ORGANIZATION OF OPERATION THEATRE AND

INFECTION PREVENTION

By Dr.ABRHAM.A
Assistant professor of surgery
February 2023
 outlines

• Purpose of operation theatre complex

• General Principles of OR Design and
Construction
• Asepsis

03/21/2024 2
 Purpose of operation theatre complex
• OT complexes are designed and built to carry out
diagnostic, therapeutic and palliative procedure.
• Many such set ups are customized based on :
- size of hospital
- patient turnover
- speciality specific.
• The aim is to provide the maximum benefit for
maximum number of patients arriving to the
operation theatre.
03/21/2024 3
 General Principles of OR Design and
Construction
• Important design considerations include:
- the mix of inpatient and outpatient
operations
- patient flow into and out of the OR area
- the transportation of supplies and waste
materials
- flexibility to allow the incorporation of new
technologies
03/21/2024 4
 General Principles of OR Design and
Construction
• The supplies and instruments likely to be
needed must be easily available.
• Effective communication must be in place
among the members of the OR team, the OR
front desk, and the rest of the hospital.
• Built-in computer, phone, imaging, and video
systems can enhance efficiency and safety by
facilitating access to clinical information and
decision-making support.
03/21/2024 5
 Design of the operating department
Principles
• the physical features of operating departments
are often different.
• they are all designed around some widely
accepted principles.
• which are the outcome of the experience of
surgeons and the impact of the biomedical
sciences.

03/21/2024 6
 Design of the operating department…
• The individual principles upon which the
design of each operating department is based
are as follows:
• Scope of service -this depends on which
surgical services are to be catered for.

03/21/2024 7
 Design of the operating department…
• Workload-
- this is largely the outcome of the scope of service
- an estimate of which determines the number of
operating rooms
• Needs of special services-for example:
- the implantation of orthopaedic devices requires
systems for ultraclean and smooth air flow.
- the cardiac surgical team may need a perfusion room
in which cardiopulmonary bypass equipment can be
prepared.
03/21/2024 8
 Design of the operating department…

• Accessibility-there needs to be a speedy

access to the ICU,ER ,local X-ray and the places
where patients are accommodated both
before and after an operation
• Supplies
• Repeatedly used and disposable equipment
come either from an adjacent dedicated TSSU
or CSSD which supplies the whole hospital.

03/21/2024 9
 Design of the operating department

• The basic design of today's OR consists of a

quadrangular room
• Adequate space :so that staff can move freely with
in their zone
• Need for maneuvering and parking patient’s
stretcher next to operating table and for parking
trolley without congestion
• 25m2 is absolute minimum
• 5x6.5m(32m2) is better
• 42m2 is ideal
• 64m2 in central hospital or developed nation
03/21/2024 10
 Design of the operating department…

• Ceiling height should be at least 10 ft to allow

mounting of operating lights, microscopes,
and other equipment on the ceiling.
• An additional 1 to 2 ft of ceiling height may be
needed if x-ray equipment is to be
permanently mounted

03/21/2024 11
 Design of the operating department…

• The operating complex is designed so that a

high standard of cleanliness can be maintained.
• Junctures between walls, ceilings and floors are
curved to prevent the collection of dust.
• All equipment should be movable so that the
theatre can be cleared for cleaning.
• all surfaces should be smooth and easily
washable.

03/21/2024 12
 Different zones of OT complex
• Four zones can be described in an OT complex
based on varying degrees of cleanliness.
• the bacteriological count progressively
diminishes from the outer to the inner zones.
• maintained by a differential decreasing
positive pressure ventilation gradient from the
inner zone to the outer zone.

