Minimising the spread of infection in the operating department.
Abstract: We live in a world of continuing advances in technology, surgical techniques and rapidly improving medicine. Despite these advances, diseases are continuing to thrive and cause infection both in the community and, more disturbingly, in hospitals. Damani (2003) states that medical care is more complex than ever before, and this has resulted in hospital acquired infections (HAls) increasing due to organisms which are resistant to antibiotics such as: methicillin resistant staphylococcus aureus (MRSA) and vancomyan resistant enterococci (VRE). Wilson (2006) explains that hospitals provide a particularly fertile breeding ground for resistant micro-organisms, due to the widespread exposure to antibiotics and the many opportunities that hospitals provide to transfer MRSA between vulnerable patients and into sites which are susceptible to infection, such as wounds and invasive devices. Damani (2003) emphasises again that the key to successful control of antimicrobial resistant pathogens in hospitals is good isolation techniques, and especially rigorous attention to hand hygiene by all members of staff who are in contact with patients affected or colonised with resistant pathogens. The aim should be to eliminate the infection as quickly as possible and to ensure that the patient's period of isolation is kept to a minimum. Advice and knowledge about the control of infection is therefore imperative.

KEYWORDS Ventilation / Hand washing / Waste responsibility / Theatre attire / Infection management
Article Type: Report
Subject: Cross infection (Control)
Cross infection (Research)
Nosocomial infections (Control)
Nosocomial infections (Research)
Hospitals (United Kingdom)
Hospitals (Environmental aspects)
Author: Wilson, Rachel
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Topic: Event Code: 310 Science & research
Product: Product Code: 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 300545543
Full Text: Patients undergoing operations are highly susceptible to infections due to the invasive procedures carried out in the operating department. They are considered to be highly vulnerable as the operating theatre environment provides plenty of opportunities for micro-organisms to be transferred (Wilson 2006). This paper will discuss various ways in which the risk of infection can be minimised in the operating department. This will include: the chain of infection, hand washing, theatre attire, waste management, the design of the operating theatre and the basic principles of perioperative care. Legal and ethical implications regarding infection control will also be discussed.

Hospital acquired infections and the chain of infection

Hospital acquired infections (HAIs) cost lives. In 2007, the National Audit Office (NAO 2009) recorded 9,000 people as having died after contracting infectious agents such as MRSA or Clostridium difficile (C. difficile) whilst being treated in hospital. In 2004, the Department of Health confirmed that 300,000 was the best approximation of the number of HAls per year (NAO 2009). According to Horton and Parker (2002) these statistics increase patients' stay in hospital by between 7 and 11 days, and cost the NHS over one billion pounds a year. All the infections were contracted in hospitals, with 44% of these down to the 'superbug' MRSA. Wicker and O'Neil (2006) state that 30% of HAls could have been prevented. Infection is the process in which micro-organisms enter the body through a susceptible site and multiply out of control, resulting in disease. Infection may be caused by reservoirs such as bacteria, viruses, parasites or fungi. For infection to be transmitted the following must be present: an infectious agent, a reservoir with a portal of exit, mode of transportation, a portal of entry into the susceptible host and finally a susceptible host. These components are referred to as the 'chain of infection' and only when one of the links is removed, can infection be prevented (Munson &Traister 2005). The first link in the chain is the infectious agent, also called a pathogen, which is capable of causing disease. Agents can be bacteria, fungi, parasite worms or viruses. Agents can lead to diseases such as tuberculosis and can mutate further into more virulent forms such as influenza virus (Alters & Schiff 2009). Agents cannot survive efficiently without a viable environment, and this is called a reservoir. This is the second link in the chain and it is the habitat in which the infectious agent will live, grow and multiply. Reservoirs can be animals, humans or the environment (Mercier 1997).

