IHEA Healthcare Facilities Management Conference 2012

Operating Theatre Infection

A Case Study

John Colquhoun
Healthcare Industry Director, AECOM

October, 2012

Hospital Acquired Infections – State of Play

- Bugs
• More virulent strains
• Multiple delivery vectors

- Nosocomial Infection Rates

• More acutely ill in-patients
• Higher infection rates

- Changes in healthcare
• Technology – more complex
• Models of Care

- Mitigation
• Infection control plan and implementation
• Hospital design
• Systems and Action
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Hospital Acquired Infections – So Who is Responsible?

- Hospital designers ?
- Infection Control Committees ?
- Staff and visiting doctors ?
- Engineering Department ?
- Hospital Administrators / Government ?
- Anyone who enters a hospital ?

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Background to Case Study

- Major Metropolitan Hospital

• Well-trained and dedicated staff
• Good maintenance procedures

- Paediatric Cardiac Surgical facility

• Cardiac surgery and pace-maker implant procedures – neonates
thru to teens

- Increased Infection Rates

• Sudden unexplained increase in post-operative infection rates

- Client Addressing ALL Potential Sources

• Airconditioning, cleaning, CSSD, staff health, sterile material
handling procedures, theatre microbiology etc

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Background to Investigation

- HVAC - The Usual Suspect

• Testing and Commissioning ??
• Air change rates ??
• Pressure gradients ??
• Filtration failure ??
• Air Distribution issues ??
• Particle counts ??

- Commission to Review HVAC

• Design
• Condition
• Performance

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Paediatric Cardiac Surgery – Typical OT Layout

Its Busy, Complex and High Risk
• Long Procedures - up to 5
hours
• 8 to 12 Staff or more
• Lots of Equipment (heat
generation and airflows)
• Multiple Pendants, lights
• Lots of pathology tests
• Larger number of potential
Scale:

1 metre approx
infection paths
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The Case Study Paediatric Theatre Suite –

Two theatres plus support facilities

Paed. General
Theatre Parents
Lounge,
Sterile Setup Meeting
Theatre Sterile Corridor
Cardiac Theatre Scrub Bay and Bed Holding
Sterile Store
OT Suite
Paed. Cardiac Reception
Theatre
Sterile Stores

Paed. ICU

Operating Theatre Infection Case Study Page 7

The Paediatric Theatre Suite – Floor Plan

Cardiac Theatre
Sterile Store Paed. General
Theatre
Sterile Setup
Paed. Cardiac
Theatre

Scrub Bay
Paed. ICU

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

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Paediatric Theatre Suite – Initial Observations

Cardiac Theatre Theatre at Rest –
“Sterile” Store
+ Paed. General
Theatre
• Low particle counts
Sterile Setup • Correct pressure
Paed. Cardiac ++ + regimes
Theatre
No apparent problems
(other than store)
++
Scrub Bay
Paed. ICU

+ +
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting
+ + +
OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile)
o Suite Entry o
Operating Theatre Infection Case Study Page 9

Paediatric Theatre Suite - HVAC

Cardiac Theatre Airconditioning –
Sterile Store
++ Paed. General • Terminal HEPA’s
Theatre
Sterile Setup
• Good air distribution
Paed. Cardiac ++ + • Correct pressures
Theatre

Only apparent problem

++ • “Dirty” relief to
Scrub Bay
Paed. ICU “sterile” store
+ +
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting
+ + +
OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Theatre Corridor – (non-Sterile)
o Suite Entry o
Operating Theatre Infection Case Study Page 10

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Paediatric Theatre Suite - HVAC

Cardiac Theatre Airconditioning –
Sterile Store
++ Paed. General • “At Rest” air
Theatre
Sterile Setup
distribution (checked
Paed. Cardiac ++ + with smoke pencils)
Theatre
• Verifies CFD Model
• Demonstrated Good
++ Practice
Scrub Bay
Paed. ICU

+ +
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting
+ + +
OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Theatre Corridor – (non-Sterile)
o Suite Entry o
Operating Theatre Infection Case Study Page 11