03/21/2024 13
 Different zones of OT complex
transfer zone
• the reception area where the patient arrives,
• the recovery and staff changing areas and
• the points of entry to the department from
the rest of the hospital

03/21/2024 14
 Different zones of OT complex

• clean zone
• a transition area between the transfer and sterile
zones;
• it must also incorporate storage areas for theatre and
pre-sterilised equipment
• Sterile zone
• the operating room and sterile preparation room
• where the equipment for individual operations is
assembled
• Disposal zone
• the least clean area where the detritus, such as swabs
and dirty instruments is dealt with.
03/21/2024 15
 Different zones of OT complex

Plan of an individual operating theatre with clean (blue), sterile (white) and disposal (pink)
03/21/2024 16
zones
 Scrub station
• 96cm height, with water taps with sensor
10cm high.
• Hot and cold water.
• Soap liquid and scrubber.

03/21/2024 17
 Electricity.

• Ensure round the clock electric supply.

• Stand by generator system.
• Central field illumination 2000-3000
candles/sq.meter.
• Floor around table 200-300 candle/sq.meter.
• Four power outlet on each wall at height of
1.5 meter.
• Structured cabling system.

03/21/2024 18
 Operating light.
• Shadowless,mobile,hanging pendent, easily
maintainable OT lights.
• Intensity should be 4000 lux at incision and
8000lux at 9cm deep.

03/21/2024 19
 Air conditioning.

• Control asepsis, controlled air flow,

positive pressure.
• Maintain temp. 22 degree for comfort.
• Humidity 50-60 %.
• 100% fresh air with 20 changes/hr.
• Central air conditioning system.

03/21/2024 20
 Ventilation.
• There should be positive pressure ventilation
with lowering pressure gradient from the
sterile to protective zone.
• All anesthetic gases to be vented out to
exhaust.

03/21/2024 21
 Plumbing.
• Swearage shaft should not pass through
operating room.
• Toilets to be provided in change room area.
• All type of safety measure to be taken.
• Gas pipe line system to be ensured.

03/21/2024 22
 Water supply.
• Adequate and running fresh water supply to
be ensured.
• Taps should be easily handled or foot
operated.

03/21/2024 23
 Autoclave room.

• Provision of steam supply.

• Proper maintenance of autoclaves.
• Theater sterilization unit.
• Attached to the theater.
• Equipments to be kept in cupboards.

03/21/2024 24
 Location.
• Maximum six rooms in one OT
complex, preferably ground floor.
• Easy access to CSSD, sterialization
unit, emergency and surgical wards.
• Maximum protection from sun,
sounds, heat and wind.
• Independent in general traffic flow.
• Easy access to other area of OT.

03/21/2024 25
 # of Ots.
• # of OTs = one OT for 50 surgical beds.
• # of operation per suit shouldn’t exceed 6/day
or 8-10 hrs/day.

03/21/2024 26
 The operating team
• Should be as small as possible
• It consists of ;
• 1. surgeon 2.his assistant
• 3. the scrub nurse responsible for the
instrument
• 4.the circulate nurse to fetch & carry
• 5.the anesthetist
• 6. his assistant if he has one

03/21/2024 27
 The operating team…
• Two other people are important .
a. the theatre charge nurse responsible for
organizing theatre
B. the ‘theatre dresser' who is less educated
but knows its routine and where things are.

03/21/2024 28
The floor is important
• it should have slope toward an open channel
along the foot of the wall at the unsterile end of
the theatre to make it easier to wash.
• Fit a spurge pipe to the wall at the sterile end
150mm above the floor, so that the whole floor
can be flooded by turning a tap.

03/21/2024 29
The wall of theatre
• should be smooth but they need not be tiled
• Gloss paint is satisfactory for the walls and
• Every time a door is opened, dusts from the
floor is whirled into the room.
• There is no need for a door b/n changing
rooms and the theatre.
• A door is only needed b/n the sluice and
sterilizing room.

