Operating Room and Burn Unit

INFECTION
CONTROL IN THE
OPERATING AND
DELIVERY ROOMS
Ma. Laarni D. Canceran, R.N.
Department Manager, St. Luke’s Medical Center- Global City

Operating Room
 Characteristic features:
• Patients are at risk due to exposed wound
• Natural body defenses are depressed
• Most patients are compromised
• Our goal is to decrease Surgical Site Infection
(SSI)

Operating Room
• Room needs to be as
clean as possible
• Houses special
equipments that can
be source of infection
• Set up should take
infection control
principles into account

Operating Room Divisions
 Design and Traffic Pattern – 3 zone concept
 Unrestricted Area which includes the patient reception
area, locker rooms, lounges and offices.
 Semi-restricted Areas which include the storage areas
for clean and sterile supplies, work areas for storage
and processing of instruments and corridors to
restricted areas of the suite. Traffic is limited to
authorized personnel and patients. Personnel are
required to wear gown and hair covering.
 Restricted Area includes all areas where personnel are
required to wear surgical masks and scrub attire at all
times. It includes operating suites, clean core and scrub
areas.

Relative humidity should be approximately
30%-60% in most ORs and in the PACU
Air-change rate in OR of 20 to 25 air
changes per hour (ACH)
Recommended temperatures for ORs are
between 68°F and 73°F (20-23°C) during
surgery , and recommendations for the post-
anesthesia care unit (PACU) are between 70°F
and 75°F (21-24°C)
American Society of Heating, Refrigerating and Air-Conditioning
Engineers, Inc. ASHRAE Journal Ventilation
New Ventilation Guidelines
For Health-Care Facilities

The IC Team should be notified
whenever the air delivery system
for the OT has been shut down
for maintenance or malfunction.
The IC team in conjunction with
facility engineers will assist with
determination of need for any
environmental monitoring needed
once the ventilation system is re-
established. At a minimum
positive pressure, inspection of
filters and air changes per hour
should be verified prior to use of
the affected OT after
interruption. The theatre should
be used only after clearance
from the IC team.

Handling of Infectious Patients

 A room may be designated for "precaution
cases"(infectious/communicable)” of an infectious patient.
If possible the room at the farthest corner of the area shall
be assigned for the case, OR it will be scheduled last for
the day, provided it is not a stat case.

• The inanimate theatre environment should, under normal circumstances, have
a negligible contribution to the incidence of SSI.
• Floors and walls will never be sterile nor is there any point in trying to
achieve that level of cleaning. Floors are rapidly re-contaminated after
cleaning and disinfection and that they should be cleaned at the end of
each session/case. Disinfectant may not be required, except when cleaning
body fluid spillage.

 Walls and ceilings are rarely
heavily contaminated, cleaning
them once a month is
reasonable.
 Correct site decontamination of
blood and other potentially
infectious materials should be in
compliance with the standards.
 Brooms of whatever materials
and vacuum cleaners are not to
be used; wet mops shall be
used instead.

http://www.ems.org.eg/esic_home/data/giued_part2/Operating%20Theatre.pdf

Environmental Microbiologic sampling
Routine microbiologic sampling of the OT air or surfaces is not recommended
because the results obtained are only valid for the time period and for the
location sampled. Instead, such studies should be limited to recommendations
from the IC-Team, investigations of clusters or outbreaks of infection, or to
validate changes in the ventilation system (e.g. installation of new AHU).
http://www.ems.org.eg/esic_home/data/giued_part2/Operating%20Theatre.pdf

Environmental Decontamination
• Aerosolized Hydrogen Peroxide is a new
method of surface area decontamination
that is recommended recently by Infection
Control experts as an adjunct to our usual
manual cleaning. This method eliminates
the deficiencies and inconsistencies
inherent in manual cleaning contributed
by the human factor.
• UV light no-touch environmental
disinfection using ultra violet technology

MOBILITY
 The number of persons present during an operation must be as small as
possible
 Walking in and out during an operation must be kept to a minimum.
People are the most important source of microorganisms in the OR. It is
also certain that the number of microorganisms in the air increases as
the numberof people and movements in OR increase. Walking in and
out disturbs the flow of air, causing unwanted temperature fluctuations.

