Unit 2 Operating Department Care Skills 5N3767 by The Open College

Operating Department Care Skills - 5N3767

2013

Operating Department Care Skills 5N3767

UNIT TWO: INFECTION CONTROL

All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any format by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the proprietor and copyright owner of the course. Reproduction is prohibited. Unauthorised use may give rise to a claim for damages and/or be a criminal offence Printed and published in Ireland By The Open College Written by Siobhan Lynch Licensed holders of the copyright and publication rights for Ireland

Operating Department Care Skills - 5N3767

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MODULE UNITS: 1. Safety and Health 2. Infection Control 3. Client Care and Clinical Activity 4. Communication

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UNIT 2 INFECTION CONTROL By the end of this unit you should be able to:

 Observe the following in the operating department: o dress code. o appropriate standards of personal hygiene.  Outline the common methods by which cross infection occurs and effective means of breaking the chain of infection.  Identify the various applications, uses and disposal of detergents and disinfectants in the operating department.  Identify the appropriate procedures for: o handling body fluids and tissues. o handling blood bags. o handling blood products.  Recognise the indicators for damp dusting in the operating department.  Demonstrate the skill of damp dusting in the operating department.  List the principles of aseptic technique including the methods of creating and maintaining a sterile field.  Outline the local practice for the cleaning of equipment, walls and floors within the operating department.  Recognise knowledge of timing cleaning procedures appropriately.

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THEATRE ATTIRE & PERSONAL HYGIENE Although surgical attire was introduced in the early 1900s for the purpose of reducing the microorganisms shed into the environment, this practice did not firmly take hold until the 1930s and 40s. This is when the surgical gown, cap, and mask replaced the traditional nurse's uniform on a more consistent basis.

Today, the purpose of surgical attire is multipurpose. Not only do operating room personnel wear surgical suits, gowns, and masks, they also wear sterile gloves and approved eyewear to protect against transmission of blood borne pathogens and other hazardous materials.

All personnel entering restricted areas of the operating department should wear designated theatre attire. The National Institute for Health and Clinical Excellence (NICE 2008) concluded that all staff should wear specific non-sterile theatre wear in all areas where operations are undertaken. Personnel are able to influence the environment by maintaining personal hygiene, wearing theatre attire correctly, reporting potential health problems and monitoring visitors. Local policy needs to show consideration for the issues surrounding cultural and religious beliefs in the wearing of theatre attire (Afpp 2007).

Personal hygiene and clean smart dress code are central to maintaining a clean and healthy environment for staff and patients. Hygiene habits and practices of staff can lead to, or prevent the spread of infection or disease.

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GOOD HYGIENE PRACTICES INVOLVE:

Wash daily. Clean uniform â&#x20AC;&#x201C; follow local dress code. Clean shoes, free from splashes. Fingernails clean, short no false nails/nail varnish. Hair tidy and clean, covered. Jewellery removed. Avoid strong perfumes/aftershave.

Theatre attire is designed to minimise the transfer of microorganisms from the mucous membranes, skin and hair of the surgical team to the patient. It also provides the surgical team with some protection from the patient.

Theatre attire should consist of a two-piece trouser suit. It should also be:

Made of a close-knit material with antistatic properties. Resistant to bacterial strike-through. Flame resistant. Lint-free, as lint can increase the number of airborne particulates. Coloured to reduce glare. Cool and comfortable with maximum skin covering. Professional in appearance. Provided freshly laundered and in good condition. REF: www.afpp.org.uk

Hands should be washed before and after donning theatre attire. Theatre attire should be removed when it becomes wet or soiled, and placed into containers specially designed for contaminated laundry, to reduce the potential for cross-contamination.

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Theatre attire should be changed following environmental cleaning of the operating theatre and before the commencement of a new operating list.

Theatre personnel should change into outdoor clothing before leaving the theatre environment; however this is not always feasible. If theatre personnel are required to leave the theatre environment without changing, fully fastened and clean over jackets may be worn, as determined by the individual practice setting.

THE THEATRE UNIFORM:

Scrub Suit Proper surgical attire lends to environmental control within the operating room. The standard surgical suit consists of a two piece pants suit with a tunic top (made of a closely woven fabric). It is important when dressing to assure that clothing does not come into contact with the floor. This would enable contaminants from the floor to be transported into the operating room, exposing patients to undue risk. Tunic tops that do not fit closely to the body should be tucked into the scrub pants.

Headwear All head and facial hair should be covered completely by a head cover/cap - surgical site infections have been traced to organisms isolated from the hair and scalp. Disposable headwear is preferable, however cloth hats are permissible if laundered and inspected for holes/imperfections in an approved facility.

Headwear should be donned prior to donning the scrub suit. This eliminates the possibility of hair or dandruff being shed onto scrub clothing.

Headwear should be changed daily, unless it becomes soiled, when it should be changed immediately. Headwear should always be worn in laminar flow theatres during prosthetic implant operations (ICNA 2002).

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Masks The rationale for wearing masks in a surgical setting is to contain the microorganisms expelled from the mouth and nose. They also protect the wearer from potential splashes of body fluids and blood. Masks may offer some protection from inhalation of surgical smoke and laser plume.

Filtration levels vary according to manufacturerâ&#x20AC;&#x2122;s specification and masks should be selected according to the level of protection required, for example, exposure to mycobacterium tuberculosis.

To don a mask properly the fit should be snug. The top tie should be tied high up on the back of the head and the lower ties should be tied at the base of the neck. There should be no gapping on the sides of the mask. Gapping allows respiratory contaminants to escape, unfiltered, into the clean surgical environment.

