Infection and its prevention have been a prime concern of mankind for a long time. “Infection is a condition that results when a microorganism is able to invade the body, multiply and cause injurious effect or diseases.” (McCall & Tankersley, 2007:71) Infection control therefore refers to policies and procedures used to minimize the risk of spreading infections, especially in hospitals and human or animal health care facilities. The purpose of this is to reduce the occurrence of infectious diseases.
The aim of this essay is to look at how infection control and the theatre environment impact on a patient undergoing surgery. The first part of the essay looks at infection control in the hospital setting in general; touching on issues such as hospital acquired infection like Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (CD). Then the essay delves into the design of the surgical theatre and how it impacts on patients; it further talks about surgical etiquette placing much emphasis on hand washing as this is the first defence in preventing transmission of pathogen (Radford et al, 2004). Finally a conclusion is drawn on all the issues raised and their impact on the patient undergoing surgery.
In the past, surgery would have been performed in a convenient location such as the patient’s home or a hospital ward with only basic infection control in place (Essex-Lopresti 1999). In Phillips (2004) describes the process for preparing the room as rudimentary, amounting to little more than removing furniture and non essential items and boiling linen, perhaps fumigation if time allows. Today, most surgery takes place in operating theatres that are specially designed for that purpose.
There are two types of infection, the endogenous and exogenous infection. Endogenous infection occurs when microorganisms that normally exist harmlessly in one part of an individual to become pathogen, whereas exogenous infection happens when microorganisms from other source or from other person, object, animal or the environment (Woodhead 2005).
Infection control refers to policies and procedures used to minimise the risk of spreading infection especially in hospitals. Nosocomial or hospital acquired infection (HAI) occur in approximately 5% of all hospital patients. The longer a patient stays in hospital, the higher the risk of getting HAI and sometimes even leading to death. There are many reasons why patients infected with HAI: Firstly weak immune system which makes them more vulnerable to infection due to patient sickness or treatment. Secondly, infection agent can be introduced to the patient by medical procedures and thirdly, on admission with infectable disease agent, patient can transfer diseases to a patient or patient to staff or visitor (Jones, 2008).
HAI has, over the past few years dominated the media with its coverage of the “superbugs”, in particular MRSA and CD. A HAI or nosocomial is that which is acquired or develops as a result of treatment while the patient hospitalised for more than 48 hours and who did not have signs and symptoms of such infection on admission. Radford et al (2004) cited the research of Emmerson et al (1996) 9% of patients admitted to hospital acquire HAI from surgical wound infection after hospital discharge.
MRSA has the ability to resist to one or more conventional antibiotics. Study suggests many people are carriers of MRSA but are colonised in their nose or back of their throats and on their normal flora. Report from BBC news (2005) stated that about 100,000 get infected with MRSA each year when they get admitted into hospital. The only way health care workers can reduce this infection is; a good hand washing between patients, a good standard hygiene in hospital and patients with MRSA treated in a highly isolated as much as possible.
The operating theatre is designed in accordance by national and processional guidelines as described by Woodhead et al (2005). Each department is divided into three zones, the outer or dirty zone which is unrestricted area where normal clothing can be worn; it contains the entrance to changing areas and usually has access to remove theatre waste. The clean or semi-restricted zones are the staff changing rooms, anaesthetic and recovery rooms and sterile supplies. Access is restricted and all personnel and patients have to wear theatre attire. There is exception sometimes to patients that need support, such as children, mental ill patients or translators to the anaesthetic room.
The sterile or restricted zones include the operating theatre, preparation rooms and the scrub areas. Surgical attire and possible masks will need to be worn at all times (Davey & Ince 2004). Sterile areas should avoid overcrowding by theatre staff to reduce the risk of accidental contamination to sterile instruments and layout. To reduce airborne contamination, movement of staff and patient should be kept to a minimum. This helps to reduce airborne bacteria from entering the operating theatre (Woodhead 2005).