OR ATTIRE
• hair covering
• mask
• foot wear
• gloves

•A distinction must be made between the general clothing in the
OR complex(scrub suits) and the sterile clothing to be worn over it
by the surgical team immediately surrounding the operating table
•No wrist watches, jewellery or piercings may be worn

•In the OR complex, operating room clothing is worn. This clothing is not worn outside
the OR.
•In order to maintain the zone system in practice, it is important that everyone complies
with it.
•When someone has to leave the OR complex for a short time, for instance for brief
administrative activities, a white coat or other item of protective clothing be worn over
the scrub suit. This does not apply when examination or treatment of a patient must
take place in the ward.
•Between operations, clothing is changed when it becomes dirty or wet
•Clean operating room clothing must be put on each day

Double Gloving
• The transmission of HBV and HCV from surgeon to patient and
vice versa has occurred in the absence of breaks in technique
and with apparently intact gloves (Davis 2001). Even the best
quality, new latex rubber surgical gloves may leak up to 4% of
the time.
• Single gloves had a blood-hand contact rate of 14% while
surgeons wearing double gloves had only a rate of 5% (Tokars
et al 1995; Tokars et al 1992)

Guidelines for Double Gloving
• The procedure involves coming in contact with large amounts
of blood or other body fluids (e.g., vaginal deliveries and
cesarean sections).
• Orthopedic procedures in which sharp bone fragments, wire
sutures and other sharps are likely to be encountered.
• Surgical gloves are reused. (The possibility of inapparent holes
or perforations in any type of reprocessed glove is higher than
with new gloves.)

Surgical handwash or surgical handrub must be
performed preoperatively by surgical personnel
to eliminate transient and reduce resident hand
flora.
Pre-operative Hand Hygiene

Name ___________________________ Sex_______ Form Control #: _____________
Service provider : Consultant/ Surgeon Resident Nurse Intern Surgical Technician
Department : GS Ortho ENT Uro Others, please specify: ____________________
•Purpose
•To decrease the number of resident and transient microorganisms in the skin.
•To keep the population of microorganisms minimal during the surgical procedure by suppression of growth
•To reduce the hazard of microbial contamination of the surgical wound
•Materials
Antiseptic rub, face mask, cap, eye goggles and nail pick
Surgical Scrub Procedure
Activity Done Not Done Remarks
I. Preparation for Surgical Rub Procedure
General Preparation:
•Skin and nails should be kept clean and in good healthy condition.
•Fingernails should not extend beyond fingertips to avoid glove puncture.
•Fingernail polish should not be worn.
•Artificial materials must not cover natural fingernails.
•Remove all jewelry.
II. Preparation Immediately before Surgical Rub
• Inspect the hands for cuts and abrasions.
• Be sure all hair is covered by headgear/bouffant cap.
• Adjust disposable mask snugly and comfortably over nose and mouth.
• Wear eye goggles if needed.
III. Surgical Rub Procedure
1
Wash hands and forearms with antimicrobial soap (such as chlorhexidine or approved alternative soap) and running water
immediately before beginning the surgical hand scrub.
2 Clean the subungual areas of both hands under running water using disposable nail cleaner
3a
Apply 2-3 ml (6 drops) of antiseptic soap from the dispenser to the hands. (or follow manufacturer’s recommendation)
3b
Wash the hands and forearms for 3 – 6 minutes including at least 30 strokes each hand. Pay particular attention to the fingers,
cuticles and interdigital spaces and working the antimicrobial soap to four sides of the forearm. Avoid splashing your surgical attire.
4
Rinse thoroughly hands and forearms under running water, holding hands higher than elbows and away from surgical attire,
allowing water to drip from flexed elbows.
5
Dry hands and arms with sterile linen before donning sterile gloves and gown. (Double glove if with cuts or abrasions.)
6
Repeat the above procedure on the following instances:
Relief during handing-off process between scrub personnel.
To start another OR procedure.
To return to the sterile field when you already scrubbed out.

• Visitors to the operating room include visiting doctors from other
wards, parents of young children while thay are brought to the OR,
partners who attend Cesarean, and technicians
• The number of persons present during an operation must be kept to a
minimum. Everyone must be aware of the risks of infections and must
maintain the necessary discipline.
• The number of movements must be kept to a minimum.
• Visitors who are present during the operation must wear the standard
surgical clothing. For a brief visit (less than or equal to 15mins) overalls
with cuffs around the arms and ankles will suffice. In addition,
disposable masks and hair covers are worn.
 For longer visits (more than 15mins) visitors must follow the clothes
changing procedure for the staff

Patient's Clothing
•The patient wears operating room clothing.
•The patient does not wear shoes.
•In the OR complex, the patient wears surgical
cap.

