Fundamental Principles that Underpin Surgical Practice
Introduction:
An operation theatre can be defined as a facility within the premises of a hospital that is designed with the sole purpose of carrying out surgical procedures within a sterile environment (Conway, 2007). Operation Theatre design is governed by scientific principles that empathize on improving the efficiency of the operating room and team while reining in operational costs and ensuring patient safety. Typically operation theatres are expensive and complex as they tend to cater to multiple needs (Ehrenwerth, 1999). The environment in the OT comprises the patient and hospital personnel along with the equipment and technology. The temperature, airflow, humidity, and lightning within the OT play a crucial role in Perioperative surgical procedures. The personnel working in this highly specialized and stressful environment are significantly impacted by the physical environment and design of the OT (Gofrit et al., 2016). Perioperative care includes the entire gamut of pre, intra and postoperative care for the patient undergoing surgery.
Main Body:
1. The acceptable environmental levels in the operating department and their relation to fundamental scientific principles and aspects of theatre design including zoning.
The design parameters for operating Suite must include avoidance of outdoor sources of noise. The walls and ceiling must be aesthetically pleasing while simultaneously ensuring that all unrelated hospital traffic in the area is avoided. The suite must have a convenient communication line with important departments like anesthesia, Surgery, post-operative wards, ICU, Pharmacy, blood bank, laboratory, and so on. The suite must be designed with provisions for future alternations and expansions (Ehrenwerth, 1999). The adjacent corridors must have a minimum width of 3 mts to ensure smooth movement of trolleys and stretchers. Sliding doors must be preferred to reduce air turbulence within the suite. Equipment like an autoclave must be kept within the suit to avoid contamination of scrub staff while moving to pick up the sterile equipment. A preference should be given to high-speed autoclaves and sterilizers. (Gupta, Kant and Chandrashekhar, 2005)
Smooth non-slip floors, washable ceilings, and walls that do not allow a buildup of static electricity are important considerations for the OT design. The OT must incorporate refrigeration facilities for emergency medications, taps, and communication equipment that do away with the need for hand operation are preferred to avoid chances of contamination of personnel during procedures. X-ray illuminators, emergency communication facilities and sealable rooms are also integral factors while designing modern-day Operation Suites (Gupta, Kant, and Chandrashekhar, 2005), (Gofrit et al., 2016). Higher temperatures lead to greater humidity and condensation build-up as well as sweating of the surgical team. Both these conditions can be risky for patients undergoing surgery as well as foster bacterial build-up Adequate lighting is needed for the personnel to complete the procedure comfortably and without unwanted incidents.
The main considerations for OT design include (Gupta, Kant and Chandrashekhar, 2005):
· Ensuring a high standard of asepsis
· Maintaining high safety standards
· Promoting optimization in the use of both OT and OT personnel
· Ensure working conditions and OT environment are conducive to the health and well-being of both patients and staff. Ensure that all acoustic, lighting, and thermal requirements as well as comfort levels for them are met and maintained.
· Minimize maintenance and make room for flexibility in operations.
· Co-ordinate services and regulate the flow of traffic, including personnel, contaminated equipment, and sterile equipment.
· Ensure that the separation of spaces is done based on functionality alone.
· Ensure that the environment is soothing and free from stress.
A commonly seen occurrence in most operation suites is a lack of bifurcation between the contaminated items going out of the OT and sterile items going in. By ensuring clean and scrubbed floors, tiles, and other surfaces as well as demarcating in and out paths for patients as well as equipment and personnel, post-operative infection can be negated or reduced considerably (Conway, 2007). The OT design must reflect this ideology along with the need to ensure minimum discomfort to patients (Servant, Purkiss and Hughes, 2002). Thus scrubbed personnel must ensure that they do not unknowingly contaminate themselves, their co-workers, or surgical equipment. The OT environment including scrub clothes must remain sterile throughout the procedures being carried out in the suite including the handling of equipment from the autoclave (Davey and Ince, 2007). Minimum movement within the sterile area during the procedure is also considered highly effective for maintaining the OT environment. Zoning is a process that is followed across Operating suites to help ensure minimum contamination. In this method, the Suite is divided into various zones based on the level of cleanliness and bacterial count that keeps diminishing as one progresses from the outer zones toward the inner ones. Typical zones include Protective Zone followed by a Clean zone, Sterile Zone and Disposal Zone (Gupta, Kant and Chandrashekhar, 2005).
2. The impact surgical safety checklists (WHO & surgical check-in procedure) have with regards to minimizing harm to patients
Typically, check sheets and checklists are important and integral aspects of patient safety in OT As part of its efforts to reduce post-operative infections and improve the outcomes of surgery, the World Health Organization has proposed several lists for the attention and implementation of personnel on surgical teams and Perioperative care (Wicker, 2015). These lists pertain to safe anesthesia, prevention of SSI and ensuring teamwork for the performance of surgical teams, and so on. A few of these surgical safety check sheets have been listed below (Who.int, 2017):
Check sheet for Prevention of Surgical site infections:
· Hand washing
· Proper use of antibiotics
· Decontamination and sterility of instruments
· Proper wound care to avoid trauma
· Preparing the skin using antiseptics as required
Checklist for Safe Anesthesia
· Ensure the presence of a trained and qualified anesthetist during the surgical procedure
· Monitoring of blood pressure, temperature, and pulse as required
· Follow the check sheet for anesthetic medication and machine during the pre-intra and post-operative phases as required.