Masks are not to be left hanging around the neck, placed on top of the head or stored in a pocket for future use. Once worn, masks are contaminated with respiratory expiration and should be discarded. The life of a mask is limited to approximately 1-1/2 to 2 hours. Protective face shields should be worn whenever activities could place personnel at risk of splashes or aerosol contamination. Occasionally, filtration masks may be required when dealing with certain patients such as those with pulmonary tuberculosis. Footwear Footwear in theatres should provide adequate protection and a risk assessment should be done to determine whether the type of footwear is suitable for decontamination. The purpose of such footwear is to provide antistatic properties. Footwear should be well fitting, supportive and protective. Shoes should provide protection from spillages and accidentally dropped equipment. Footwear worn in theatres should be for that use only and should be cleaned regularly (using appropriate PPE).

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INFECTION CONTROL Good infection prevention and control is essential to ensure that patients who undergo any surgical procedure within the operating theatre receive safe and effective care. Effective infection prevention and control must be part of everyday practice and be applied consistently by everyone. Safe working practices must be followed for all patients regardless of known or suspected infection.

MICROORGANISMS Microorganisms are microscopic and were the first forms of life to develop on earth approx 34 billion years ago. Microorganisms live almost everywhere and play an essential role in the environment – food production and drugs. Existence of microorganisms was first hypothesised in the late middle ages. During the14th century – The Bubonic Plague further hypothesised that the disease was caused by microbes. In the 17th century the microscope was invented – this allowed the proof to be observed. Many microorganisms do not normally cause disease in man, existing in a state of either COMMENSALISM, where there is little or no benefit or harm to man, or in MUTUALISM, where there is some benefit gained by both partners. This non-harmful balance exists when the immune system works well, but these same organisms can cause infection when the latter fails. This changed property is shared by many other microorganisms which can cause infectious disease in the immune-comprised individual, these are called PATHOGENS.

Microbes cause disease by directly damaging tissues and weakening bodily functions or by producing toxins that do. NORMAL FLORA: The normal human body is host to trillions of microbes. All are acting as a part of our normal defence mechanism against possible invaders. Number varies between 4000 and 400,000 in each square centimetre of our skin and mucous membrane which, if stretched out covers 8 tennis courts!!!!! Staphylococcus aureus is one of those found on the skin and in moist areas of 50% of healthy individuals. Most microorganisms can reproduce rapidly, especially bacteria which evolves swiftly to survive new environments and respond to environmental stresses. This rapid evolution is important in medicine as it has led to the recent development of the ‘Super bugs’.

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CATEGORIES     

Bacteria. Fungi. Protozoa. Viruses. Prions.

BACTERIA Are single-celled microbes that reproduce by splitting in two (binary fission). Each individual cell is capable of carrying out all of the activities needed to metabolise and reproduce. Bacteria grow best in moist conditions and can live in a wide range of temperatures.

They cannot grow at low pH (i.e. in acid conditions). In the right conditions of warmth, acidity and moisture they can multiply very fast indeed, producing millions of cells in a few hours. (danger zone 5°C to 63°C, 37° perfect temp.) Some bacteria form spores which are resistant to drying and heating. When conditions become favourable again to growth, they germinate and an active vegetative cell is released. There are more than 5,000 known species of bacteria, with new ones constantly being discovered. Each cell is bounded by a wall which maintains the shape of the bacterium and gives it protection. Examples include, Tuberculosis; Diptheria, Anthrax.

FUNGI

Are a large diverse group of spore-forming organisms. They have a rigid cell-wall. They are found widely in the environment and are divided into 3 main types, which are: Multi-cellular filamentous moulds Macroscopic filamentous fungi Single celled microscopic yeasts

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Fungi can cause superficial or systemic infections. A fungal infection usually appears on the skin [superficial], as the organisms live on a protein called keratin. This protein makes up the nails, skin and hair. The various symptoms of a fungal infection depend on the type of fungus that has caused the infection. Symptoms and appearance also depend on the part of the body infected. Examples of superficial fungal infections are: thrush, athleteâ&#x20AC;&#x2122;s foot. Systemic infections are more serious such as Aspergillus, a lung infection.

PROTOZOA

Are a large group of single celled organisms, which lack a rigid cell wall and usually chloroplasts. They vary widely in size, cell structure and form, ranging from amoeba with its very fluid shape and simple internal organisation to very complex organisms. Most protozoa are aquatic or animal parasites and can cause infections such as malaria, head lice, tape worms, scabies.

VIRUSES

Are different from other microbes, as they are small and have no cellular structures and can only multiple inside the living cell/animal/plant or other microbes. This process harms the host resulting in a disease == causing the cell to die or to change. Most viral infections are short lived; examples of virus infections include influenza, glandular fever, chicken pox, hepatitis A and B.

They can be destroyed outside the body by heat, radiation and some chemicals. Antibiotics have no effect on viruses. Most drugs that destroy viruses also destroy the host cell. The best protection against viruses is provided by vaccines (i.e. weakened strains of the virus that trigger the immune system). Many viruses mutate continuously rendering vaccines ineffective.

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PRIONS

Mad cow disease (BSE) and the similar human new variant Creutzfeldt-Jakob Disease {CJD) are fatal diseases in which the brain tissue breaks down. It is believed that rogue proteins called Prions are to blame. These are not microbes in the usual sense because they are not alive, but the illness they cause can be transmitted from one animal to another.

INFECTIOUS PROCESS An infection is a pathological process, which involves the damaging of the body tissues by microorganisms or by toxic substances produced by these organisms. How Infection is Spread 

DIRECT CONTACT == occurs when one person infects the next by direct person to person contact.