Transport to and across the transfer area
Transport of the patient to operating room can take place in three ways:
1. On the day of the operation, either in the ward or at the boundary of
the operating area, the patient is lifted onto a clean bed with clean
bedding, which is wheeled next to the operating table. After the
operation, this bed is used again to transport the patient to the recovery
room or the nursing ward.
2. The patient is wheeled to the boundary of the operating room area in
his/her own bed. There, the patient is lifted onto an operating surface on
wheels or a mobilift, after which it is wheeled into the operating room.
After the operation the patient is lifted from this system onto a bed with
clean bedding in the recovery room

Transport to and across the transfer area
3. If it is not possible to lift the patient onto a clean bed or an
operating surface on wheels outside the operating room(for
example if the patient is in a traction bed), an exception can
be made and the patient can be wheeled to the operating
table on his/her own "dirty" bed from the nursing ward. In
that case, the bed must be made up with clean bedding in the
nursing ward and domestically cleaned insofar as possible.
•The risk of infection is the same in every part of the transfer
area. No link has been demonstrated between one of the
above-mentioned systems of transport and the chance of
infection. The choice between these three methods can be
based on practical and economic considerations.
•The bed a patient was lying in his/her ward may only be
wheeled to the operating table in exceptional cases.

Pre-Operative Showers
• 4% Chlorhexidine
solution used,
preferred night before
and morning of
surgery
• Cochrane review,
showed no clear
evidence or advantage
• Pre-operative shower
reduces SSIs

Re-use of Single use Items
• Big issue
• Little available evidence of harm from reuse, FDA
says oversight is warranted
• Problems involved- thousands of equipment and
supplies, re-processing differs, need for authority,
issue of efficacy

• Single-use equipment
Reuse of disposable/ single-use equipment
is not recommended. Chemical disinfection
and sterilization processes may damage or
weaken the integrity of single-use items
and make them unsafe for use.

Centralized Sterilization Area
• Training

INFECTION CONTROL IN THE
BURN UNIT
Ma. Laarni D. Canceran, R.N.
Department Manager, St. Luke’s Medical Center- Global City

Burn Wound Patient
• Among patients at highest risk for hospital-
acquired infections
• Have lost a portion of their integument that
would ordinarily be a strong barrier to
invasion of microorganisms
• Necrotic tissue in the burn eschar– combined
with the presence of serum CHON, provides
a rich culture for MOs

Infections
• Most common cause of death in burn patients
• Most common site of infection are the burn wound
and lungs
• May also initiate a septic response accompanied
by multi-organ failure

Types of Burns
• Majority of Burns– caused by thermal injury
• Adults– flame burns
• Children– scalding and flames
• Others– chemical, electrical, fire cracker injuries

Epidemiology of Burn Wounds
 The development of infection depends on the
presence of three conditions:
• Source of organisms-
• A. Burn wound of patient
• B. Environment
• C. Endogenous flora
• Mode of transmission
• Susceptibility of the patient.

Sites of Environmental Contamination in
Burn Care Facilities
Site Microorganism
Hydrotherapy equipment P. Aeruginosa, E. Cloacae
Sink faucets P. Aeruginosa
Faucet handles P. Aeruginosa
Bars of soap P. Aeruginosa
Towel racks P. Aeruginosa
Sink basins P. Aeruginosa
Transportation equipment P. Aeruginosa
Water supply P. Aeruginosa
Sink drains P. Aeruginosa

Sites of Environmental Contamination in
Burn Care Facilities
Site Microorganism
Nebulizer/humidifier water P. Aeruginosa
Counter surface P. Aeruginosa
Bed Rails P. Aeruginosa
Air Providencia stuartii
Chair (hydrotherapy area) E. cloacae
Filling hose E. cloacae
Matresses Acinetobacter calcoaceticus
P. Aeruginosa

Mode of Transmission
• Contact-- either via the hands of the
personnel caring for the patient or from
contact with inappropriately decontaminated
equipment.
• Droplet spread.
• Airborne spread.
 In general, the larger the burn injury, the greater the
volume of organisms that will be dispersed into the
environment from the patient.

Patient Susceptibility
What Lowers Physical Defenses:
• Invasive devices, such as endotracheal tubes,
• Intravascular catheters and urinary catheters,
 Bypass the body’s normal defense mechanisms..

