SURGICAL SITE INFECTIONS


is being updated currently and due for publication in April 2019. Many of the recommendations made are practised by theatre teams in many specialities. It remains to be seen whether there will be new recommendations which may change practice again. One concern which has not received too much attention is the role of environmental cleaning of the surgical space, whether that is in a catheter lab or in a fully equipped operating room.


Cleaning the environment Health Protection Scotland undertook some research last year providing a report5


support workers to assist the teams with cleaning to ensure a faster turnover. In some departments, cleaning is undertaken carefully and assiduously, in others, items get left out or the task is undertaken hurriedly. One of the key observations made is that the process of cleaning theatres between procedures is unassigned, ie undertaken by different members of the team at different times with little accountability and only quick visual checks to ensure it has all been done. Jefferson et al describe a study6


which showed that if operating


rooms were cleaned to an optimal level, at each opportunity during a shift, that nurses spent 27% of their on-duty time undertaking cleaning. One of the recommendations following the report was that Scottish Health Boards were asked to ensure that there is sufficient time to clean between patients and for routine cleaning. The study used a simulated environment with no patient reality, so truly soiled equipment might have taken considerably longer to clean. There is certainly pressure on


surgical time and turnover between patients. The gap between one patient in the surgical environment and the next has always been seen by management and surgical colleagues as time wasted – when theatres could be better used. This ignores the importance of cleaning the environment appropriately and carefully before the next patient is ‘admitted’. At the end of a surgical procedure it is possible that much of the equipment is contaminated and needs to be conscientiously cleaned and dried, as well as the floor cleaned, instruments wrapped and contained for safety for transport and a myriad of other activities before the room is ready to be set for subsequent patients. Cleaning between patients is usually undertaken by theatre team members, although some enlightened units have employed and trained healthcare


where they mark high - touch objects or others that are highly likely to become contaminated, with fluorescent marks which can easily be wiped from the surface or found again with UV light. If the target mark was removed or substantially disrupted, the object was considered clean, if the mark remained, the object was not cleaned. Shockingly, across 71 operating


theatres in six acute hospitals, the mean thoroughness of the cleaning was found to be only 25%. Across the hospitals there was wide variation between 9% and 50% as well as across specific objects there was also a large range, 0% to 70% for the best cleaned items which were the overhead main theatre light, the doors and the telephone. High touch objects - or this author


would prefer they were labelled ‘frequently touched objects’ - are those that are routinely handled by members of the team and are at risk of being contaminated by the hands of others increasing transmission rates. They may be the overhead light, the


items being forgotten from the cleaning schedule - specifically IV poles, the anaesthetic machine, patient monitors and the operating table.


diathermy trolley, the patient warming machine and items used to position patients for surgery. Dancer also reported7


Mitigating the risk To mitigate risks, a policy should be developed for theatres with the infection control team, perioperative clinicians and managers as well as


Tomitigate risks,apolicy should bedeveloped for theatres with the infection control team, perioperative clinicians and managers aswell as housekeeping services.


14 l JULY 2018 l OPERATING THEATRE


housekeeping services. The policy should schedule items to be cleaned between patients, intermittently used equipment principles and terminal cleaning schedules. The terminal clean is usually undertaken at the end of each day by the theatre team but additionally by a specifically employed member of staff who will use a scrubbing machine on each of the theatre floors, whether the room has been used or not. The latter is often done late in the night. Ideally the protocol will identify which specific staff should undertake which cleaning tasks. The supervisor should be identified and the process of documentation of regular checks developed.


The policy should specify the PPE which should be used by staff when they are undertaking any cleaning role. It is often omitted by the individuals – a high risk personal strategy. Spill kits should be available in each operating room or pair of theatres, and readily accessible, to mop larger spills of blood and body fluids. The local policy will indicate the means of immediate clearance or spot cleaning which should be undertaken as necessary for small spills and the chemistry to be used for each type of spill.


Regular audits of the quality of the cleaned environment should be undertaken, preferably with the clinical lead and an infection prevention team member. The audit document should reflect all the items in the policy and cleaning schedule, reflecting frequency of cleaning and by whom. Equipment which is brought to


theatre for the surgery should be cleaned before it enters the theatre and after it has been used and is returned to storage.8


There are some


very fragile electronics in use in modern operating theatres, so it is essential that manufacturers’ guidance is adhered to when cleaning the kit.


Ventilation Ventilation is one of the key agents of reduction of infection in the surgical environment, with increased risks to patients if the ventilation systems do not achieve and maintain the required standards. The link between SSIs and theatre air quality has been well established. Plants serving a conventional operating department,


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