INHALATION == occurs when microbes exhaled or discharged into the atmosphere by an infected person are inhaled by and infect another person.

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INOCULATION == can occur following a sharps injury from contaminated blood, eg. HBV, HIV, HCV.

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INDIRECT == when an intermediate carrier is involved in the spread of pathogens from the source of infection to another person == such as == hands, air, vectors.

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INGESTION == can occur when organisms capable of infecting the gastro-intestinal tract are ingested. When an infected person excretes these organisms, faecal – oral spread can occur. Organisms can be carried on contaminated objects, hands, food, drink.

If microorganisms are able to defeat the host's defences of the immune system, the infection process follows several stages: 

PENETRATION OF TISSUE: and adherence to/or entry into cells.



MULTIPLICATION: at varying rates depending on the host and the organisms.

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SPREAD TO OTHER TISSUES: enters via one system of the body and infects other system.



DAMAGE TO TISSUE: by the release of toxins and enzymes.

CHAIN OF INFECTION The chain of infection represents the chain of events leading to the transmission of an infection. Within the chain are a circle of links, each representing a component within the cycle. Each link must be present and in sequential order for an infection to occur. Knowledge of this cycle allows the HCW to provide and implement care measures as appropriate to safe guard the client's health and well-being.

Who is vulnerable to Infection The ability to resist infection depends on: Age (very young/old). Nutrition. Stress. Fatigue. Health. Drugs. Disease. Injury. Open wounds.

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RESERVOIR: Is the environment in which a microorganism can survive, such as people, environment, equipment, water, food. Reservoirs allow the agent to survive or multiply.

PORTAL OF EXIT: Is the route by which the microorganism leaves the reservoir and can be transferred by direct or indirect methods. This can be by excretion, secretion, droplets or by skin scales. Also the placenta acts as a portal of exit in the transmission of infection from mother to foetus. MODE OF TRANSMISSION: Is the way in which a microorganism is acquired. It can be acquired by CONTACT, DROPLET OR AIRBORNE. The ability to infect at this stage depends on the microorganism's ability to infect, fix to the host, ability to invade and multiply and the strength of the host's immune system. PORTAL OF ENTRY: Is the route by which the infectious agent gains access to the susceptible host. Often the same as the portal of exit. Entry points === respiratory tract, gastro-intestinal tract, urinary system, the skin. SUSCEPTIBLE HOST: Is the final link. Certain groups of people are vulnerable (elderly, young and the immune-compromised patients, surgical patients, diabetic patients) because their bodies' defence mechanism is weakened or underdeveloped. The introduction of foreign objects {sutures, IV cannulas, prostheses} also increases a person's susceptibility to infection. Breaking the Chain In order to break the cycle within the chain, one or more links must be removed. Damani {2003} â&#x20AC;&#x201C; suggests that the mode of transmission link is the easiest to break. The application of standard precautions, adherence to clinical policies and implementing transmission based precautions as appropriate, are the overall key factors in breaking the chain of infection.

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Infection Control Measures: Are designed to reduce the risk of infection. These measures apply to the care of all clients/patients regardless of their diagnosis or infection status. They apply to blood, body fluids, broken skin, mucous membranes.

Measures include the following: 1. 2. 3. 4. 5. 6. 7. 8.

Personal hygiene standards & dress code. Hand washing. Appropriate cleaning procedures. Colour coding technique. PPE. Segregation of linen. Waste disposal techniques – segregation, labelling. Medical aseptic technique.

A ventilated theatre should have an air change rate of around 20 air changes/hr (1 air change every 3 minutes). Each air change will reduce airborne contamination to 37%. Keep operating room doors closed in order to optimise the efficiency of the ventilating system. Keep ‘traffic’ in and out of the operating room to a minimum during surgical procedures. Trolleys entering theatre should be designated for use in that theatre only and cleaned after each patient. Traditionally “dirty” cases are put last on the list; however it is not always necessary to put the “dirty” case last on the list provided the cleaning of relevant surfaces can be done adequately before the next patient. If it is judged that these processes can be carried out adequately during a list, there should be no extra hazard. If “dirty” cases (i.e. patients likely to disperse microbes of particular risk to other patients) are placed last on a list, this can facilitate the process of adequate cleaning/decontamination of the relevant surfaces.

HAND HYGIENE: The evidence for supporting a link between hand hygiene and contact transmission of infection is dated in history. It was first established by Oliver Wendell Holmes in the US {1843}. The current spread of antibiotic-resistant organisms can be attributed, at least in part to a failure by health-care personnel to wash frequently and effectively. SARI –2005, is a blueprint for the prevention and control of antimicrobial resistances in healthcare settings.

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Hand hygiene is a key component of this document and all staff must be familiar with this document. Many studies have shown that the bacteria that causes hospital-acquired infections are most frequently spread from one client to another via the hands of healthcare workers.

WHAT ARE YOUR HANDS CARRYING? TRANSIENT MICROORGANISMS: Located on the hands' surfaces. Easily acquired by direct contact. Easily transferred. Acquired from contact with body fluids, apparently clean surfaces. Easily removed by hand-washing. RESIDENT MICROORGANISMS: Are deep seated within the epidermis and colonise the skin. Play an important role in protecting the skin from invasion by other harmful species. Are not considered to be a risk to clients/patients during routine clinical care. Antiseptic/surgical hand hygiene is required to reduce their presence prior to invasive procedures.

Cuts and abrasions must be covered with a dressing that is waterproof. Contamination with blood or body fluid must be immediately washed with soap and water. Staff that have exudating lesions, eczema or similar skin conditions should be reviewed by the Occupational Health Department before participating in exposure prone procedures. Hands must be decontaminated before and after every patient contact, as per hand hygiene policy. Hand decontamination is an important contributor to reducing infections. Hands must be decontaminated by an appropriate method.