03/21/2024 30
The ceiling
• at least 3.5m high
• The roof timbers solid enough to support an
operation light
• It should also have a pair of 2m fluorescent
tube

03/21/2024 31
• Shelves
• set 50mm away from the wall on metal rods.
• all should be at least a meter high so that
trolley can be pushed under them.
• The anesthetist needs a small lockable
cupboard & a trolley.
• Ideally he also need a sink .
• Electric socket should be 1.5m above the
floor to minimize danger of igniting of
explosive gases.
03/21/2024 32
 Equipment

•The operating table in the center of the room can be raised, lowered, and tilted in any
direction.
•The operating room lights are over the table to provide bright light, without shadows,
during surgery.
•The anesthesia machine is at the head of the operating table.
This machine has tubes that connect to the patient to assist him or her in breathing during
surgery, and built-in monitors that help control the mixture of gases in the breathing circuit.
03/21/2024 33
 Surgeon and assistants equipment
• People in the operating room wear PPE to help
prevent germs from infecting the surgical
incision.
• This PPE includes the following:
- a protective cap covering their hair
- masks over their lower face,
- shades or glasses over their eyes

03/21/2024 34
 Surgeon and assistants equipment

• •vinyl gloves on their hands; latex is used as

well, but much less common
• •long gowns, with the bottom of the gown no
closer than six inches to the ground.
• •protective covers on their shoes
• •if x-rays are expected to be used, lead
aprons/neck covers are used to prevent
overexposure to radiation

03/21/2024 35
 PREVENTION OF INFECTION
• Sterilization-a process that involves the
complete destruction of all microorganisms,
including bacterial spores
• Disinfection-reduces the number of viable
microorganisms but does not necessarily
inactivate bacterial spores
• Cleaning-a process that physically removes
contamination but does not necessarily
destroy microorganisms

03/21/2024 36
 Infection control
• Antisepsis places a barrier which destroys
organisms between the wound and the external
environment.
• In surgical operative practice the objective of
asepsis is to have as few organisms as possible in
the immediate vicinity of the operating field.
• This is achieved partly by ventilation control but
principally by ensuring that everything that
comes into contact with the field is first
rendered sterile.
03/21/2024 37
 Infection control…
• A number of methods of infection control are
available
• There are three major factors of importance in
the operating field:
 sterilization of instruments and equipment
 skin preparation and draping of the patient
 preparation and clothing of the operating
team
03/21/2024 38
 Sterilization

• There are two types of sterilization:

- heat sterilization
- cold sterilization
• The process applies to instruments and
equipment for use in a procedure where the
skin is breached but not necessarily to
gastrointestinal endoscopy.

03/21/2024 39
 Methods of heat sterilization.
• High pressure steam sterilizer.
• Dry heat sterilizer.

03/21/2024 40
 Heat sterilization

 Steam under pressure

• Sterilization is dependent on the temperature
attained and the length of time for which this is
maintained
• the higher the temperature, the greater the
lethal effect on microorganisms.
• An increase in ambient pressure raises the
boiling point of water, so higher steam
temperatures can be achieved at higher
pressure.
• This process is carried out in an autoclave.
03/21/2024 41
 Steam under pressure …

• The instruments or drapes to be sterilized are

usually pre-packed in a container which is
permeable to the steam but which will not
subsequently let in organisms.
• Air is sucked out to create a vacuum and the
instruments are then exposed to moist heat
under pressure.
Typical cycles are:
• 134°C and 30 lb/in2 for 3 min
• 121°C and 15 lb/in2 for 15 min.
03/21/2024 42
 Sterilization by steam.
Advantage:
• Most commonly used.
• Effective.
• Shorter sterilization cycle time.

03/21/2024 43
 Sterilization by steam…
Disadvantages:
• Requires continuous source of heat.
• Requires equipment.
• Requires strict adherence to time,temprature
and pressure settings.
• Difficult to produce dry packs, specially in
humid climates.
• Plastic items can not withstand high
temperatures.
03/21/2024 44
 Steps to follow:
• 1-decontaminate and clean properly.
• 2-jointed instrument should be in the opened
or unlocked position or disassembled.
• 3-Instruments should not be held tightly
together by rubber bands.
• 4-arrange packs in the chamber to allow free
circulation.
• 5-wrap instrument in a double thickness of
muslin.
03/21/2024 45
 Steps…
• 6-Sterilize at 121c for 30 min for wrapped
items,20min for unwrapped items.
• 7-wait 20-30 min,open the lid, allow
instrument packs to dry completely.
• 8-unwrapped items must be used immediately
or stored in covered sterile containers.

