SURGICAL SITE INFECTIONS


Temperature of the theatre is related to aspects of infection prevention and is managed by an effectively working ventilation system. The temperature range recommended should be maintained between 18 to 25˚C on a regular basis, but can be manipulated to suit individual patient needs – such as vulnerable, elderly or paediatric patients. The warmth assists in preventing surgical site infection by a factor of three but should not be the cause of discomfort to the surgical team. In the past it was necessary to set a humidity level within the theatre, however this is no longer required to control risks associated with the use of flammable gases, microbial contamination and electrostatic charges, which posed a fire hazard.15


Detergent versus disinfectant One of the great cleaning debates surrounds the use of detergents or disinfectants. Detergent based cleaning might remove microorganisms but it is unlikely to kill them, whereas disinfectants are more effective at killing pathogens but are more expensive and have greater impact on the materials they are cleaning. The Cleaning Manual in NHS determines that we should use detergents whereas all the recommended practices from US and Australia cite disinfectant use.16


Education and training There is no question that understanding of the microbiological environment, in the operating theatre, is important to everyone who is responsible for cleaning and ensuring the safest place for a patient to have their surgery. However, I am sure that I am not alone in saying that I have never received any education on effective cleaning, and as with many practices which are later discredited, not been shown how to do it properly, other than by a peer.


Conclusion If we are to tackle the serious problem of antimicrobial resistance and the multi-drug resistant microorganisms found in hospitals then further emphasis needs to be made on the value of cleaning in hospitals. The frequency of surgical site infections in many patients who visit our theatres indicates that we are not doing everything we can to reduce the risk.


16 l JULY 2018 l OPERATING THEATRE


There is little doubt that contact transmission occurs a great deal in healthcare and because the organisms are invisible they are ignored in the cleaning schedules. The visual checks which we make are insufficient to assess that what cleaning has been done has been effective. The frequently touched areas in an operating room need to be observed and studied so that we can be sure that our cleaning schedules focus on the key items and not follow the US which has different ventilation standards, different chemicals for cleaning, people to clean and different furniture. There are too many variables. There are new and expensive technologies being devised and sold into the NHS which may be effective for cleaning side rooms or isolation rooms but will not be practical solutions for operating theatres, except possibly for terminal cleans. However, the likelihood is that


slower, less pressurised cleaning which is undertaken by trained individuals (whoever they may be) may well pay dividends by reducing the number of microorganisms on surfaces of equipment and in the general environment.


This could significantly affect the numbers of patients suffering surgical site infections.


References


1 National Patient Safety Agency. The Revised Healthcare Cleaning Manual 2009.


2


Tanner J, Khan D, Aplin C et al Post discharge surveillance to identify colorectal surgical site infection rates and related costs.vJ. Hosp Infect 2009: 72; 243-50


3 Charani E, Ahmed R, Tarrant C, Birgand G, Leather A et al. Opportunities for system level improvement in antibiotic use across the surgical pathway. Int J Infect Dis 60 (2017) 29- 34 Accessed at https://www.sciencedirect.com/ science/article/pii/S1201971217301327


4


WHO Global guidelines for the prevention of surgical site infection 2016 Accessed at http://www.who.int/gpsc/ssi-guidelines/en/ 5 Health Protection Scotland NSS Time to Clean


n


July 2017. Accessed at www.hps.scot.nhs.uk/ resourcedocument.aspx?id=6106


6


Jefferson J, Whelan R, Dick B, Carling P, 2011A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN Journal 93(3) 358-364


7 Dancer SJ 2011 Hospital cleaning in the 21st Century. Euro J of Clin Microbiol and Infect Dis 30(12) 1473-1481


8


AfPP Standards and Recommendations for Safe Perioperative Practice 2016. Harrogate England


9 HTM 03-01Part A Specialised Ventilation for Healthcare Premises. Nov 2007 Accessed at https://www.his.org.uk/files/4713/7907/0658/ HTM_03-01_Part_A_Specialised_Ventilation _for_Healthcare_Premises.pdf


10 McHugh SM, Hill AD, Humphreys H, Laminar airflow and the prevention of surgical site infection. More harm than good? Surgeon 2015 Feb ;13(1) 52-8


11 Health Building Note 26. 2004 Facilities for Surgical Procedures: Volume 1 https://assets.publishing.service.gov.uk/govern ment/uploads/system/uploads/attachment_ data/file/148490/HBN_26.pdf


12 Hsin-Shun Tseng, Shi-Ping Liu, Shi-Nian Uang, Li-Ru Yang, Shien-Chih Lee, Yao-Jen Liu, and Dar-Ren Chen. Cancer risk of incremental exposure to polycyclic aromatic hydrocarbons in electrocautery smoke for mastectomy personnel. World J Clin Oncol 2014; 12: 31 Accessed at https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3922599/


13 Hoffmann PN et al Microbiological commissioning and monitoring of operating theatre suites. Accessed at https://pdfs.semanticscholar.org/78aa/6019a6 6b851ef6cbf18740925b3fd5d5770d.pdf


14 Rafat Al Waked Effect of ventilation strategies in infection control inside operating theatres. 2010, Engineering Applications of Computational Fluid Mechanics, 4:1, 1-16, Accessed at DOI: 10.1080/19942060.2010. 11015295


15 Ibid 16 Dancer SJ. Controlling Hospital acquired Infection: Focus on the role of the environment and new technologies for decontamination. Clin Microbiol. Rev October 2014:27; 4, 665-690


I am sure that I am not alone in saying that I have never received any education on effective cleaning, and as with many practices which are later discredited, not been shown how to do it properly, other than by a peer.


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