· Heart rate and pulse oximetry monitoring as required during the procedure.
`Checklist for ensuring safe surgical teams
· Ensure the availability of all team members
· Ensure adequate team preparations and planning for the surgical procedure
· Obtain informed consent from patients or relatives as required
· Confirmation of patient allergies to be done meticulously
· Confirmation of patient, site ad procedure prior to commencement of surgery
· Ensure proper communication between team members.
The surgical check-in procedure also called the surgical safety check sheet lists the steps taken by the Healthcare team prior to prepping the patient for surgery (Wicker, 2015). The steps prepared by the WHO in 2008 need to be carried out by a member of the surgical team while the patient is conscious except in exceptional cases, when the relative of the patient may be approached. The steps are listed below (Orthoinfo.aaos.org, 2017), (Who.int, 2017):
Checklist before check-in for surgery
· Confirmation of patient identity
· Confirmation of planned surgical site, procedure, and surgical consent
· Proper marking of the surgical site
· Confirmation of medical allergies
· Anesthesia checklist
· Preparation for blood transfusion in case of emergency during the procedure
Checklist before the commencement of surgery
· Introduction of team members
· Reconfirmation of surgical consent
· Review of plans related to surgery, anesthesia, and nursing
· Giving antibiotics to a patient
Checklist before check to leave the OT
- Recording the procedure in the patient’s medical records
- Counting instruments, needles, and sponges used during the procedure
- Labeling of specimens if any
- Checking of equipment used during surgery
- Discussion of post-operative recovery plans
3. Consider the ways you maintain a sterile field including aseptic technique and sterility of self and equipment. Describe the process of sterilization
The need for sterilization of equipment and personnel is essential for a successful surgery. Studies point to the fact that 14 to 17 percent of all infections acquired from hospitals post-surgery tend to be surgical site infections, better known as SSI. Interestingly, the rate of such infections is strongly impacted by the quality of the OT. Careful planning, periodic checks, and regular and continuous training can go a long way in negating the risk factors that tend to trigger SSI (Spagnolo et al., 2013). The probability of SSI is determined by the extent of contamination at the site of surgery. Interestingly, OT design can directly influence the prevention of SSI dramatically.
A sterile field refers to an area that is free of not only microorganisms but spores as well. Each and every healthcare personnel is responsible for maintaining the sterile field created in the OT (Safeguards for invasive procedures, 1998). This can be easily done by clearly defining the in and out path for patients, and using sterile equipment including sterile gowns, gloves, and so on alongside sterile equipment during procedures in the OT. Used material has a tendency of losing sterility and hence needs to be discarded before a new procedure. (Wicker and Dalby, 2017), (Austincc.edu, 2017)
Sterilization of equipment and personnel is essential to ensure minimization of SSI and maximize the recovery chances for the patient post-surgery (Safeguards for invasive procedures, 1998). Sterilization of equipment is done by the sterile processing departments and is divided into 4 areas, viz., decontamination, assembly and packaging, sterile storage, and distribution areas. Reusable equipment, supplies, and instruments are cleaned and sterilized in the decontamination area using both chemical disinfection processes and mechanical cleaning processes including autoclave. They are then assembled and packed in the nest section before being taken for proper storage in the sterile storage area until required. The distribution area is used for the preparation and delivery of carts; exchange of cart inventory and replenishment, telephonic order filling, requisition order filing, and patient care equipment delivery (Urmc.rochester.edu, 2017).
Antiseptic techniques used in surgical practice are part of the Perioperative procedures followed by all personnel in the surgical team (Wicker and Dalby, 2017). The anesthetist, anesthetic nurse, and circulating nurse tend to remain in the non-sterile area and need not be scrubbed. However, since the human body cannot be sterilized 100 percent, procedures like hand washing, usage of barriers like gloves and aprons for protection, proper handling of disposables, and so on must be ensured by all team members. Clean clothes (scrub clothes); masks, caps, clean shoes, and shoe covers are a must for all personnel in sterile areas (Wicker and O'Neill, 2010).
4. Explain how infection control is implemented in the surgical environment; consider Personal Protection Equipment, disposal of waste, and Control of Substances Hazard to Health.
Infection control implementation in the surgical environment is essential for the healthy recovery of the patient post-surgery (Gould, Brooker and Gould, 2008). Towards this end, the surgical team must follow some procedures including promoting a safe climate during the Perioperative phase; maintaining proper hand hygiene at all times, use personal protective equipment as and when required including gloves, gown, apron, cap, mask, and eye protection; maintain cough etiquette and respiratory hygiene, ensure proper handling of specimens, equipment (both contaminated and sterile); ensure proper disposal of waste including bio waste, hazardous waste, and sharp objects. Implementing infection control during surgery is essential to ensure that the patient s not exposed to SSI or post-operative infection from the hospital premises (Hughes and Mardell, 2009), (Gould, Brooker, and Gould, 2008).