HOW TO CLEAN HANDS Hand rubbing with alcoholâ&#x20AC;&#x201C;based hand rubs is the preferred routine method of hand hygiene if hands are visibly not soiled. Hand washing with soap and water is essential when hands are visibly soiled. It is important that a defined technique is used when performing hand hygiene, so it is effective:

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The 3 Levels of hand hygiene are: SOCIAL. ANTISEPTIC. SURGICAL.

SOCIAL HAND WASHING TECHNIQUE: Remove jewellery. Turn on taps. Wet hands, with warm water. Apply 5mls of liquid soap to hands. Wash using defined method. Rinse well. Turn off tap with paper towel or hands free method. Pat dry hands. Discard paper towel in bin.

SOCIAL HAND HYGIENE RATIONALE Attain socially clean hands

AGENT Good quality liquid soap and warm water

DURATION INDICATION 15 seconds

Remove dead skin cells Remove most transient organisms

Start and end of shift Eating Handling food After patient contact Removing gloves Using lavatory Handling soiled material / equipment

ANTISEPTIC HAND HYGIENE TECHNIQUE SAME AS PER SOCIAL HAND WASHING SURGICAL HAND HYGIENE

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SURGICAL HAND HYGIENE RATIONALE AGENT

DURATION

INDICATION

Remove transient and reduce resident microorganisms

3-5 minutes

Before invasive surgical procedures

Antiseptic soaps

Technique: nontouch technique

HANDRUBS / HAND GELS Washing hands frequently with soap and water is = inconvenient = time-consuming = often causes skin irritation. Need to make cleaning hands, faster, more convenient and less irritating. Experts now recommend that healthcare workers routinely clean their hands with an alcohol-based hand rub { gel, foam, rinse}. Numerous studies have shown that alcohol-based hand rubs remove bacteria from hands more effectively than washing hands with plain soap and water. In most studies, alcoholbased hand rubs removed bacteria from the hands to a greater degree than did washing hands with antimicrobial soap and water {Boyce, J.M, Pittet, D, et al, 2002}. ALCOHOL-BASED HAND RUBS: Requires less time === 15 secs. Can be strategically placed. Readily accessible. Multiple sites. All patient/client care areas. WHEN TO USE ALCOHOL HAND RUBS : If hands are NOT visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning your hands. For example:

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Before contact with patient/client. After contact with patient/client skin. After having contact with body fluids, wounds, or broken skin. After touching equipment or furniture near the patient/client. After removing gloves.

APPLICATION OF HAND RUBS: Apply quarter sized amount to palm of hand. Rub together. Cover all surfaces of hands and fingers. Include areas under and around fingernails. Continue rubbing hands together until alcohol rub dries – use the same technique as per social hand washing. Don’t rinse. CAUTION: If after cleaning your hands 5-10 times with the alcohol-based rub, you feel a buildup of emollients on your hands, wash hands with liquid soap and water.

GENERAL POINTS FOR HAND HYGIENE: Only use liquid soap from a dispenser. Never use open topped jars of hand emollients. Gloves must never be regarded as a substitute for hand washing. Hands must be washed before and after glove use. Ensure all sinks are equipped with liquid soap, paper towels, and alcohol hand rubs. Ensure alcohol hand rubs are conveniently located within the care area.

Recommendations for pre-operative surgical scrub: • • • • • •

Agents or methods of skin decontamination that cause skin abrasions should not be used. Using a scrubbing brush on the skin is not recommended. The first wash of the day should include a thorough clean under the fingernails; a brush or orange stick can be used. Nailbrushes should be single use disposable. An approved antiseptic agent should be used for hand washing. ‘Surgical scrub’ hand wash should be for a minimum of 2 minutes.

In between cases, use of alcohol gel hand rub, applied using correct technique, is considered adequate in the operating theatre where the surgeon’s hands are clean and have already been decontaminated.

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Personal Protective Equipment: GLOVES PPE is used in addition to normal uniform to protect both the client and staff from cross infection and reduce the spread of microorganisms. PPE is one of the main principles of standard precautions. It is both the employers and employees responsibility to ensure it is provided and worn appropriately. The decision about what PPE to wear depends on: the type of work you are doing; the type of care you are providing to your client; the risk associated with a task. All decisions should have regard to current health and safety legislation and local infection control guidelines. PERSONAL PROTECTIVE CLOTHING: Gloves. Aprons. Face masks. Eye protection/goggles. GUIDELINES: PPE should be easily accessible. It is a health and safety requirement. Usage should be based on a risk assessment of the task to be undertaken. PPE is single use only. Must be disposed of correctly. GLOVES {STERILE & NON-STERILE} Gloves should be worn to reduce the risk of exposure to infectious agents and/or material that may be carried on the hands for both the HCW and the client. Gloves are made of a variety of materials (e.g., latex, vinyl, nitrile and rubber). Alternatives to latex should be available for HCWs or clients with a latex allergy. Hand hygiene should always be performed following glove removal. No attempt should be made to wash gloves in water or clean them with alcohol gel. SHOULD BE WORN: Emptying catheters, removing catheters, dressing wounds, cleaning body fluid spillages, care activities where there is a known/suspected infection. Before handling blood, body fluids, secretions, and contaminated items. When touching mucous membranes and non-intact skin. Gloves must never be used as a substitute for hand hygiene.