Ventilation, temperature, humidity and airborne contamination have an important role in the design of a good operating theatre. In order to control the movement of air, the operating department requires specialised ventilation system. Usually the system employed in ventilating modern operating departments are laminar airflow (LAF) technology and positive pressure (PP) systems; these are in theory designed to reduce surgical site infections. The theatre is particularly arranged in a way so that air pressure is filtered moving air from clean to less clean areas and this continues when the theatre room is not in use. This is in place to reduce the airborne contamination, reduce expired anaesthetic gases and to control temperature and humidity, thus reducing and minimising bacterial growth. Adequate ventilation in theatre can be achieved by properly closing theatre doors, windows are well sealed, ceiling solid and the floor impermeable to washable material with no gaps or cracks and covered joints where it meets the wall. Also shelving should be kept to a minimum (Weaving P, et al 2008).
In orthopaedic theatre the air is ultraclean. These system are used when the risk and consequences to developing infection are greater. Ultra clean air, provided by the laminar flow systems, is designed to move particle free air over the aseptic operating field in one direction; it can be in vertically or horizontally sweeping away particle
in its path. These canopies have the capacity to provide up to 400 to 500 air change per hour and can reduce the incidents of surgical site infection ,so together with good practice and the use of prophylactic antibiotics, the impact of surgery upon the patient should be favourable (Woodhead et al 2005) .
37ï¿½ C and high humidity is the optional where most bacteria reproduce, to keep a theatre room free from bacteria the temperature should be between 20 to 24oc and humidified air levels of 50 to60%, this help to suppress bacteria growth, also help create a good impact upon the surgical patient, as infection rates are considerably lower (Davey and Ince 2004). Infants, children and burnt patient need a warmer temperature to avoid hypothermia, therefore each operating theatre have its own controls for regulating the temperature (Mangum 2001). There are two types of lighting found in theatre, the laminar lighting used to light the operating theatre and auxiliary and the surgical lighting. Both harbour microorganisms on it surfaces due to the movement and activities of staff in the operating theatre (Phillips 2004). This should be clean regularly to reduce the risk of infection.
The theatre must be damp dusted before the first case of the day, and it is essential to clean and disinfect all contaminated areas of the theatre at the end of each case (Mangum, 2001) Infection control as defined earlier as policies and procedures use to minimize the risk of spreading infection, staff do not always go by this policies and guidelines. For example policies on air movement in the department, normally doors between the anaesthetic room and theatre are mostly left open by staff therefore affecting the positive pressure from working effectively. Staff need constant trainings and made aware of updated policies. These measures will help to control infection.
According to Woodhead et al (2005), 300 million skin squames are shed per day and about 10% of this have microorganisms of which smaller particles stay as airborne for some hours. Some big particles may rest on work surfaces, furniture and equipment. 37% of airborne microbial contamination can be reduced if in every 3 minutes air is changed in the theatre.
Different type of waste should be separated and disposed of in the right way. All waste known, or considered to cause disease in humans or other living organisms is considered infectious waste (DH, 2006). In the authors trust yellow is the colour coding for clinical waste which can cause a risk of infection or can be hazardous. Green bags for the linens. All waste bags should not be more than three quarters full (Davey & Ince, 2004) and it is the duty of the staff to ensure that and dispose off in the appropriate manner to meet the requirement of the control of substances hazardous to health regulation (COSHH).
Maintaining a safe and clean environment is essential for a good impact upon surgical patients, but staff themselves can be a source of microbial contaminated (Green et al, 2003). Staffs are screened by their occupational health department. They are annually screened for such infections as human immunodeficiency virus (HIV) and hepatitis B.; this screening is mandatory and is design to protect patients from exposure from infected staff. Microorganisms are shed from exposed skin, hair and mucus membranes, so to achieve a sterile field and to reduce infection for both patients and staff; staff need to wear appropriate clothing, prepare patients, use sterile equipment and eliquette during surgery.
According to Radford et al (2004), every staff working within the theatre context needs to change into suit and trousers as classed as personal protective equipment (PPE) made from cotton fabric to reduce skin cells to the surroundings. Other PPE such as footwear, mask, eye protection etc. are also worn by staff as an infection control measure during surgery. Hospital Acquired Infections may not be eradicated but many outbreaks can be prevented through effective hand washing. Transient microorganisms are easily removed during hand washing therefore it is one of the most important procedures to prevent the spread of infection (Woodhead & Wicker 2005).
