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Theater protocols

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									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.

                                                   2
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.


                                                        3
Factors affecting control of infection

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



                                         4
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.



                                                            5
       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.
                                                           6
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.
                                                   7
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.




                                                   8
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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.

                                                       10
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.
                                                  11
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.



                                              12
   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
                                                            14
 Settlement of negligence
 claims in this area is very
 costly.



                               15
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.



                                                        16
   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 .




                                             17
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.




                                                 18
Preoperative preparation of patient




                                      19
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.




                                                   20
Changing area

   Should be adequate in size, secure
    locker, clean& adequate supply of clean
    closing with toilet &washing facilities.




                                           21
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.

                                                  22
Cups

   Cups are not important in general
    surgery may have significance in
    implant surgery.




                                        23
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.




                                           24
Visor should

   Be made of synthetic fabric.
   Not be touched by hand.
   Not be put in pocket.
   Be destroyed after single use.




                                     25
Gloving

   There is little evidence that wound
    infection related to glove puncture, so
    hand washing is essential.




                                              26
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.




                                              27
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).
                                               28
   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..

                                                        29
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.




                                                30
    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.


                                                   31
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).



                                                   32
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.

                                                           34
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.


                                                    35
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.


                                               36
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.

                                                      37
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.
                                                        38
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.



                                                39
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.


                                               40
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.



                                                      41
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.

                                                     42
   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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