Mode of TransmissionRisk Factors
• Duration of hospitalization
• Burn wound size
• Transfusions
• Resistance of microorganisms to topical
antibiotic agents
• Resistance of microorganism to systemically
administered antimicrobial agents

Characteristics of Burn Wound Infection
• Focal gangrene that spreads throughout the
wound
• Conversion of a partial-thickness wound to a
full-thickness wound
• Hemorrhagic discoloration of sub-eschar tissue
• Focal, multi-focal or generalized dark brown,
black or violaceous discoloration
• Changes in the unburned skin at the wound
margins char. by edema and violaceous
discoloration

Definitions for Burn Wound Infections
 Burn infections must meet the following criteria:
 Criterion 1: Patient has a change in burn wound
appearance or character, such as dark brown,
black or violaceous discoloration of the eschar,
or edema at wound margin
 And Histologic examination of burn biopsy
shows invasion of organisms into adjacent
viable tissue

 Criterion 2: Patient has a change in burn wound
appearance or character, such as dark brown,
black or violaceous discoloration of the eschar,
or edema at wound margin
 And At least one of the following:
a. Organisms cultured from blood in the absence of other
identifiable infection
b. Isolation of herpes simplex virus in biopsies

 Criterion 3: Patient w/ a burn has at least two of
the following signs or symptoms with no other
recognized cause: fever (>38˚C) or hypothermia
(<36 ˚C), hypotension, oliguria (<2oml/hr),
hyperglycemia at previously tolerated level of
dietary carbohydrate, or mental confusion
 And at least one of the following:
a. Histo exam of burn biopsy shows invasion of organisms
into adjacent viable tissues
b. Organisms cultured from blood
c. Isolation of herpes simplex virus in biopsies

REMINDERS:
• Purulence alone at the burn wound site is
not adequate for the diagnosis of burn
infection; such purulence may reflect
incomplete wound care.
• Fever alone in a burn patient is not adequate
for the diagnosis of a burn infection
because fever may be the result of tissue
trauma or the patient may have an
infection at another site.

Prevention and Control
 There is evidence that improvements in the
prevention and control of infections in burn
patients has led to improvements in patient
survival

BURN WOUND INFECTION CONTROL
MEASURES
 Goals:
• Control the transfer of endogenous organisms to
the burn sites
• Prevent the transfer of exogenous organisms from
other persons to patients

GENERAL MEASURES
 Ward setting
• Burn cases should be accommodated in Burns Unit
• Burns Unit must be physically separated from other areas
• Single rooms should be provided for isolation
 Ventilation
• Filtered air at positive pressure into individual rooms,
extracted in the corridor outside each room
• Air from ventilated rooms should be extracted to the
exterior
• No direct airflow between Burns Unit and other areas

GENERAL MEASURES
 Environmental hygiene
• Daily mopping of furniture, bedside lamps, door
handles or knobs
• No sharing of wash bowls, or furniture (e.g., beds
and chairs)
• Restrict stuffed toys and items which cannot be
effectively decontaminated
• Minimize linen agitation

GENERAL MEASURES
 Visitors and Traffic Control
• Orient all visitors to burn unit infection control
practices ( i.e. Hand washing, gowning and
isolation precautions)
• Limit amount of visitors present at any one time
• Screen visitors for infection and restrict if present
• Monitor visitors for compliance with infection
control practices

GENERAL MEASURES
 Hand Washing
• Hand washing should be done before and after
each patient contact with antiseptic .Hand washing
sinks should be conveniently accessed
• Antiseptic hand rub is an alternative for hands
without visible dirt

 Use of Barrier Techniques
- Used to prevent contact transmission of
microorganisms from patient to patient via
contaminated hands and clothing of HCW who provide
direct care
• Use of gloves and gown made of impermeable
material
• Washing of hands before donning of gloves and after
removal of gloves– need not be sterile for routine non-
invasive patient care
• If sink is not directly accessible, alcohol should always
be at bedside (this is a necessity)

On Gowns and Aprons...
• Protective gown or apron is worn to prevent soiling
and in-apparent contamination of personal
uniform
• Should be replaced in-between patients

On gloving...
• Gloves should be worn when contact with
blood, body fluids, secretions and excretions
• Gloves(sterile) should be worn for burn
wound dressing
• Gloves should be changed when
contaminated with secretions or excretions
from one site prior to contact with another site,
even if care of the patient is not completed
• Hand washing after removing gloves

