves IB

35. Antimicrobial prophylaxis
 Administer a prophylactic antimicrobial agent only
when indicated IA
 Administer by the IV route the initial dose not more 1
hour before incision IA

36. Intraoperative
 Ventilation system
 Cleaning and disinfection of environmental surfaces
 Microbiological sampling
 Sterilization of surgical instruments
 Surgical attire and drapes
 Asepsis and surgical technique

37. Ventilation
 Maintain positive pressure ventilation in the operating room
IB
 Maintain a minimum of 15 air changes per hour with at least
3 fresh air IB
 Do not use UV radiation in the operating room to prevent
SSI IB
 Keep operating room doors closed except as needed for
passage of equipment personnel and the patient IB
 General traffic in & out of the OT should be reduced as far
as possible.

38. Asepsis and surgical technique
 Alcoholic solutions preferred over aqueous solutions
for skin preparation.
 Single use sachets of solutions ; not multi-use bottles.
 Wounds should not be drained unless absolutely
necessary.
 If drainage is used , use a closed suction drain, insert it
through a separate incision distant from the operative
incision and remove it as soon as possible IB

39. Evaluation of infection control
practices
 Checklists
 Surveillance

40. Evaluation of infection control
practices
Checklists
• Used to evaluate everyday performance and
compliance to infection control practices
• Provide feedback to OT staff to rapid intervention.

41. Evaluation of infection control
practices
Surveillance IB
• Use CDC case definitions to identify SSIs and all other
HAIs either during hospital stay or after patient
discharge.
• Provides incidence rate of infection
• Stratifies risk factors HAIs that need strong
intervention.

42. Sampling of OT air and floor swabs
 OT air will be sampled by using culture plates
circulated through the OT atmosphere manually and
kept in OT for 1 hour. OT door should remain closed
during the sampling hour.
 Swabs will be taken from OT floor, table, Walls, Boyle‘s
Apparatus, A.C. duct and light source in all OTs. The
sampling will be done once a month.

44. Everyone

45. Remember we are More important than
many

46. 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.

47. Importance of Staff Education
 Speicify the staff for
duties and
responsibilities.
 Education is a matter
of continuity
 Train under the seniors
observation.
 Train the staff with
scientific goals