03/21/2024 46
 Dry heat
• In this type of sterilization a higher
temperature for a longer period is required,
e.g. 160°C for 2 hours.
• It is suitable for sterilizing airtight containers
and fine instruments that are susceptible to
corrosion.

03/21/2024 47
 Sterilization by dry heat.
Advantages:
• Effective method.
• Protective of sharps or instrument with cutting
edge.
• Leaves no chemical residue.
• Eliminates wet pack.

03/21/2024 48
 Disadvantages:
• Not used for plastic and rubber items.
• Penetrates materials slowly and unevenly.
• Requires oven and continuous source of
electricity.

03/21/2024 49
 Steps to follow:
1-decontaminate,clean and dry all instruments.
2-place instruments in a metal container with tight
fitting.
3-after desired temperature is reached, begin timing.
- 170◦c---60min,
- 160◦c----120min,
- 150◦c----150min,
- 140◦c------180min.
4-after cooling, remove packs.
03/21/2024 50
 Low-temperature steam/formaldehyde

• A combination of dry saturated steam and

formaldehyde sterilizes at a lower
temperature (73°C)
• suitable for heat-sensitive materials and
equipment.

03/21/2024 51
 Cold sterilization

 Irradiation
• Gamma rays at high intensity are lethal to cells,
including those of microorganisms.
• The method is not feasible in a hospital setting.
• used by industry for the sterilization of mass-
produced disposable items such as syringes,
catheters and sutures.

03/21/2024 52
  Chemical sterilization
• An alternative.
• High level disinfectants will kill endospores after
prolonged exposure(10-24hr).
• Glutaraldehydes and formaldehyde.
• Leave residue
• Rinsing in sterile water is essential.
• Glutaraldehydes is expensive.
• Formaldehydes is irritative to skin.
• Solutions can be used for 14-28 days.
03/21/2024 53
 Chemical sterilization…
 Ethylene oxide
• This is a highly penetrative gas that, under
controlled conditions,
• has good sterilizing properties.
• killing most bacteria, spores and viruses.
• It is ideal for heat-sensitive, delicate items
such as electrical equipment or endoscopes
• largely an industrial process for sterilizing
single-use plastic items.

03/21/2024 54
 Chemical sterilization…
 Glutaraldehyde
• Alkaline glutaraldehyde is a liquid chemical
disinfectant
• used to clean lensed instruments such as
flexible endoscopes or cystoscopes,
• which have many heat-sensitive components.
• It is, however, a highly toxic, irritant and
allergenic substance.
• its use should be carefully controlled by
trained staff
03/21/2024 55
 Other sterilizing methods.
• Gas sterilization.(formaldehyde gas, ethylene
oxide gas).
• Ultraviolet light sterilization.
• Other chemical sterilants.
paracetic acid.
paraformaldehyde.

03/21/2024 56
 High-level disinfection.
• Can be used if no sterilization.
• Destroys all microorganisms except some
bacterial endospores.
• Can be achieved by boiling, steaming and
soaking in chemical disinfectants.
• To be effective, all steps in performing each
method must be monitored.

03/21/2024 57
 High level disinfection.
Steaming(moist heat)
• All vegetative bacteria are killed at temperatures
of 60-70c within 10min.
• HBV,is inactivated in 10min when heated to 80c.
• Inexpensive.
• Easily taught to health worker.
• Require no special chemicals or dilutions.
• Leave no chemical residue.
• Heat sources are commonly available.