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The aim of wearing gloves is: To protect hands of staff. To protect clients/patients. To prevent cross-infection. GLOVES should not be worn unnecessarily, as adverse skin reactions can occur. Gloves are not a substitute for hand-washing. Gloves are single use only, and it is very important to wash hands and dry thoroughly following glove removal and to prevent skin irritation. Gloves used for client care should: Be single use only. Conform to European Union standards. Be sterile if contact with a sterile body site is anticipated and for aseptic procedures. Fit the wearer and be appropriate to the task. Be removed in a manner to prevent contamination. Be changed between procedures on the same client (e.g., upon moving from a contaminated body site to a clean body site). Removed after the task or episode of client care. Removed if punctured, soiled with bodily fluid or after contact with contaminated environmental surfaces. Not be worn unless required and not for longer than necessary. Glove types: Latex gloves (non powdered) are recommended for sterile invasive procedures and potential exposure to blood. Nitrile gloves should be worn by HCWs with latex allergy on the advice of occupational health. Nitrile gloves are usually coloured, so care should be taken not to mistake nitrile with latex gloves. Vinyl gloves may be used for personal care but are not recommended for blood contact. Non-sterile disposable or reusable. Gloves are recommended: For all activities that carry a risk of contact with blood, body fluids, secretions or excretions or contaminated items or surfaces for example: washing a client who has been incontinent; blood sugar testing; invasive procedures e.g. taking blood; obtaining and handling laboratory specimens; when in contact with mucous membranes (lining of the eyes, nose, mouth, anus and vagina) and non-intact skin (example= wound, skin rash); when handling contaminated equipment and the environment; when handling chemicals including household cleaning products and disinfectants. Gloves should not be worn for administrative tasks such as using a telephone or a computer keyboard or writing in a clientâ&#x20AC;&#x2122;s case/nursing notes.

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APRONS Worn to protect clothing during procedures likely to generate splashes of any body fluids. Aprons help to reduce the risk of spreading microorganisms. They are single use only and should be disposed of immediately after use appropriately and hand hygiene performed. An apron or gown should be worn when close contact with the client may lead to contamination of the skin, uniform or other clothing with infectious agents, blood, body fluids, secretions or excretions. The type of apron or gown required depends on the degree of risk of contact with infectious material and the potential for blood or body fluids to penetrate through to clothes or skin. A clean non-sterile disposable plastic apron is generally adequate where there is a risk that the front of uniform/clothing may become contaminated with blood, body fluids, excretions or secretions. Aprons/Gowns should be: Suitable for the task to be performed. Single use â&#x20AC;&#x201C;used for one procedure or episode of client care and then discarded and removed before leaving the client care area.

EYE PROTECTION {goggles/visors} Used where there is a high risk of splashes and when handling chemicals. Visors are single use only. Goggles == clean and disinfect.

MASKS The principle use of masks is to protect the nose/mouth of staff during procedures which generate splashes of any body fluids, and respiratory precautions. There are various types, and they must be worn correctly, handled as little as possible, and for single use only. Hand hygiene should be performed after removal. FACE AND EYE PROTECTION Face and eye protection should be worn by HCWs during any procedure or activity where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. Face protection consists of one of the following: Fluid repellent surgical mask with separate goggles/eye shield. Face shield. Fluid repellent surgical mask with integrated eye shield. Respirator (FFP2/3) masks with separate goggles or eye shield. FFP2/3 masks are not required for standard precautions.

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Face protection should be: Selected according to the anticipated risk of the procedure. Worn over the nose and mouth and fitted snugly to the face. Single-use or if reusable, single person use. Cleaned and disinfected according to manufacturer's instructions after each use.

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ENVIROMENTAL CLEANING The goal of environmental control in the operating room setting is to keep microorganisms to an irreducible minimum in order to provide a safe environment for the patient and healthcare worker. DECONTAMINATION The term decontamination is an overall term used for the processes used to render an item safe for use. Cleaning, disinfections and sterilisation are used to remove microorganisms from the hospital environment and from equipment used for patient care. High standards of cleanliness and hygiene are necessary to create an environment that reduces the risk of infection being transmitted. It is a process which removes or destroys microorganisms, thus rendering an object safe for use. It involves cleaning, sterilisation and disinfection. The method selected must consider the level of risk of infection to the patient. Cleaning is a process, which physically removes organic matter but does not necessarily destroy microorganisms. In order to decontaminate patient equipment effectively, all organic debris (for example, blood, tissue and other body fluids) must be removed during the cleaning process in order to reduce the risk of transmission of infectious agents. DISINFECTION Means reducing the number of microorganisms present on an object. However, disinfections does not kill all bacterial spores. The most adequate method is by washing with hot water and detergent [moist heat]. This method is achieved by washing items in instrument washer/bed pan washer/dishwasher at a high temperature. Cleaning should be performed on a regular basis to reduce the amount of dust, organic debris, and microbial load in surgical environments. Operating rooms should be cleaned before and after each surgical procedure and at the end of each day. Cleaning also may be necessary during any surgical procedure. Environmental cleaning is a team effort involving surgical personnel and environmental services personnel. The ultimate responsibility for ensuring a clean surgical environment rests with perioperative staff. All horizontal surfaces in the OR (eg, furniture, surgical lights, equipment) should be damp dusted before the first scheduled surgical procedure of the day with a clean, lint-free cloth.

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Equipment from areas outside the OR should be damp dusted before being brought into the OR. Dust and lint are deposited on horizontal surfaces. Proper cleaning of these surfaces helps reduce airborne contaminants that may travel on dust and lint. Preparation of the OR should include visual inspection for cleanliness before procedure starts, supplies, and instrument sets are brought into the room. Although the level of contamination that can influence surgical site infection rates is not known, a clean surgical environment will reduce the number of microbial flora present. Common Cleaning agents in HSE    

Neutral detergent. Cream cleanser. Enzymatic detergents to break down organic matter. Disinfectants as agreed locally for e.g. blood borne viruses HIV, HBV, HCV, known transmissable infections, e.g. MRSA, Clostridium difficile, Norovirus.