The third link in the chain is the portal of exit, that is - the route that the agents take out of the reservoir, thereby causing disease to other hosts. The main portals include blood and respiratory, digestive, urinary and reproductive systems. The mouth and nose are common exits for respiratory infections such as the cold virus. Blood-borne diseases such as the human immunodeficiency virus (HIV) leave the reservoirs via needles, i.e. hypodermic syringes, bleeding or insects (Alters & Schiff 2009). The fourth link is the mode of transmission. This is the method that an infectious agent will use to move from a reservoir, through a portal of exit and into a potential host. Modes include direct and indirect contact, air and common vehicles; these will be discussed later (Lindsay et al 2011).

The fifth link is the portal of entry which agents use to enter their potential hosts.This can occur by various means including breaks in the skin, the respiratory and digestive systems. The genital tract and the conjunctiva are other portals. Agents can infect cells when entering via broken skin, which could have resulted from trauma, bite or injection (Wilson 2006). The final link is the new host, who is a person who can become unwell when exposed to disease, causing micro-organisms. In relation to HAls it is the patient who is the potential new host (Alters & Schiff 2009).The operating department is the ideal environment for microorganisms to flourish and grow. This is due to breaks in infection control procedures and practices, and invasive surgical procedures. These factors leave a patient in a vulnerable state with their immune system weakened and can result in a susceptible host and a portal of entry for the chain of infection to begin (Wilson 2006). This highlights the fact that the initial design of the theatre has an impact on preventing the means of transmission for infection. Horton & Parker (2002) emphasise that one of the fundamental principles contributing to infection control is the creation and overall maintenance of a safe environment, ensuring patient and staff safety. Ventilation, humidity and baseline temperature all affect the presence and the spread of microorganisms within the theatre (Radford et al 2004).

Ventilation

Indirect transmission refers to the transfer of an agent from a reservoir to a host by suspended air particles or inanimate objects (Palin 2007). Airborne transmission occurs when infectious agents are carried by droplet nuclei suspended in air. Laminar flow ventilation combats this in theatre by continuously moving highly filtered ultraclean air, of less than 10 colonyforming units of bacteria per cubic metre circulating within the theatre under positive pressure, to remove any airborne bacteria generated during surgery (Lindsay et al 2011). An ultraclean air system is used to further reduce airborne contamination and has the capacity to provide up to 400 air changes per hour. This is employed in orthopaedic theatres, due to the fact that only a very small number of bacteria is required to produce deep infections within bones (Horton & Parker 2002).

Weaver et al (2008) declared that the ventilation system was in place to filter air from clean to less clean areas and that ventilation can combat infections such as C. difficile that will thrive in the correct environment (Horton & Parker 2002). A minimum of 20 air changes per hour of filtered air should be delivered in the theatre and the temperature should be between 18 and 25[degrees]C. Humidity should be sustained at 40-60% to inhibit microbial growth and also for staff comfort (Damani 2003). Even the walls and ceilings of the theatre are covered with non-porous material that is impervious to bacteria and dust and can be easily cleaned. Personnel numbers in theatres should be kept to a minimum due to the risk of infection increasing according to the amount of movement and microorganisms present. Microorganisms will use theatre staff as a reservoir within the chain of infection and Palin (2009) emphasises that staff wearing non-sterile theatre attire should keep their movements in and out of the department to a minimum. Decontaminating equipment and preparing equipment before an operation is essential to minimise movement (McArthur-Rouse &Prosser 2007).

Hand washing

Infections can arise from two sources. An endogenous infection results from microorganisms which are part of the patient's own body flora and can cause infection in the immune-compromised host. Alternatively an exogenous infection may be acquired from an external source, i.e. from an infected patient to another patient (Wilson 2006). This can be achieved by direct transmission when an infectious agent is transmitted from a human reservoir to a susceptible host by direct contact, which can occur through skin-to-skin contact. Efficient hand hygiene is vital because the majority of healthcare tasks are carried out using the hands, resulting in them being the main mode of transmission of infectious agents in hospitals (Ghorbani et al 2012).