Hand antisepsis started in the 1860 by Joseph Lister. He realised decay is caused by microorganism and it can be prevented by disinfecting the clinical environment and all equipment with carbolic acid. It also included staff having their hands washed in a solution of 5% carbolic acid before undertaking surgery. Other development on surgical hand antisepsis occurred including scrubbing the hands and arms with a brush where the term “scrub” comes from. Also introduction of alcohol rubs in the late 1990s which contain antiseptic agent such as chlorehexidine gluconate alcohol solution which when rubbed on the hands does not need rinsing (Tanner 2008).
Hand washing takes place before and after patient contact, following removal of protective clothing, immediately following contamination with blood or body fluids and after handling contaminated or potentially contaminated articles (Davey and Ince 2004, p39). This hand washing is a form of standard precautions for all staff to practice since staff cannot tell which patient is contaminated; therefore it is one of the most important procedures to prevent the spread of infection. Healthcare workers handling patient with their catheter, bed linen, wound, disposal of linen and waste come in contact with microorganisms. Also staff or practitioners caring for MRSA patients can have the pathogen on their skin for a few hours, this means it can transfer to another patient or staff easily. During these times, hand washing is vital to help stop the spread of infection.
Surgical hand scrubbing gets rid of transient microorganisms which help to minimise the number of resident microorganisms in the recent study of Tanner 2008. Before hand scrub, all jewellery with the exception of single plain band must be removed. False nails and nail polish is not acceptable, since they harbour pathogens as studied by Heddewick et al (2000). Aqueous antiseptic solution such as Chlorhexidine gluconate and providone-iodine are efficient in removing transient organisms and reducing resident organisms to a safe level. Frequent hand wash minimise a low bacterial count under gloves which is accepted by all healthcare workers.
To start effective hand scrub, temperature of the water must be checked; also arms and hands must be wet before applying anti-microbial solution. The hands and arms are washed from fingertips to the elbows and hands are held higher than elbows in order to prevent microorganisms dropping back to the fingertips. There is no agreed time for how long a surgical hand wash should last, but between 2 – 5 minutes have been vouched for by most researchers as enough and effective. Hands should be properly dry. Alcohol based hand rubs are also effective for use between patient contact. When used, the right technique should be employed to ensure it covers the relevant areas and left to dry (Woodhead et al 2005).
Sterile gowns are worn after hand scrub to prevent bacteria from scrub staff to the surroundings or operating site, thus reducing surgical side infection (SSI) (Radford et al ,2004). Gloves must be put on using the closed gloving technique, not touched by the staff members’ bare hands. During orthopaedic operation, double gloving is recommended as any perforations will be highlighted and sterility will not be compromised. Surgical instrument and sterile equipment are prepared in the preparation room just before use, thus minimising the risk of contamination from airborne microbes. Patients are then positioned on to the table before a scrub nurse wheels the trolley into the operating area (Davey and Ince, 2004).
A patient’s skin around the incision site is disinfected to reduce the number of bacteria present so as to reduce the risk of endogenous infections. The most effective antiseptic are those which are alcohol based. This has to be left on the skin to evaporate before draping begins (Weaving et al, 2008). The rationale behind this is to reduce the natural flora from getting into the incision and avoiding the patient contracting SSI. The rest of the patient is covered by draping which comes in disposable or reusable; this is to provide a sterile field in which the operating team can work without risk of contaminating themselves or the instrument. Draping start from the incision site working out towards the peripheries and should not be removed until dressing applied and surgery completed (Radford et al, 2004).
Infection can not be totally eliminated and has serious consequences for the patient; however the risk of contracting infection can be reduced by adhering to infection control procedures and policies such as effective hand washing, wearing the appropriate personal protecting equipment. The design of the operating department also plays an important role in the success of controlling infection. Ventilation system needs to be working effectively to achieve its use; temperature and humidity parameters need constant checking. The continuous education of staff about theatre policies and regular update of the policies will go a long way to help reduce infection in theatre.