Correct dilution of disinfectants is essential! In the event of surgery being carried out on a patient who is known to be infected with clostridium difficile, or on a patient who has come from a closed ward area deemed to be at high risk by the infection control team, all clinical areas with which the patient has had contact must be deep cleaned with, for example, Actichlor Plus. General cleaning should be carried out regularly in addition to preparations on the day of surgery. Floors and sometimes walls and ceilings must be washed in all rooms used as part of the operating theatre suite. Any furniture including instrument tables, operating tables and cabinets must be wiped clean to avoid the build-up of dust. The operating room must be kept free of unnecessary equipment and clutter. The anaesthetic room/other areas should be free of clutter and unnecessary equipment to facilitate cleaning. The theatres should be visibly clean and free from dust. Items and equipment must not be stored directly on floor. Floor areas must be kept free. Storage areas: items should be stored in racks above floor height. Ventilated grilles in doors should not be occluded or obstructed by equipment. Storage of supplies and consumables in preparation/rooms off operating room, should be kept to a minimum, with appropriate stock rotation to ensure no build-up of dust. The fabric in theatre should be kept in a good state of repair. Any chipped tiles, defects in floor or fabric of area should be replaced or repaired. Theatre trolleys must be free of dust and without dirt or spillage; the fabric of the trolley should be in good condition.

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DAMP DUSTING: Damp dusting should be done before the first scheduled incision time of the day. Dust is the main carrier of microorganisms and pathogens. Equipment or procedures for cleaning must not spread dust around. Dry Dusting is banned without static cloths! Never use a sweeping brush in a patient area and vacuum cleaners must be fitted with special bacterial retaining filters (complying with BS 5415 standards). Damp dusting results in less air contamination. Use colour coded cloths and equipment. Fold cloth repeatedly to utilise entire clean area. Rinse cloth in clean solution while dusting. Water must be changed frequently. Damp mopping is used on floor areas. Always wear PPE. Damp dust when?

Routine, before and between cases. Table, floor, trolley, etc. Spillages - immediately. Multi patient use items.

Daily Cleaning Areas around the surgical suite are cleaned according to need during the day. Scrub sink areas need particular attention during the day, particularly because water, a vehicle for bacterial contamination, is frequently splashed on the floors and walls. Scrub areas are frequented by surgeons who may or may not have removed protective shoe covers between cases. Frequently, in the course of a busy schedule, blood and debris can be tracked from one surgical suite to another through pooled water at the scrub sinks. The halls and doorways of the operating room are frequented by heavy traffic and also need particular attention. Patient trolleys must be cleaned with disinfectant after each use. Linen must be removed and disposed of in the proper receptacle, and side rails, legs, and castors must also be cleaned. All furniture, surgical lights, and fixed equipment used in the operating suites must be damp dusted with a dean, lint-free cloth and a hospital-grade chemical disinfectant. Environmental dust falls to horizontal surfaces, carrying disease causing microorganisms with it.

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End of Day Cleanup --- TERMINAL CLEAN

A terminal clean is performed in addition to the end of day cleaning in high risk areas, such as theatre. During this end of day clean all equipment and furniture is removed, surfaces are damp wiped with disinfect as per local policy, floors are hovered and washed.

DEFINITION: A terminal clean is a thorough, extensive cleaning and disinfection of an operating room. At the end of the theatre list all operating room suites, scrub sink areas, utility rooms, hallways, furniture, all equipment and furniture used during a surgical procedure, are thoroughly cleaned with a hospital approved disinfectant. During the cleaning process, mechanical friction is instrumental in the destruction of microorganisms. Floors should be cleaned using a wet-vacuum system. This can be a centralised built-in system or a portable wet-vacuum. Mop heads must be sterilised or a disposable mop head (used once only) used in the operating room suite. Solutions and mop heads are changed for each suite and the buckets cleaned before new solution is mixed. The pads of the operating table are removed to expose the under-surface of the table. All surfaces of the table and pads are cleaned with particular attention to hinges, pivotal points, and castors. It is necessary to move the table to clean under the supporting post and castors. Doors and walls are spot cleaned with disinfectant. Additional attention should be paid to supply cabinet doors in the area around the latches or handles. Linen bags are sealed and removed to the appropriate disposal area. PROCEDURE: THEATRE DEPARTMENT: WEAR APPROPRIATE PPE. ENSURE CLEANING SIGNS ARE IN PLACE. PREPARE DISINFECTANT SOLUTION AND HAVE ALL NECESSARY AIDS – CLOTHS, MOP, HOOVER. DAMP WIPE ALL REMOVABLE FURNITURE PAYING ATTENTION TO WHEELS AND CASTORS. MOVE ALL REMOVABLE FURNITURE TO HALLWAY. SCRUB ALL KICK BUCKETS AND RACKS. VACUUM AIR CONDITIONING GRILLS. CLEAN ALL SHELVES AND UNITS. DAMP WIPE WITH DISINFECTANT ALL OVERHEAD LIGHTING. WASH WALL SURFACES WITH DISINFECTANT SOLUTION. EMPTY BINS, CLEAN SOAP DISPENSERS AND REFILL AS REQUIRED. REMOVE OPERATING TABLE MATTRESS AND WASH, THROUGHLY CLEAN BASE OF TABLE AND THEN REMAKE OPERATING TABLE. SCRUB ALL SINKS. HOOVER ALL FLOORS. WASH FLOOR WITH DISINFECTANT. RETURN FURNITURE TO ROOM WHEN FLOOR IS DRIED

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Colour Coding for Infection Control

Cloths/equipment in sanitary areas/washroom floors.