Pirie (2010a) emphasises that hand washing is the single most important measure in the control of infection. It is performed to remove organisms from the skin and to prevent microorganisms using the skin as a portal of exit from one person to another. There are two forms of hand wash, the routine and the surgical. The routine is the most common form and should be practised regularly in everyday actions. In a healthcare environment this must be performed before direct contact with a patient's skin, their food, their dressings and devices (Damani 2003).

Waste responsibility

Waste in the operating department can indirectly transmit an infectious agent. Barrow (2009) states that waste management is a major issue in the healthcare setting, and an issue which is made prominent by media reports of used syringes and even human tissues being found washed up on beaches. According to Mercier (1997) hospitals must pay close attention to the disposal of their waste or risk having adverse publicity or even perhaps legal proceedings. Clinical waste is perhaps the most dangerous by-product of the operating department and must be placed in yellow coloured bags according to the Health, Safety and Welfare Regulations (1992).

Cunnigton (2006) states that members of staff in the theatre bear a major responsibility for correctly disposing of waste, which is accurately labelled under health and safety regulations. Special containers are used in the disposal of sharps; theses are necessary due to the high incidence of sharp-related injuries to hospital employees. There have been cases of infection with hepatitis B following such injuries and there is now also the added risk of HIV infection. Waste must be correctly disposed of and segregated before disposal in line with local waste polices (Peers et al 2001).

A patient's operation takes place within the aseptic zone of the theatre. This is the surgical area which is intended to be kept free of microorganisms by the use of antiseptics, barriers and washing techniques. Surgery alone presents a portal of entry for microorganisms. According to Davey (1999) universal infection control precautions are in place to prevent accidental exposure to serious infections such as the HIV and hepatitis viruses (HBV, HCV and HGV). These precautions were originally recommended when a person was suspected or known to have these serious infections, but because at times this information is unknown, standard infection control precautions should be used in relation to all patients.

Standard infection control procedures include that all staff should dress correctly in the operating department. Line (2003) states that staff must change into appropriate theatre attire before entering this zone. This includes a two piece pantsuit, a theatre hat and footwear with impervious soles. These provide protection for patients against the microorganisms that are shed continuously from the wearer's skin and hair. Additionally the wearer is protected from the patient's blood and bodily fluids. Damani (2003) highlights that the operating team members that are scrubbed should wear sterile gowns, gloves, masks and protective eyewear because they are part of the sterile field; any attire worn in theatre should not be worn outside of the operating environment in order to prevent cross-contamination.

Appropriate theatre attire

Pirie (2010b) states that, customarily, gowns are worn throughout sterile procedures to eliminate the spread of bacteria from the scrubbed member of staff to the operating environment or the surgical site. Theatre hats must be worn because the bacterium staphlococcus aureus is present on hair and can be transferred from hair to hand when the hair is touched. The bacteria can then be transferred from the hand of the member of staff to a patient. Weaver et al (2008) state that, once it has been worn, theatre attire becomes a vehicle of infection and must be changed if it becomes dirty with any spillage of blood or bodily fluid. Jewellery must not be worn by staff in the operating department because microorganisms will adhere to indentations in metal. A wedding ring however can be worn, as being ordered to remove this can contravene a person's human rights (Williams & Smith 2008). In surgery, the patient's skin is breached, allowing microorganisms an easy portal of entry to internal organs and tissues. The surgical hand wash is used in relation to this. It produces the same result as the routine hand wash, but also reduces residential organisms to a minimum level by using antiseptics (Horton & Parker 2002). Antiseptics are used because they contain antimicrobial agents, and these are more effective in removing resident microorganisms and breaking the chain of infection than using soap or water alone (Damani 2003). The Centre for Disease Control and Prevention (CDC 2002) suggests that '30% of HAIs may be prevented if correct hand washing is accomplished', yet the World Health Organisation (WHO 2009) highlights that even though hand washing is perhaps the simplest way to break the chain of infection, the lack of compliance in hand hygiene is problematic worldwide.

