OPERATION THEATRE

SURVEILLANCE
DR.T.V.RAO MD

22-02-2016

Dr.T.V.Rao MD

OPERATION THEATRE IS A PRIORITY AREA

FOR SAFETY

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Dr.T.V.Rao MD

The floors and walls should be absolutely smooth and easily cleanable and
should have minimum and neatly made or no joints.

Flooring should be non porous, scratch proof, anti skid and antistatic (epoxy
resin flooring) .

The walls should also be covered with smooth material like granite with
minimum joints.

The ceilings should be painted with oil paints which give smooth finish.

All the electrical fittings and water pipe lines in the OR must be concealed.

The OR complex should have only one entry and all the windows should be
air tight in restricted and semi-restricted area.
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Dr.T.V.Rao MD

Planning consideration
Zoning :
To ensure the aseptic condition the operating dept is
divide into 4 zone :
1.

Protective zone

2.

Clean zone

3.

Sterile zone

4.

Disposal zone
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Dr.T.V.Rao MD

Advantages of zoning
1.

Minimizes risk of hospital infection.

2.

Minimizes unproductive movement of staff, supplies &

patient.

3.

Increases efficacy of operative team members.

4.

Ensures smooth workflow.

5.

Deceases hazards in operating room.

6.

Ensures proper positioning of equipments.

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Dr.T.V.Rao MD

Avoid contamination of wound.

Although Unpreventable.

Chances of cross infection.

Contamination of surgical wound is mostly from skin / mucous membrane being

incised.

Other sources : nose, throat, hand, skin of operating team members.

Air contamination : omnipresent problem.

All logical precaution & preparations should be done.

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Dr.T.V.Rao MD

Maintaining the Operation theaters is a priority

Stress must be laid on
Temperature
Humidity
Ventilation
Temperature :

24-270 C
Relative Humidity : 450 600 C
for adult
550 650 C for infants
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Dr.T.V.Rao MD

VENTILATION / AIR CHANGE

1 change / hr : contamination reduced

by 60%

2 change / hr : contamination reduced

by 86%

10 change / hr : contamination reduced

Turbulant / mixing air distribution

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by 99%

Downward displacement piston system

Dr.T.V.Rao MD

Unidirectional airflow system / lamellar flow ventilation

Prevention of Infections is Priority

in Any Health Care Areas
Prevention of airborne microbial

contamination will prevent the surgical site

infections. To achieve this basic strategy we
should follow the certain guidelines. Which
would include, proper and continuing
education to staff to prevent shedding of
microbes and restrict the unnecessary
movements of OT staff within and outside the
OT environment.
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Dr.T.V.Rao MD

Basic care of Operation Theatres.

Reduction of Microbial counts is important.

Paying great attention to Floors Using

many chemicals not necessary

too

Keep the floor Clean and Dry - with

Vacuum cleaner and Wet cleaning
techniques

Keep the mops dry when not in use,

Frequent cleaning of Walls and Roof is not

needed

Number of persons present and Movements

they make, has direct relation to increase of
bacterial counts

Prompt disposal of Theatre waste out of the

theatre is of top priority

Handling of Air in Operation theatre.

Critical parameters for air quality include ( WHO Guidelines)
(1) Maintenance / validation of efficacy of filters
(2) Pressure gradient across the filter bed and in the operation
theatre
(3) Air changes per hour (minimum 15 air changes per hour)
(4) Temperature and humidity should be maintained between 2022C and 30-60%,

Air pressure vented to the operation theatre.

Direction of air flow should be from clean to less clean

areas.

Environmental cleaning should be twice daily

Proper design and ventilation of operating theatres(HVAC) systems

HEPA filters indicated in operating rooms designated for orthopaedic

implant procedures

Air Can be a Risk Factor in Health

Care

Microbiological contamination of air in

the operating room is generally
considered to be a risk factor for
surgical site infections in clean surgery.
Microbiological quality of air may be
considered as mirror of the hygienic
condition of the operation theatres.
The quality of indoor air depends on
external and internal sources, such as
ventilation, cleaning procedures, the
surgical team and their activity
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Dr.T.V.Rao MD

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Surveillance means Environmental

Monitoring
Environmental

monitoring means the

microbiological testing
of air, surfaces and
equipment in order to
detect changing trends
of microbial counts and
micro-flora
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Dr.T.V.Rao MD

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Why Surgical Site infection is

important
Infection control and basic

hygiene should be at the heart

of good hospital
management. Infection of the
surgical-site is a leading
complication of surgery.
Microbiological contamination
of air in the operating room is
generally considered to be a
risk factor for infections of
surgical site in clean surgery
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Why We need Surveillance ln Operation

Theaters
Surgical site infections (SSIs)
are second to third most
common site of health care
associated infections. These
complications of surgical
procedures cause
considerable morbidity, and
mortality. If these occur deep
at the site of the procedure, can
carry mortality as high as 77 %
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Dr.T.V.Rao MD

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Quality of Air can be sampled

Evaluation of the

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quality of air in
operating theatres
can be performed
routinely by
microbiological
sampling and
particle counting

Dr.T.V.Rao MD

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Air Surveillance of Operation

theatre
Scope- To determine air bacterial count in OT and to detect pathogenic bacteria
like staphylococcus aureus.
Factors influencing:
Number of persons present.
Body movements,
Disturbances of clothing.
Methods of Air surveillance:

Settle plate method.

Slit sampler method (from given volume)

Particle counter ( non viable count )

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Dr.T.V.Rao MD

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Why Monitoring Air quality

The survival of micro-organisms

in the air is dependent on a

number of interacting factors,
and is not easy to predict. This is
one of the main reasons why
routine monitoring of airborne
bacteria and fungi can be
important, especially where
Surgical Procedures are
conducted
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Dr.T.V.Rao MD

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STANDARD GUIDELINES AND PLANNING

FOR AIR SAMPLING
There are no universally

agreed standards for

any country or place
regarding when to
undertake
microbiological
sampling in the
operating theatre and
on the interpretation of
sampling results

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Dr.T.V.Rao MD

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Why we need the surveillance of Operation

theatres
However, there is sufficient evidence to support the

undertaking of microbiological air sampling in the

operation theatre as part of the vigilance & safety of
an operating theatre, after any major structural
replacements (not including High Efficiency
Particulate (HEPA) filter changes and as deemed
necessary by the hospital infection control
committee. Health care workers should follow certain
guidelines before air sampling.
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Dr.T.V.Rao MD

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Passive monitoring
by Settle plates

Passive monitoring typically employs settle plates petri dishes

containing appropriate culture media, which are opened and

exposed for a given time and then incubated to allow visible
bacterial and fungal colonies to develop and be counted. Settle
plates are only capable of monitoring those viable biological
particles that sediment out of the air and settle onto a surface over
the time of exposure. They will not detect smaller particles or
droplets that remain suspended in the air and they cannot sample
specific volumes of air, so the results can only be considered semiquantitative at best.
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Dr.T.V.Rao MD

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Follow the Standard Operating

procedures
Prior to air sampling, obtain

the suitable air sampling

equipment from a laboratory,
establish laboratory time-lines
for sample collection,
processing and provision of
results and should not ignore
to consult the hospital
microbiologist or infection
control unit.
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Dr.T.V.Rao MD

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Bacterial Counts vary as per the existing

circumstances
Bacterial counts in
operation theaters
are influenced by
the number of
individuals present,
ventilation and air
flow methods.
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Dr.T.V.Rao MD

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When to do Air Sampling

Air sampling should be done after the

all new or replacement work has
completed. The ventilation system
should run continuously for 24 hours
before sampling and the theatre
surfaces and fixed equipment,
ducting and air diffuser plates have
to be cleaned.

However many do for

frequently monitoring the

operation theaters
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Dr.T.V.Rao MD

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RECOMMENDED METHODS
SURVEILLANCE

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Dr.T.V.Rao MD

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RECOMMENDED METHOD FOR AIR

SAMPLING

A single or multiple samples should be collected from

each operating theatre.
The air sampler should be checked for cleanliness before
use by following the manufacturers instructions.
The theatre being sampled should have been left vacant
for a minimum of 15 minutes, preferably one hour. To
avoid false-positive results the theatre doors must be
kept closed prior to and during the sampling period.
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Dr.T.V.Rao MD

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Standard protocols of collecting the

specimens

Air sampling was performed

with settle plates methods.

Petri dishes containing blood
and/ or / MacConkey agar were
transported to operation
theatres in sealed plastic bags.
The plates were labelled with
sample number, site within
theatre, time and date of
sample collection
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Dr.T.V.Rao MD

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Placements and Processing the

specimens
The plates were placed at
four chosen places in the
operation theatre at about 1
metre above the ground, and
exposed for 30 minutes to 1
hour minutes. After this
exposure, the plates were
covered with their lids and
taken to laboratory in sealed
plastic bags and incubated at
37C for 24 hours.
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Dr.T.V.Rao MD

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RECOMMENDED METHOD FOR

AIR SAMPLING
A single sample should be collected from each operating
theatre.
The air sampler should be checked for cleanliness before

use by following the manufacturers instructions.

The theatre being sampled should have been left vacant

for a minimum of 15 minutes, preferably one hour. To

avoid false-positive results the theatre doors must be kept
closed prior to and during the sampling period.
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Dr.T.V.Rao MD

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Settle plate Method

22-02-2016

Using blood agar, It is being

practiced in basic hospitals to
detect pathogenic bacteria
major isolate being
Staphylococcus aureus bacteria
in hospital air. Settle plate
method with blood agar where
the plates have to be kept at 1
meter height on the four corners
of room and results are obtained
based on the mean colony
number on the all culture plates
after a prescribed time

Dr.T.V.Rao MD

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RESULTS AND INTERPRETATION:

Culture plates should be incubated under optimum
conditions in the microbiology laboratory. Early
culture reports hardly available until after 24 hours of
incubation. Aerobic cultures on non-selective medium
(preferably Blood agar) should not exceed 35 colony
forming units of bacteria and fungi per cubic meter of
air for a conventional theatre and 1cfu for an ultra
clean theatre to perform joint replacement and cardiac
surgeries [1].
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Dr.T.V.Rao MD

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Are there any Rigid or Absolute

Guidelines in Bacteriology Laboratory

No
These counts are not rigid
standards and are intended
as a guideline only. Even
though the swabs are taken
for OT surveillance to
isolate and identify the
clostridia spores, air
sampling is must to
measure the safer load of
microbes

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Dr.T.V.Rao MD

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Pros and Cons of Swabbing the

environment and Culturing
In some of the hospitals OT sampling is done by swabbing and

plating on the blood agar and results are being announced

after 24-48 hours of aerobic incubation. By the above
mentioned method quantitative estimation of the microbial
load is not possible. Literature which is supporting for this
kind of practice is not available from various sources.
Moreover, this type of cultures on non-selective medium will
create unnecessary confusion while detecting OT sterilization
status and which should be abandoned
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Dr.T.V.Rao MD

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PROCESSING OF SAMPLES

Swabs taken from different articles

were streaked in Blood and
MacConkey agar .These culture plates
along with those exposed in air were
incubated at 37C under aerobic
conditions for 24 hrs. After incubation
the colonies were counted and
identification of isolates was
performed. Concentration of airborne
bacteria was expressed as colony
forming units per cubic meter cube
(cfu/m3).
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Dr.T.V.Rao MD

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Slit Sampler and Air centrifuge

Because of recent advances

in certain surgical
procedures and bacterial
counts settle plate method
is replaced with Slit sampler
and Air centrifuge
equipment through which
we can calculate the safe
levels of colony counts
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Dr.T.V.Rao MD

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Slit Sampler and Air centrifuge

There are several

different types of air

samplers available and
the manufacturers
instructions for use must
be followed. If
affordable, the preferred
method is to use a
sampler with timer and
remote control
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Dr.T.V.Rao MD

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Slit sampler and Air centrifuge

Determine the Results

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The sampling equipment will

determine the volume of air
sampled. Sampling volume
needs to be more than 0.25 m3
(250 L) and optimally around
1m3 (1000 L).

Once sampling is completed,

remove the test strips/agar plate
aseptically and label it clearly
and send it the processing
environment.

Dr.T.V.Rao MD

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Placement of Air Sampler

The air sampler should be

placed in the middle of the

theatre table at the height
of 1 meter and to be
secured on a trolley.
The air sampler should then

be switched on either by
remote control or manually,
before leaving the room.
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Dr.T.V.Rao MD

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What the Scientific Studies Say

A number of studies have been carried

out in operation theatres to determine
relationship between total bacterial air
count in OT and risk of infection. It has
been observed that counts in the range
of 700-1800/m3 were related to
significant risk of infection and the risk
was slight when they were below
180/m3.14

Ref Parker MT. In Hospital Associated Infections,

Guidelines to laboratory methods. WHO, Regional Office
for Europe, Copenhagen. 1978; 28-32.
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Dr.T.V.Rao MD

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WHAT ABOUT ANAEROBES

Even today most of the surgeons are worrying about

the OT associated infections with anaerobes like

clostridium tetani in most of the instances. Infections
with Cl. tetani are associated with very bad surgical
procedures which includes the over jealous
manipulations of the tissues of surgical site and
leaving the dead tissue in the surgical site at the end
of the procedure and also heavy dust in the operation
theatre environment.
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Dr.T.V.Rao MD

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WHAT ABOUT ANAEROBES

Surveillance for clostridia spores is an age

old concept of OT surveillance and lost its

importance with the available and
applicable OT sterilization and disinfection
awareness Programme and practices.
Today we rarely encounter a infection with
C.tetani
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Dr.T.V.Rao MD

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When to Test for Clostridia spp

Routine testing for
clostridia spores is not
mandatory except
during certain
situations like new
constructions or
structural alterations
are made to the
theatre
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Dr.T.V.Rao MD

42

Use your Rationalism in establishing and making

decisions of Operation Theaters

Routine sampling of floor,

walls or furniture which are
not in direct contact with
patients are not the sources
of infection. They do not
contribute in the prevention
of nosocomial infection,
unless there is an epidemic.
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Dr.T.V.Rao MD

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However many factors play a role in

Infections
A large body of information is available which

indicates that prevention of post operative

infection is dependent on several factors
including effective theatre design, sterilization
and disinfection procedures, good surgical
technique, bacterial contamination of theatre
air, discipline which includes restricting the
movement of staff [2].
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Dr.T.V.Rao MD

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What are our achievable goals

So prevention of airborne microbial contamination

will prevent the surgical site infections. To achieve

this basic strategy we should follow the certain
guidelines. Which would include, proper and
continuing education to staff to prevent shedding of
microbes and restrict the unnecessary movements of
OT staff within and outside the OT environment.
22-02-2016

Dr.T.V.Rao MD

45

Good Hand Washing Practices

Save many Lives
BEST HAND WASH
IS
Alcohol with Chlorhexidine.

2.Alchool without Chlorhexidine.

3 Chlorhexidine 2 %
4 Chlorhexidine 4 %

5 Povidone with Iodine 7.5 %

6 Triclosan 1 %

Or Anything NEW

WORD OF CAUTION ON
SURVEILLANCE
There

are no absolute measures universally agreed on

Operation Theatre surveillance the protocols vary
from circumstances of working , work load of
patients and critical care procedures

I wish professionals should follow the updated

information

Dr.T.V.Rao M D
47

REFERENCES:
1Davis N., Curry A, Gambhir AK, Panigrahi H, Walker CR,

Wilkins EG, Worsley MA and Kay PR Intraoperative bacterial

contamination in operations for joint replacement. J Bone
Joint Surg Br 1999; 81-B:8869.
2.Colquun J, Partridge L. Computational Fluid Dynamics

Applications in Hospital Ventilation Design. The Australian

Hospital Engineer 2003; 26 (1) 35-40.
3. Guidelines to standards for operating rooms. Located at.

http://www.health.wa.gov.
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Dr.T.V.Rao MD

48

REFERENCES:
. 4Geeta Mehta. Microbiological

theatre 2005.

surveillance of operation

http://www.orthoteers.org.
5. Dharan S, Pittet D. Environmental controls in operating theatres.
J Hosp infect 2002; 51(2) 79-84.
6. Department of Health, Western Australia. Private Hospital
Guidelines, 3rd edition. 1998. http://www.health.wa.gov.
7 Updates on Operation theatre surveillance

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Dr.T.V.Rao MD

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 Program

Created by Dr.T.V.Rao MD for Medical and

Paramedical Professionals under Universal educational
program on Human safety in Health Care
Email

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