Hand wash sinks & all other washroom areas.

Cloths/equip all general areas – ward, dept, office etc.

ALL kitchens, ward or main.

Disposable – cloths for isolation rooms and theatre.

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ASEPTIC TECHNIQUE & THE STERILE FIELD Asepsis is the state of being free from living pathogenic microorganisms. Aseptic technique is a method employed to maintain asepsis and protect the patient from HCAIs. It protects the healthcare professional from being contaminated with the patient’s blood, body fluids and toxic substances. The patient is particularly at risk for invasion of exogenous bacterial infections because the most significant protective barrier (the skin), is interrupted during surgery. The term Aseptic Technique infers absolute cleanliness, without contamination, and in fact, prevention of contamination. This not only addresses personal performance of medical staff members, hospital employees and visitors, but also the methods used for sterilisation and processing of instruments and equipment used within the operating room as well as maintaining an impeccably clean environment. Surgeons, assistants, and perioperative personnel who have performed a surgical hand scrub and donned sterile gowns and gloves, should be considered sterile. Care must be taken to avoid inadvertent contamination of these team members. The surgical gown is considered sterile in the front from axilla to waist level, from hands to just above elbows and from side to side. Although the back of the gown is considered unsterile, it is poor technique and inappropriate to touch a scrubbed team member on the shoulder or back. If you need to gain the attention of the surgeon or member of the sterile team, it is highly recommended that you enlist the assistance of the circulating nurse in charge of the room. The Sterile Field

The sterile field consists of those areas in the operating suite that are covered with sterile drapes as well as personnel wearing sterile gowns. Generally speaking these areas may include:      

The patient. The back table. The mayo stand. The microscope. Radiological equipment. The surgeon, assistant, scrub person.

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The sterile field is constantly monitored by the personnel in the room. All items within the sterile field should be sterile. All items placed upon, or within, the sterile field should be sterile. When presenting items to the sterile field there are a variety of things to be checked, proper packaging, package integrity, and sterile indicators are a few. Although presentation of supplies to the sterile field is not a difficult skill to master, it is one that requires practice to become proficient. Operating room activities pertaining to asepsis and aseptic practices have the greatest direct impact upon the surgical team in helping to reduce the patient's risk to surgical site infection. The goal of asepsis is to prevent the contamination of the open surgical wound by isolating the operative site from the surrounding non-sterile environment. The surgical team accomplishes this by creating and maintaining the sterile field and by following aseptic principles aimed at preventing microorganisms from contaminating the surgical wound.

The principles of aseptic technique include the following principles. 1. Scrubbed persons function within a sterile field. The surgical team is made up of sterile and non-sterile members. Sterile members or "scrubbed" personnel work directly in the surgical field while the non-sterile members work in the periphery of the sterile surgical field. All surgical team members wear scrub attire. In addition to scrub attire, scrubbed persons must wear a sterile surgical gown, mask, and gloves within the sterile field to establish bacterial barriers. These barriers protect the patient from the transmission of microorganisms from the surgical team.

2. Sterile drapes are used to create a sterile field. Sterile surgical drapes establish an aseptic barrier minimising the passage of microorganisms from non-sterile to sterile areas. Sterile drapes should be placed on the patient, furniture, and equipment to be included in the sterile field, leaving only the incisional site exposed. During the draping process, only scrubbed personnel should handle sterile drapes. The drapes should be held higher than the operating room bed with the patient draped from the prepped incisional site out to the periphery. Once the sterile drape is positioned, it should not be moved or rearranged. Keep in mind that after the patient and operating room tables are draped, only the top surface of the draped area is considered sterile.

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3. All items used within a sterile field must be sterile. Sterilisation provides the highest level of assurance that all instruments, sutures, fluids, supplies, and drapes are void of microorganisms. The sterility of a package is determined by events, not by time. To ensure sterility, all sterile items need to be inspected for package integrity and sterilisation process indicators, such as indicator tape and internal chemical indicators, prior to introduction onto the sterile field. If a package has been compromised, it should be considered contaminated and not be used.

4. All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. All sterile items should be dispensed to the sterile field by methods that preserve the integrity of the items and sterile field.. Non-sterile personnel, usually the circulating nurse, must use good judgement when dispensing sterile items onto the sterile field either by presenting them directly to the scrubbed person or placing them securely on the sterile field.. Sterile items that are tossed onto the sterile field may displace other sterile items, penetrate the drape, or roll off the sterile field causing contamination to occur.. When opening wrapped supplies, the non-sterile person should open the top wrapper flap away from them first, then open the flaps to each side. The last wrapper flap is pulled toward the non-sterile person opening the package. This technique of opening a wrapped package ensures that the non-sterile person does not reach over the sterile item inside. All wrapper edges should be secured to prevent flipping the wrapper and contaminating the contents of the sterile package or field. After a wrapper has been opened, the inside of the wrapper and its contents are considered sterile with the exception of the 1-inch outer edge of the wrapper. This 1-inch outer edge of the wrapper is considered the "margin of safety" between sterile and non-sterile. When a package is double wrapped, each institution's policies and procedures determine if one or both wrappers are opened before presentation to the sterile field. When opening a peel package, the non-sterile person opens the package by rolling the wrapper over his or her hands and presenting the inner contents of the package to the scrubbed person. The package and its contents must be presented in such a way to prevent contamination of the sterile item or the scrubbed person. When determining package content sterility, the inner edge of the heat seal is considered the line separating sterile from nonsterile.