Deane (1999) states that gloves are used by staff in the operating room to provide a physical barrier between the wearer and the patient's wound. They protect the wound from being contaminated by bacteria present on the surgeon's hands and additionally they protect the surgical team from infections from the wound. Gloves are single use items because frequent use creates an ideal breeding ground for microorganisms to develop and grow. According to Ellis (2010) surgical gloves were originally introduced to safeguard the surgeon from infection and skin irritation, and not to protect the patient from bacteria on the surgeon's hands. Al-Benna (2010) states that double gloving can also be employed, offering an improved level of protection to the wearer by up to '87% if the external glove is perforated'. Masks are also to be worn to protect the wearer from any blood splatter during surgery from a patient's wound that could result in transmission of a blood borne virus such as HIV. Masks must be capable of arresting low velocity droplets and eye protection is also used in the same way as masks (Kirk & Ribbons 2004).

All equipment in the operating department must be sterile to deter microorganisms from using inanimate objects, such as beds, as potential vehicles for their transmission. To render a medical device safe for further use, decontamination is required which is a combination of cleaning, sterilising and disinfecting to destroy microorganisms (Radford et al 2004). Surgical equipment is labelled 'high risk' due to the close contact it has with a patient's skin and it therefore must be sterilised. Sterilisation indicates the inability for living things to reproduce therefore resulting in the inactivation of microorganisms. All members of the operating department team have a responsibility to ensure that equipment such as infusion pumps, drip stands and vital sign monitors are efficiently cleaned after every use (Horton & Parker 2002). Richmond (2009) states that a good understanding of how medical devices can become contaminated is vital, in order to prevent the spread of infection.

Management of infection

Infection control is a concern for everybody and it must be mandated at the highest level of management in hospitals with an infection control committee and team in place. The infection control team should prioritise the surveillance and monitoring of infections, reflecting on current guidelines regarding infection control including annual audits (Weaving & Cooper 2006). Damani (2003) emphasises that the management of risk and infection control falls upon all the members of staff in the operating department and it is their responsibility under the health and safety guidelines. If a risk management strategy is not in place to combat infection control, then it is a failure to the patients and a threat of liability may follow. A patient can sue for breach of duty at common law against a hospital for a hospital acquired infection. For example in January of 2008 the NHS Litigation Authority announced that it had set a new record for compensation pay out (reaching [pounds sterling]5 million) to a famous actress who contracted MRSA whilst staying in hospital (Elliot 2009).

Conclusion

It is essential that staff take individual responsibility for implementing infection control policies. The professional body for an operating department practitioner is the Health Professions Council (HPC) and it clearly states in the HPC standards of conduct, performance and ethics (HPC 2008) that a practitioner must 'deal fairly and safely with the risks of infection'. Similarly the Nursing and Midwifery Council's (NMC 2008) role exists to 'safeguard the health and wellbeing of the public'.

The expected outcome following a surgical event is a cure of the condition, primary healing and a safe, stress-and infection-free recovery. The infection control procedures available to the operating team aim to reduce and remove infectious and harmful organisms by eliminating methods of cross-infection, and they are ultimately in place to protect the public from contagion. Infection is a complication in healthcare that can be avoided by the knowledge of certain risks and appropriate infection control. It is a legal and moral obligation that all staff in the operating theatre uphold infection control policies. Practising this safely will prevent the spread of microorganisms and break the chain of infection. All routine practices should be upheld including adequate hand washing, protective clothing, the safe management of waste and bodily fluids, and good cleaning and hygiene standards. To effectively minimise the risk of infection in the operating department risks must be accessed, correct policies and procedures must be practised, and adequate knowledge of microbes and their chain of infection must be gained. Ultimately a zero tolerance attitude needs to be employed by all members of staff in the prevention of infection within the operating department.

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Acknowledgment

I would like to thank John Morley, my tutor at Teesside University, for his support and guidance during the writing of this article

Correspondence address: c/o AfPP. Daisy Ayris House, 42 Freemans Way. Harrogate. HG31DH. Email: rach_wifson@msn.com

About the author

Rachel Wilson

1st year ODP student

Teeside University

No competing interests declared
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