Paediatric Theatre Suite - HVAC

Cardiac Theatre Airconditioning –
Sterile Store
++ Paed. General • Maintenance
Theatre
Sterile Setup
• Cleaning
Paed. Cardiac ++ + • Filters
Theatre • Regular Testing
• Air flows
++ • Air distribution
Scrub Bay
Paed. ICU • Particle counts
• Filter validation
+ + • Achieved > AS Class
Theatre Sterile Corridor 350, ISO Class 7
Parents
and Bed Holding Lounge,
Meeting
+ + +
OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Theatre Corridor – (non-Sterile)
o Suite Entry o
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HVAC Review Outcomes and Further Action

- HVAC -
• Theatre HVAC Design Appropriate (except sterile
store air supply)
• Condition Good – checked all plant and equipment
• Testing – regular and up to date – no real issues – air
distribution and particle counts as expected
• Air flow test with smoke in static situation as expected
• Because of the complexity of cardiac surgery, need to
review HVAC dynamics during surgery

- Where to from there ?

• No obvious deficiencies in hospital procedures
• Lets do a “Dry Run” cardiac procedure and observe
any possible suspects
• We went back to basics and simulated a paediatric
cardiac operation
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The “Dummy” Run

- Objectives
• Run through all the usual procedures and review for potential
causes of infection transmission from any source

- Procedure
• Theatre set up
• Staff enter, gown and scrub
• Equipment switched on (heat output and fan drafts checked)
• Pendants and surgical lights in place and on
• Air flows demonstrated with equipment on plus patient and staff in
place
• Staff simulated all their usual activities including departure and
return from theatre for blood samples and equipment

- Outcomes – various – forseen and unforseen – Read on !

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The Dynamics of Cardiac Surgery

Cardiac Theatre
Sterile Store Paed. General Impacts of Activity on Static Air
++ Theatre
Sterile Setup
Distribution and Sterile Air
Paed. Cardiac ++ + Management –
Theatre

• Doors Opening and closing

++ • Doors propped open during
Scrub Bay
Paed. ICU setup and patient entry
• Location of theatre lights
+ + • Changes in Air Flow
Theatre Sterile Corridor• ChangesParents
in Temperature
and Bed Holding Lounge,
• Equipment heat output
Meeting
+ + • Equipment +cooling fan
impacts
OT•SuitePeople moving within
Reception &
Sterile Store Pneumatictheatre
Sterile Store
Tube•station
People moving in and out
of theatre
Theatre
Theatre Corridor – (non-Sterile)
o Suite Entry o
Operating Theatre Infection Case Study Page 15

Paediatric Theatre Suite – Setup - Trolley Exposure

Cardiac Theatre • Theatre setup - Long
Sterile Store Paed. General prep times, doors
Theatre
Sterile Setup
open for long periods
Paed. Cardiac – (dust transfer?)
Theatre • Potential contam. of
unwrapped sterile
supplies on trolleys –
Scrub Bay
Paed. ICU (Infectious staff?)
• “Normal” Practices
need Review?
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

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Paediatric Theatre Suite – “Sterile” Store Sterility

Cardiac Theatre • Surgeon scrubs and
Sterile Store Paed. General
Theatre
gowns – followed by
Sterile Setup retrieval of headgear
Paed. Cardiac from “Sterile Store”
Theatre
• Air flow checked
• Doubtful sterility !
Scrub Bay
Paed. ICU

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

Operating Theatre Infection Case Study Page 17

Paediatric Theatre Suite – Outside Contamination

Cardiac Theatre
• Family Movements –
Sterile Store Paed. General (comfort to children
Theatre
Sterile Setup
during admission to
Paed. Cardiac gen. theatre. Some
Theatre infectious or dusty.
Not required to be in
sterile garb/over-
Scrub Bay
Paed. ICU shoes)
• Potential contam. of
clean corridor?
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

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Paediatric Theatre Suite – Staff travel during procedures

Cardiac Theatre • Staff Travel from
Sterile Store Paed. General Theatre to Pn Tube –
Theatre
Sterile Setup
(sometimes via ICU)
Paed. Cardiac Blood samples to
Theatre Path (– up to 40 per
procedure !)
• Can be in excess of
Scrub Bay
Paed. ICU 100 trips in and out
of theatre for bloods,
equipment and other
Theatre Sterile Corridor reasons
Parents
and Bed Holding Lounge,
• Potential
Meeting
contamination to
Cardiac Theatre?
OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

Operating Theatre Infection Case Study Page 19

Paediatric Theatre Suite – Staff Infection to Trolleys

Cardiac Theatre • Infectious Staff –
Sterile Store Paed. General
Theatre
• Potential airflow from
Sterile Setup sterile zone over
Paed. Cardiac trolleys with exposed
Theatre
instruments and
donor tissue –
Paed. ICU
Scrub Bay
• Potential source of
contamination transfer
to surgical site?
Theatre Sterile Corridor Parents
and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Theatre Corridor – (non-Sterile) Suite Entry

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Paediatric Theatre Suite – Staff to Patient Infection

Cardiac Theatre • Shedding, lint
Sterile Store Paed. General
Theatre
• Infectious staff
Sterile Setup • Potential airflow
Paed. Cardiac within sterile zone to
Theatre
patient/surgical site
• Airflow from
Paed. ICU
Scrub Bay
anaestheticist over
drape and patient

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

Operating Theatre Infection Case Study Page 21

Paediatric Theatre Suite – Staff travel to external stores

Cardiac Theatre • Staff Travel from
Sterile Store Paed. General Theatre to Stores
Theatre
Sterile Setup
via corridor – (10
Paed. Cardiac times/procedure ??)
Theatre • Potential
Contamination to
Cardiac Theatre?
Scrub Bay
Paed. ICU

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

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Paediatric Theatre Suite – Building risks

Cardiac Theatre
• Damaged and dirty
Sterile Store Paed. General building components -
Theatre Horizontal surfaces,
Sterile Setup
Paed. Cardiac
doors and wall
Theatre coverings – minor
defects noted
• Potential risk?
Scrub Bay
Paed. ICU

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

Operating Theatre Infection Case Study Page 23

Paediatric Theatre Suite Combined Potential Infection Paths !

Cardiac Theatre • What is the culprit??
Sterile Store Paed. General
Theatre
Sterile Setup • Who knows, but -
Paed. Cardiac
Theatre
• It all adds up to risk!!

Scrub Bay
• Need for constant
Paed. ICU review and vigilance

Theatre Sterile Corridor Parents

and Bed Holding Lounge,
Meeting

OT Suite
Reception &
Sterile Store Sterile Store Pneumatic
Tube station

Theatre
Corridor – (non-Sterile) Suite Entry

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Outcomes – HVAC and Engineering

• Physical tests on HVAC revealed nothing of great concern
• Regular testing regimes were in place and satisfactory
(best we have seen)
• Need to modify theatre relief duct to sterile store so that HEPA
filtered air is delivered to sterile store (Storage of surgeons head
gear and other surgical gear is then in sterile conditions)
• Repair damaged doors and wall sealing

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Outcomes – Other Surgical Practice and Infection Issues

• Ensure that parents and family who attend to

children in the general theatre are correctly
attired for theatre access to keep clean corridor
sterile (or keep them out of theatre suite?)
• Frequent need for staff to travel outside theatre
with blood samples (Could be overcome with a
pass-though from theatre to the corridor)
• Frequent need for staff to travel outside theatre
to store (Could be overcome with maintenance
of sterile conditions in corridor or use dedicated
store attached to theatre, or better planning)
• Exposure of sterile instruments and donor
tissue on setup trolleys which may be exposed
to infectious staff or non-sterile air for extended
periods before surgery commences – don’t
• Monitor health of staff more closely
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Happy Endings -

- Infection Rates Returned to “Normal” Levels

- Was this because of actions resulting from
the study ?
- Was it because CSSD and other potential
process infection sources were resolved ?
- Were staff simply more vigilent in their
approach and work practices ?
It probably doesn’t matter why, but the
required outcome was achieved

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Conclusions -

• The facility design and HVAC generally looked consistent with

normal good practice
• There were initially no obvious issues re the theatre procedures
or staff behaviour that would indicate infection control issues

The Lessons -
• It needed all parties to stand back, review their usual practices and
see where the issues might be - ie Back to Basics

• The back to basics approach should be taken in all areas of health

facility activity – it can only improve infection control

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So Who Is Responsible for Infection Control ?

• There are, of course, designated people ad groups responsible

for infection control. However -
• We are all responsible
ƒ Constant vigilance – business as usual is not good enough
ƒ Get outside your comfort zone – cross professional boundaries
ƒ Speak up
ƒ Sometimes a new pair of eyes will spot a problem

Operating Theatre Infection Case Study Page 29

Thank You

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