03/21/2024 58
 High-level disinfection by boiling.
• Effective and practical.
• Kill all vegetative form of bacteria in 20min.
• Will not kill all endospores reliably.

03/21/2024 59
 Preparation of the patient's skin

• Up to half of all wound infections are caused by

bacteria resident on the skin.
• Their quantity can be reduced by having the
patient shower on the morning of the operation
with an antiseptic substance such as
chlorhexidine.
• At the start of the operation a wide area of skin
around the incision site is cleaned with a
povidone-iodine or chlorhexidine solution.

03/21/2024 60
 Preparation of the patient's skin
• Either of these combined with ethyl alcohol
gives better disinfection
• but organisms still persist in hair follicles and
sweat glands.
• Pools of residual alcohol must be avoided
because they can be ignited by a spark from
an electrocoagulation instrument.

03/21/2024 61
Preparation of the patient's skin …
• Either of these combined with ethyl alcohol
gives better disinfection
• but organisms still persist in hair follicles and
sweat glands.
• Pools of residual alcohol must be avoided
because they can be ignited
• by a spark from an electrocoagulation
instrument and cause a burn

03/21/2024 62
 Shaving

• Patients have traditionally been shaved for

operations.
• when a razor is used it can cause minor nicks
and scratches bringing bacteria to the surface
and increasing the incidence of wound
infections.
• If the skin has to be shaved, then clippers
should ideally be used as close to the start of
the operation as possible
03/21/2024 63
 Isolation of the operation field

• The area to be operated on is isolated using heat-sterilised

surgical drapes.
• These are usually cotton sheets, although cotton can quickly
become wet and lose its protective ability.
• Newer impermeable materials and disposable drapes have
been introduced, but they are more expensive.
• Self-adhesive plastic drapes are often used for irregular or
extensive operation sites,
• Drapes also serve to identify the aseptic operating zone in
which the surgeon, assistants and scrub nurse work.
• Any equipment,instruments or staff that come into contact
with the drapes must also be sterile
03/21/2024 64
 Preparation of the operating team
Scrubbing up
• Scrubbing up is the term given to the hand and arm
cleaning process undertaken at the start of an operation.
• It was formerly a ritualised process of alternate scrubbing
and rinsing of yttttttttttthe fingers, hands and arms with a
brush for a defined period of time.
• This is now known not to be necessary and that brisk
scrubbing of the skin with a brush can cause microtrauma
to the epidermis and increase the bacterial count at the
skin surface.
• An initial scrub of the fingernails at the start of an
operating list is all that is required and should take about
3-5 minutes.
03/21/2024 65
 Preparation of the operating team
• All jewellery is removed.
• The fingers, hands and forearms are cleaned
thoroughly using a medicated detergent.
• Chlorhexidine is rapidly effective and has a prolonged
action but is ineffective against bacterial spores.
• Povidone-iodine kills all organisms including spores
but does not have a prolonged effect and has a
higher incidence of allergic reactions.
• After washing, the hands are dried thoroughly with a
sterile towel;
• this further decreases the bacterial count and makes
donning of gowns and gloves much easier.
03/21/2024 66
 Gowns and gloves
• Both of these are donned with a closed
technique (i.e. the skin does not touch anything
on the outside surface) .
• Conventional sterile cotton gowns can soon
become wet and pervious to bacteria.
• They also allow contamination of the surgical
team by the patient's body fluids.
• One partial solution is to wear a disposable
plastic apron beneath the gown.

03/21/2024 67
 Gowns and gloves
• Both of these are donned with a closed
technique (i.e. the skin does not touch anything
on the outside surface) .
• Conventional sterile cotton gowns can soon
become wet and pervious to bacteria.
• They also allow contamination of the surgical
team by the patient's body fluids.
• One partial solution is to wear a disposable
plastic apron beneath the gown.