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When opening a solution container, the non-sterile person should lift the cap straight up and pour the contents of the bottle into a sterile container. The sterile container is either held by the scrubbed person away from the sterile field or placed near the edge of a sterile waterproof-draped table. Only the top rim of the bottle top and bottle contents are considered sterile once the cap has been removed from the bottle. Therefore, when sterile fluids are dispensed, the entire contents of the bottle must be poured or the fluid remaining in the bottle discarded. When solutions are poured onto the sterile field, they should be poured slowly to prevent contamination and fluid strikethrough from splashing.

5. Sterile field should be maintained and monitored constantly. It is the responsibility of the operating room staff to monitor and maintain the sterile field. Sterility can never be absolutely guaranteed, but surgical team members should make every reasonable effort to reduce the likelihood of contamination and be vigilant to breaches in sterility. When a breach of sterility occurs, team members must take immediate and appropriate action to correct the break in technique to reduce further risk of contamination. Remember, if there is doubt regarding an item's sterility, consider it not sterile. The sterile field should be prepared as close as possible to the time of use. The sterility of supplies used during a surgical procedure can be affected by the events taking place within the operating room, and the length of time the items have been exposed to the environment. Once set up, the sterile field needs to be monitored constantly. When the sterile field is left unattended, personnel, airborne contaminants, insects, and liquids can contaminate the sterile field.

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6. All personnel moving within or around a sterile field should do so in a manner to maintain the sterile field. Since the patient is the centre of the sterile field, scrubbed personnel should remain close to this area without wandering around the room. This movement can result in contamination of the sterile field. Scrubbed personnel should move only from sterile areas to sterile areas. When scrubbed personnel change positions, they should maintain a safe distance from each other and always pass each other by turning back-to-back or face-to-face. This movement reduces the risk of contamination by ensuring the scrub persons are passing either non-sterile to non-sterile or sterile to sterile. Scrubbed personnel should keep their arms and hands within the sterile field at all times to avoid any accidental contact with non-sterile items or areas. Scrubbed personnel must maintain a safe distance when approaching non-sterile objects and personnel. This safe distance or "margin of safety" is important in identifying safe boundaries between sterile and non-sterile areas. Non-sterile personnel should always remain in non-sterile areas and make contact with only non-sterile items to prevent contamination of the sterile field. It is important that the nonsterile personnel always face the sterile field on approach and should never walk between two sterile fields.

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SAFE PROCEDURES

HANDLING BODY FLUIDS Spillages of body fluids can pose risks to healthcare workers from both injury and contamination. It is important to be vigilant and be aware of health and safety issues and the recommended infection control guidelines with regards to the management of spillages. URINE SPILLAGE: Wear appropriate PPE. Identify area with hazard sign. Wipe up spillage with paper towels, discard into domestic waste bag, unless contaminated with blood or known/suspected infection. Wash area with detergent and hot water using disposable cloths. Dispose of PPE, in domestic waste, carry out hand hygiene. Do not use Hypochlorite disinfectant {milton, haztabs, actichlor, on urine as they react with the acid in urine, thus realising a toxic vapour}. OTHER BODY FLUIDS {sputum, vomit, faeces}: Wear appropriate PPE. Identify area with hazard sign. Wipe up spillage with paper towels, discard in domestic waste, unless contaminated. Wash area with detergent and hot water, using disposable cloths. Dispose of PPE, in domestic waste, and perform hand hygiene. Blood spillages: you should refer to local policy with approved disinfectant as there are procedures for small and large spills of blood. If the care setting has a spill kit it is recommended that it is used. Materials: Approved disinfectant. Personal protective equipment. 1 pair safety glasses. 1 plastic apron. Gloves. Disposable face mask. Cleaning equipment. Paper tissues. Virkon powder/Actichlor granules. Plastic scoop.

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Procedure: Small spills. Put on gloves. Moisten a paper towel with approved disinfectant, clean soiled area. Discard all waste into yellow bin. Remove gloves, wash hands. Large spills {using virkon} Put on PPE with 2 pairs of gloves. Cover spillage with Virkon powder. Leave for 3 minutes. Add 1 litre of tap water to 10g Virkon powder in bottle to give a 1% solution. Scrape powder spillage mixture into a yellow bin using the scoop provided. Moisten a paper towel with 1% Virkon and clean soiled area. Discard all waste in yellow bin. Remove gloves, wash hands. HANDLING BLOOD PRODUCTS During surgical procedures, blood transfusion may be a necessity. Hospitals must have a written policy for the collection of blood components and their delivery to the clinical area where the transfusion is to be given. Collection of Blood Products:  

 

Blood components requiring refrigeration must be stored only in blood storage refrigerators and not in ward or domestic refrigerators. Blood components must only be stored or transported, as appropriate, in boxes designed and validated for this purpose, including the time for which storage is satisfactory. The HCA must take written details to the transfusion laboratory or the blood fridge and know what type of product they are going to collect. The staff member removing blood components from the storage facility must have documentation containing the patient’s identification details and this information should be checked before removing the blood. Withdrawals and returns of blood components should be documented, including the date and time of removal and return. Staff in the ward or operating theatre must check that the correct blood component has been delivered.

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Disposal of Blood Bag {see local policy}: • • • •

Wear PPE. Dispose of the blood bag into the yellow rigid bin with the yellow lid. The disconnected blood administration set (sharp hazard) should then be placed into a sharps disposal container. Never cut the blood administration set as you are at risk of splashing yourself with the blood contained in the set.

This is the End of Unit 2:

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NOTES: