Theater protocols

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after the overall design of the theater and the
provision of good quality, well-maintained
equipment, the single most important aspect
of theater safety in the performance of all
theater staff in their various roles. A high level
of performance requires adherence to
carefully prepared protocols & guideline, good
initial training & on-going education, and good
management, including motivation of staff.
Patients are at risk from the time they leave
the ward until they return from the theater.

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 The theater

 it should be sited near the surgical wards &

should be within an easy access to the
emergency & radiology department.
 The sitting of theater is of less important than
it's design in the bacteriological point of view.
Clean & dirty area should be separated &
clearly demarcated, with minimum staff
traffic.

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 Factors affecting control of infection

 Appropriate design.
 Controlled air quality.
 Quality cleaning.
 Impermeable clothing.
 Hand scrubbing.
 Patient preparation.

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Principles in design

 an outer reception area;

 reception office.
 The reception area which patient can wait after
checking in with soft light & gentle music.
 Area for storage of trolley.
 An area of hanging clean gowns & over shoes
for patients to wear when accompanying
children to anesthetic room.

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 A clean zone including a wide, clean corridor
that allows access to & from the following:
 Anesthetic room.
 Recovery area.
 Clean storage area.
 Emergency autoclave.
 Staff relaxation of room/changing room.
 The storage area for large equipment including
xray machines, image intensifiers.
 The operating theaters.
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The scrub room
The design;
 Tow doors, one leading to the corridor & one to the
theater.
 Sinks with taps that can be manipulated with elbows
& soap holders that can be manipulated by foot pedal
or the elbows.
 Good drainage & suitable panels incorporated in the
sink to prevent splashing of clothes.
 Anti-slip floors.
 Easily cleaned shelves for gown packs & gloves.
 Adequate facilities for separate disposal of linen &
paper.
 Brushes for cleaning fingernails.
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The operating room

 It should have double door entrance from

anesthetic room & double door exit to the
clean corridor. Their should be tow small
entrance from the clean store room where
sutures, dressing & needles are kept. And an
opening from scrub room.

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 Their should also be a single exit door to the dirty
corridor for removal of drapes, instruments and
waste product and the end of procedure. All the
doors should be well sealed in order to comply with
the air ventilation system.
 The theaters, recovery room and anesthetic room
must always be designed to have adequate power
points, emergency electricity, piped gas, anesthetic
scavenging system, ancillary lighting and wall
suction. Cardiac resuscitation equipments must be
available readily.

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Optimum location of telephone has it's importance.
The temperature should range between 19 -22 C
with humidity of 45-55%.
The operating table should be adjustable with all
working parts. The cushions should be easy to
clean and in good repair. The lights should be
adjustable, sealed and easy cleaned with
facilities for attachment of Handel's so that the
surgeon of the team can adjust it.
Fixed surfaces in the theater should be avoided,
instruments should place on the trolley. Xray
viewer should be on the wall and kept in good
repair, as should electric sockets.
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Equipment

 Trolley ; should be clean and have safety

rails and oxygen cylinders with well fitting
tubes and masks, all of which are regularly
checked and empty cylinders replaced.
Trolley must be capable of being to place in
the patient in the Trendlenburg position in
case of regurgitation of the stomach contents.

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 The operating table; should be
regularly cleaned and checked to ensure that
it can be raised and lowered smoothly with
the appropriate gears for Trendlenberg tilt &
lateral tilt & adequate breaking system
accessories should be clean & available & fit
well & it is particularly important to ensure
that stirrups fit well.

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 The light should be modern & easily movable by
members of the team.
 The suction apparatus should be clean &
checked, with tubes available.
 Anesthetic machines should be in good
working order with strict correct connection.
 Electrical equipment should be regularly
checked.
 Fire policy includes regular fire drill & weekly
testing

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 Settlement of negligence
claims in this area is very
costly.

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Control of air quality

 Because the non visceral bacteriological

contamination of wound is predominantly
from the air in the theater, it is essential that
modern theaters are fitted with controlled
ventilation and filters.
 20 air Change per hour using a 5 mm pore
size filter.

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 The bacterial count can be as high as
3000 colony forming units per cubic meter.
With appropriate ventilation it can be
reduced to 200 CFU/cubic meter. It is
essential in orthopaedic surgery .

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It can be achieved by the following

 Minimizing the number of individuals in

theater.
 Avoiding excess movement of individuals in
theater.
 Ensuring that the air vents are not obstructed
and that the doors are closed.

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Preoperative preparation of patient

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Bacterial infection

 Any staff with infected skin lesion as boil,

paronichia or carrier state particularly in nose
or respiratory tract infection should be
excluded from the team.

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Changing area

 Should be adequate in size, secure

locker, clean& adequate supply of clean
closing with toilet &washing facilities.

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Clothing &gowning
 Desquamation principally occurs from lower
half of the body, changing cloth reduces the
bacterial count.
 Cotton pores are 100 Mm in size while skin
scales are 5-60 Mm.
 Wearing of elastic anklet will reduce bacterial
count by 47%.
 Charley exhausted gown important in
orthopedics not in general surgery.

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 Cups

 Cups are not important in general

surgery may have significance in
implant surgery.

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Masks

 36 bacteria are emitted per 100 words

spoken so it is not important in general
surgery but have significance in implant
surgery.
 They are important in staff protection.

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Visor should

 Be made of synthetic fabric.

 Not be touched by hand.
 Not be put in pocket.
 Be destroyed after single use.

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Gloving

 There is little evidence that wound

infection related to glove puncture, so
hand washing is essential.

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Scrubbing up

 Brush should only be used for nails,

lasting for 3-5 minute chlorhexidine or
povedon ioden soap it should be from
hand to elbow, drying is essential,
jewellery should be removed.

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Factors to be taken in to account

 Preoperative showering with

hexachlorphine is widely could be sued.
Subjects showered twice in the day before and
once at the day o f surgery showed to reduced
wound infection.

 Preoperative hospital stayIt will

increase the chance of infection ( Staph
Aureus).
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 Preoperative screening: by swabbing of the
skin and nose is expensive and not seen shown to
be alter the outcome.
 Shaving: The trauma of shaving will increase the
chance of infection rate. It is preferable to use
depilation cream or clipper.
 Transport: the value of trolley not shown to affect
the infection rate. Keeping one trolley in theater and
the other t side the theater not shown to be effective..

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Check list before premedication

 Check the identity (name ,age &unit no.).

 Check the informed consent.
 Check that the operating site has being
marked by writing RIGHT & LEFT.
 Check the allergies.
 Record.

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 Patients movement m

 The patient should be transferred from the bed

to the trolley and the safety rails raised.
 The patient should be comfortable and warm
 After anesthesia the patient should be slide not
lifted, the patient’s head should be correctly
positioned.
 IV lines should be correctly attached to trolley.

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The reception area

 An appropriately trained reception clerk.

 The insistence of written lists at all times
which can not be changed by crossing out
but must be rewritten.
 A correct operative description.
 Identification of the side to be operated on
(RIGHT or LEFT).

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In the anesthetic room

 The patient is asked for his name.

 The operation is checked against the operation
list.
 The consent is checked.
 The case notes should be read.
 The patient’s fasting should be checked.
 The presence of false teeth, caps, hearing aids
or jewellary should be checked.
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 The patient should be asked about allergy.
 ECG electrodes are applied.
 Diathermy electrode is applied.
 Induction of anesthesia.
 All drugs given are recorded.
 All drugs are kept locked.
 the is transferred into the operating room with all lines
well secured and with the appropriate documents.
 Ensure the protection of the patient against trauma.

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Special points

 The full check must have been carried out.

 the patient is observed at all times, particularly
during induction and transfer of the patient
from the anesthetic room to the operation
theatre.
 Cross-matched blood, if required, is available
and the correct units are in the storage fridge.

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Special points

 The limbs are safeguarded, especially if

paralyzed.
 Nerves are protected from pressure;
 Eyes are protected (the lids must be closed on
induction to avoid inversion of the eyelashes
and to protect the cornea against abrasions,
drying and foreign bodies.

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Tourniquets

 The pressure and time of application should be

recorded by the nurse or operating theatre assistant,
and on the unaesthetic chart by the anesthetists.
 The tourniquet width and position must be checked
by the operating surgeon.
 Esmarch rubber bandages used must be applied
with care by an experienced technician to avoid
burns.
 Disinfectant must not be allowed to run under the
esmarch bandage or tourniquets.

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Tourniquets

 The use of more sophisticated equipment must be

carefully supervised and its design understood by the
surgeon.
 The anesthetists should remind the surgeon ’tourniquet
time’ at half-hourly intervals.
 The time of release of the tourniquet is noted by the
anaesthetists.
 The site of tourniquet is inspected by the surgeon and
the scrub nurse.
 The surgeon records the total duration of the tourniquet
time in the surgical operating note.
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THE PATIENT IN THE OPERATING THEATER

 POSITIONING the patient should be

positioned correctly in relation to the
cushions particularly in lithotomy position.
 Both surgeon and anesthetist should be
fully aware of optimal position.
 Harmful positions should be avoided like
hyperextension and pressure on calf.

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Instrument handling

 Sharps should be kept in receivers and

disposed of safely using sealed containers.
 Instruments should not be left on drapes where
they can directly injured the patient.
 Disposable Instruments should discarded.
 Swabs and pack should be counted.
 Non radio-opaque swabs should not be used.

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The surgeon
 Should be familiar with the procedure.
 If he is under training the senior cover must
be present.
 He should be in good health with no upper
respiratory infection and not carrier for Staph
aureus.
 Assistant should not lean on patients.

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 When infection risk is high

General measure:
 Staff education.
 HIV vaccination.

Practical measures:
 Identify high risk patients on the list.
 Reduce number of staff.
 Prevent staff from contact with contaminated fluid.
 Non permeable gowns and mask should be wear with
eye protection and double gloves.

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 Take particular care of sharps, should
always kept in receivers.
 Swabs should be countered, should be
kept in deep plastic racks.
 Soiled linen should be placed in special
alignate bags.
 At end of operation all surfaces should be
cleaned with detergent.

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