03/21/2024 68
 Gowns and gloves …
• Gloves were formerly lightly coated or the hands
dusted with talc so as to make them easy to put on.
• However, talc is irritant, and a particularly difficult
form of adhesive small bowel obstruction may follow
contamination of the peritoneal cavity.
• Starch was then substituted, but it is now clear that
there are individuals who are starch-sensitive who
also form abdominal adhesions.
• Most surgeons therefore now use starch-free gloves

03/21/2024 69
 Infected and other high-risk patients

• Patients themselves can be a source of infection and

pose particular problems when their tissues are
exposed.
• The simplest instances are when infected patients,
e.g. those having drainage of an abscess or those with
infected open wounds, contaminate the operating room,
which can lead to contamination of subsequent
patients.
• It was previously common practice to put at the end of
elective operating lists those regarded as being able to
disseminate infection.
• However, if the theatre is adequately cleaned between
each procedure, then this practice is not essential.
03/21/2024 70
 Infected and other high-risk patients…
• Specialties, such as orthopaedics or transplant
surgery, which require ultraclean conditions
should have dedicated theatres that are not used
by others.
• Dressings or bandages from infected patients and
disposable equipment used in their operation
should be carefully disposed of in plastic sacks.
• These should only be filled to three-quarters of
their capacity (in case overfilling results in
rupture) before being sealed and disposed of by
incineration.
03/21/2024 71
 Infected and other high-risk patients…
• The usual measures to prevent cross-infection within the
operating suite include:
- use of impervious gowns and drapes so that the operating table
or surgical team do not come into contact with the patient's
blood or body fluids
- a plastic apron under the operating gown if heavy
contamination is anticipated
- latex operating gloves, although these provide little or no
protection from injuries by sharp instruments such as knives or
needles.
- operating room discipline, e.g. passing needles or scalpels
between the scrub nurse and surgeon in a transit dish to prevent
injury from hand-to-hand passage
- careful disposal of all contaminated material at the end of the
procedure
03/21/2024
into plastic sealable bags for incineration 72
 Infected and other high-risk patients…

• The term 'high-risk' has now become applicable to

groups positive for: HIV,hepatitis B Hepatitis C.
• These agents are of most concern to the surgical team
because of the risk of transmission through the patient's
blood entering the body of a member of the team .
• Other transmissible agents may appear in the future.
• the way to identify high-risk patients is:
- by the patient's own admission of infection,
- a history of high-risk behavior or
- by the detection of significant physical signs, such as
multiple injection marks from intravenous drug abuse.
03/21/2024 73
 Infected and other high-risk patients…

• Extra precautions when operating on high-risk patients

include:
Double gloving.
• Wearing two pairs of gloves reduces the likelihood of
glove perforation.
• it is usual to wear the inner glove a half-size larger than
the individual's normal size.
Eye protection.
• Goggles or visors are essential to prevent splash
contamination of the conjunctiva.
• They are most important when power tools are being
used, because these can create a fine aerosol mixture of
body fluids with a theoretical risk of viral transmission.
03/21/2024 74
 Infected and other high-risk patients…

Surgeon.
• The most experienced surgeon available should
do the operation.
Staples.
• Stapling devices should be employed for
anastomoses and skin closure to reduce the risk
of needle pricks.
Needles.
• Hand-held needles should be avoided because
the incidence of glove perforation is so high as
to be unacceptable.
03/21/2024 75
 Infected and other high-risk patients…
• Prevention of cross-infection and the infection of
healthcare workers by viral diseases depends on
the efficacy of the barrier between patients and the
surgical team;
• this consists of both the mechanical barrier (as
outlined above, by the use of impervious materials)
and that resulting from good surgical practice.
• At present there is no satisfactory prophylaxis
against either HIV or hepatitis C.
• Hepatitis B can be protected against by
immunization, and this should be mandatory for all
healthcare workers
03/21/2024 76
 REFRENCES
• OXFORD PRIMARY SURGERY
• ACS,Clinical surgery 6th edition

03/21/2024 77
 THANK YOU

03/21/2024 78