 Prevention of Cross-Contamination From Inanimate
Surfaces and Food
• Each patient should be assigned his or her own
stethoscope, blood pressure cuff, box of clean
disposable gloves and container(s) of topical
antimicrobial agent
• Items of equipment that must be shared between
patients should be thoroughly cleaned and disinfected
between patients
• Covers on mattresses should be inspected between
patients and mattresses with damaged covers should
not be used

 Prevention of Cross-Contamination From
Inanimate Surfaces and Food
• Raw vegetables have been shown to be a
source of P. Aeruginosa microorganisms that
cause burn wound infections. Patients, as
much as possible should not be fed raw fruits
and vegetables

 Prevention of Cross-Contamination From
Convalescent Patients
• Convalescent burn patients may be a reservoir of
microorganisms for cross-contamination and
infection of burn patients in the acute phase of care
• They are least likely to become infected but may be
ignored as reservoir for patients in intensive care
• Ideally, there should be a separate area for
convalescent patients and nursing staff should
handle patients without crossover between these
two patient care areas

 Hydrotherapy
• Also considers the use of barrier techniques but is a
separate entity in the prevention and control of
infection because of its emphasis on cross-
contamination
• Hydrotherapy is provided in a common area using
common equipment and involves exposure to water
• Effective decontamination of complex equipment
between patients in a limited period may be a major
challenge to burn care personnel
• Always remember that water contacts the entire burn
wounds surface

 Topical Antimicrobial Agents
 Daily Wound Care
• Aseptic technique for wound manipulation and
dressing
• All dressing should preferably be done on bedside
• Expose, clean and re-wrap less infected areas first

 Topical Antimicrobial Agents
• Applied to the burn wound surface to diminish
colonization and multiplication of
microorganisms on the surface of the wound
• Most commonly used agents:
1. Silver sulfadiazine
2. Cerium-nitrate-silver-sulfadiazine
• Microbial resistance has been reported
• Administer topical antimicrobial agents
aseptically

 Systemic Antimicrobial Agents
• Extensive use frequently leads to selection of
resistant microorganisms
• Continued use of the same antibiotics provides a
selective advantage for these microorganisms and
are able to proliferate and displace susceptible
microorganisms in and on burn wounds
• Continued colonization may lead to an outbreak
• Appropriate use of antibiotics– use in clearly
indicated situations with appropriate basis

ANTIMICROBIALS AND BURNS
• The burn wound will always be colonized with
organisms until wound closure is achieved and
administration of systemic antimicrobials will
not eliminate this colonization but rather
promote emergence of resistant organisms.
• If antimicrobial therapy is indicated to treat a
specific infection, it should be tailored to the
specific susceptibility patterns of the organisms,

ANTIMICROBIALS AND BURNS
• Empiric antimicrobial therapy to treat fever
should be strongly discouraged because burn
patients often have fever secondary to the
systemic inflammatory response to burn injury.
• Prophylactic antimicrobial therapy is
recommended only for coverage of the
immediate peri-operative period surrounding
excision or grafting of the burn wound. This
should be discontinued within 24 hours.

CULTURING
Why?
• To provide early identification of organisms colonizing the
wound
• To monitor the effectiveness of current wound treatment
• To guide peri-operative or empiric antibiotic therapy
• To detect any cross-colonizations which occur quickly so that
further transmission can be prevented.
When?
• when the patient is admitted and at least weekly until the
wound is closed.

Burn Wound Infection Prevention and Control
Summary of Approaches:
• Use of barrier techniques
• Prevention of cross-contamination from inanimate
surfaces and food
• Prevention of cross-contamination from convalescent
patients
• Hydrotherapy
• Application of topical anti-microbial agents
• Appropriate use of systemically administered
antimicrobial agents

Acknowledgement
Acknowledgement:
Mary Joann Foronda, RN
ICN, Jose Reyes Memorial Medical Center

St. Luke's Medical Center's legacy of excellence surpasses all expectations. For
over a century, St. Luke's superior brand of healthcare service has made it truly
world class.
With astounding success anchored on five pillars of expertise-expert doctors,
state-of-the-art technology, guaranteed patient safety, excellent success rate
and passionate customer service, St Luke's Medical Center is the first hospital in
the country to be accredited by the Joint Commission International(JCI).

Operating Room and Burn Unit

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Operating Room and Burn Unit