Handling of specimens is an important aspect of post-surgical care particularly in surgical procedures like biopsies, removal of tumors, foreign bodies, and so on. Specimens collected during surgical procedures need to be identified and tagged properly a loss of specimens tends to b distressing for the Perioperative team as it can lead to a delayed or incorrect diagnosis, incorrect treatment, and unnecessary surgery which could even lead to legal ramifications as well. The collected specimen must include correct patient information, correct specimen information, and labeling of the patient specimen. The personnel handling specimens must wear appropriate personal protective equipment (Wicker and O'Neill, 2010). Only one specimen must be present in the sterile area at any given time. Sterilization of equipment as a means of infection control has been found to be extremely helpful in controlling infection during Perioperative of surgical patients. The hazardous wastes that are part of the surgical procedure need to be disposed of appropriately. Adequate cleaning of the environment and surfaces that are frequently touched is also essential to contain contamination (Woodhead and Fudge, 2012).
Conclusion
Typically Operation theatres are used to carry out a variety of surgical procedures and most hospitals prefer to schedule the entry and exit of patients in such a manner that there is a minimum downtime for the patient. Unfortunately, this tends to create a situation that encourages post-operative infection, particularly if the sterile area or personnel are exposed to contamination in any manner (Hughes and Mardell, 2009).
References
Austincc.edu. (2017). Surgical Asepsis Notes. [online] Available at: http://www.austincc.edu/adnlev1/rnsg1413skillslab/sterile_technique/notes_surg_asepsis.htm [Accessed 16 Apr. 2017].
Conway, N. (2007). Operating department practice. 1st ed. Oxford: Pennant Health
Davey, A. and Ince, C. (2007). Fundamentals of operating department practice. 1st ed. London: Cambridge University Press.
Davey, A. and Ince, C. (2007). Fundamentals of operating department practice. 1st ed. London: Cambridge University Press.
Ehrenwerth, J. (1999). Designing the operating room for maximum efficiency. Seminars in Anesthesia, Perioperative Medicine and Pain, 18(4), pp.334-340.
Gofrit, O., Weissman, C., Peleg, E., Lifshits, N., Pinchover, R. and Weiss, Y. (2016). Designing a modern surgical facility. Perioperative Care and Operating Room Management, 3, pp.12-20.
Gould, D., Brooker, C. and Gould, D. (2008). Infection prevention and control. 1st ed. Basingstoke [England]: Palgrave Macmillan.
Gupta, S., Kant, S. and Chandrashekhar, R. (2005). Operating Unit - Planning Essentials and Design Considerations. Journal of the Academy of Hospital Administration, 17(2), pp.1-12.
Harsoor, S. and Bhaskar, B. (2007). Designing an ideal operating room complex. Indina Journal of Anesthesia, 51(3), pp.193-199.
Hughes, S. and Mardell, A. (2009). Oxford handbook of perioperative practice. 1st ed. Oxford: Oxford University Press.
Orthoinfo.aaos.org. (2017). Surgical Safety Checklist: Steps Your Healthcare Team Takes-OrthoInfo - AAOS. [online] Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00716 [Accessed 16 Apr. 2017].
Safeguards for invasive procedures. (1998). 1st ed. Harrogate: National Association of Theatre Nurses (NATR).
Servant, C., Purkiss, S. and Hughes, J. (2002). Positioning patients for surgery. 1st ed. London: : Greenwich Medical Media.
Spagnolo, A., Ottria, G., Amicizia, D., Perdelli, F. and Cristina, M. (2013). Operating theatre quality and prevention of surgical site infections. J Prev Med Hyg, 54(3), pp.131-137.
Standards and recommendations for safe perioperative practice. (2011). 1st ed. Harrogate: Association for Perioperative Practice (AfPP).
Urmc.rochester.edu. (2017). Basics on Processing & Sterilization -Sterile & Materials Processing Department - University of Rochester Medical Center. [online] Available at: https://www.urmc.rochester.edu/sterile/basics.aspx [Accessed 16 Apr. 2017].
Who.int. (2017). WHO | WHO surgical safety checklist and implementation manual. [online] Available at: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/ [Accessed 16 Apr. 2017].
Wicker, P. (2015). Perioperative practice at a glance. 1st ed. West Sussex, Uk: John Wiley & Sons.
Wicker, P. and Dalby, S. (2017). Rapid perioperative care. 1st ed. West Sussex, Uk: Wiley-Blackwell.
Wicker, P. and O'Neill, J. (2010). Caring for the Perioperative Patient. 1st ed. Chichester: Wiley-Blackwell.
Woodhead, K. and Fudge, L. (2012). Manual of perioperative care. 1st ed. West Sussex, UK: Wiley-Blackwell.
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