What are the problems in

developing countries in OR?

Infection Control and Design
• Inaduequate resources
of Operating Rooms

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– Limited number of operating theatre
– Lack of safe anesthesia
“Now and the Future” –
–
Lack of surgical instruments
Lack of surgical equipments (suction pumps, gloves, etc.)

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– Lack of drugs
– Inadequate sterilisation units and disinfection
– Inadequate electricity and water

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EM
EMNE ALP, M.D., PhD • Architectural problems
Erciyes University,
University, Medical Faculty,
Faculty,
Department of Infectious Diseases and

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Clinical Microbiology • Inadequate ventilation
Head of Infection Control Department
• Problems in cleaning-disinfection

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Lancet 2010;376:1055-61
 Lack of Safe Surgery
Lack of Equipments

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Lancet 2010;376:1055-61

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• No country had 100% of facilities reporting

continous supply of uninterrupted water,
electricity, and oxygen

• Most reported less than 50% supply or

availability

• A functional anesthesia machine was present in

33% (it can be as low as 3% in some countries)
 Architectural problems Architectural problems

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From Harari, Ethopia
From Karachi-Thanks to Prof. Afia Zafar

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Architectural problems Discipline in Operating Rooms

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C
ES
 • All these characteristics are from

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“Real-Life”

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• There is no simulation !!!

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The End…..
M
C

• They were retrieved from their job by

the Ministry of Health
ES

• However, Turkish people are “brave !!!”

and other videos were recorded in
operating rooms
 Guidelines for Environmental Infection
Control in Health-Care Facilities

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2010 Guidelines for Design and Construction of
Health Care Facilities-AHA Services

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www.who.int/patientsafety/en
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http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf

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Surgical Site Infections Surgical Site Infections

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•Patient •Age
•Surgeon •Obesity
•Equipments •Malnutrition • Preoperative intervention
C

•Air •Prolonged pre-

operative stay
•Infection at
• Intraoperative intervention
Intraoperative intervention
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distal sites
•Cancer
•Hyperglycemia
•Immunosuppres
sion • Postoperative intervention
•ASA class
•Comorbidities

•Hands of HCWs
•Equipment
•Air
Infection Control in Operating Rooms Operating Room Design
™Architecture • Easy access to OR

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• Separation from general traffic and air
™Proper ventilation movement

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• Easy movement of staff from one clean
™Cleaning-Disinfection area to another without passing through

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dirty areas

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™Asepsis-antisepsis • Removal of dirty materials from the suite
without passing through clean areas

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Guidelines for design and construction ofhealthcare facilities2010

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Central Station Architecture of OR

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Three Area
C

• Non-restricted area-“non-clean” (patient waiting rooms,

anterooms, recovery room, changing rooms, toilets)
– No traffic control
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– Special clothing is not necessary

• Semi-restricted area-”clean” (rooms adjoining the OR, scrub

area, coffee room, sterile storage, service areas
– Traffic control,
– OR clothing and head covering is necessary

• Restricted area-”sterile” (operating rooms, any sterile

preparation)
– Traffic control,
– OR clothing, head covering and mask is necessary

Erciyes University Hospital-Operating Rooms-2010

 Support Areas for Staff Preoperative Patient Holding Areas
• Under direct visual control of the nursing staff

• At least one patient station (7.43 m2) per OR

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• A minimum clear dimension of 1,52 m between

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patient strechers

• Provisions such as cubicle curtains for patient

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privacy

• Provided to accomodate stretcher patients and/or

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seating space

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• Hand-washing station
Erciyes University Hospital-Operating Rooms-2010 Guidelines for design and construction ofhealthcare facilities2010

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Erciyes University Hospital-Operating Rooms-2010 Erciyes University Hospital-Operating Rooms-2010

 Recovery Rooms

• A minimum of one recovery station per OR

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• Area: A min. clear floor area of 7,43 m2

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• Clearances: A min.1,52 m2

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• Patient privacy: Cubicle curtains

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• Hand-washing stations
Erciyes University Hospital-Operating Rooms-2010 Guidelines for design and construction of healthcare facilities-2010

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Recovery Rooms Recovery Rooms

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Erciyes University Hospital-Operating Rooms-2010 Erciyes University Hospital-Operating Rooms-2010

 Nurse or Control Station Operating Room Design
• The size and location of the operating
rooms shall depend on the level of

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care and equipment specified in the

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functional program

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Operating Room Design Operating Room Design

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• Class A: For surgery and other procedures that • Class B: For surgery and other procedures
require “minor sedation” that require “moderate sedation”
C

– Space req: a minimum clear floor area of 45.72 m2

ES

– Space req: a minimum clear floor area of 23,23 m2

– Clearances: a clear distance of 1.07 meters at each side,
the head and the foot of the operating table – Clearances: a clear distance of 1.07 meters at
each side, the head and the foot of the operating
– Location: Accessed from the semi-restricted corridors of table
the surgical suite or from an unrestricted corridor
adjacent to the surgical suite
– Location: Accessed from the semi-restricted
corridors of the surgical suite

Guidelines for design and construction ofhealthcare facilities2010 Guidelines for design and construction ofhealthcare facilities2010
 Operating Room Design Architectural Details
• Class C: For surgery and other procedures • The minimum clear width of door openings for
that require “deep sedation” patient use shall be 86.36 cm

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• Wall finishes in OR shall be scrubbable, able to
– Space req: a minimum clear floor area of 37.16 m2 withstand harsh chemical cleaning and monolithic

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– Clearances: a clear distance of 1.22 meters at • Wall bases in OR and areas frequently subjected

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each side, the head and the foot of the operating to wet cleaning shall be monolithic and coved
table directly up from the floor, tightly sealed to the
wall and constructed without voids

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– Location: Accessed from the semi-restricted
corridors of the surgical suite • Ceilings shall be monolithic, scrubbable and capable

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of withstanding chemicals
Guidelines for design and construction ofhealthcare facilities2010

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Erciyes University Hospital-Operating Rooms-2008 Erciyes University Hospital-Operating Rooms-2010

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Hacettepe University Hospital-before renovation- Thanks to Y. Çetinkaya ardan
HacettepeUniversity Hospitalbefore renovation Thanks to Y.Çetinkaya ardan

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Hacettepe University Hospital-before renovation- Thanks to Y. Çetinkaya ardan Hacettepe University Hospital-after renovation- Thanks to Y. Çetinkaya ardan
 Operating Room Design
• Emergency communication system: All
operating rooms shall be equipped

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• Image Viewer: All operating room shall
have access

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Hacettepe University Hospital-after renovation- Thanks to Y. Çetinkaya arda
Guidelines for design and construction ofhealthcare facilities2010

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Architecture of OR
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Scrub Facilities
C

• Scrub station shall be provided directly

ES

adjacent to the entrance to each OR

• A scrub station may serve two OR if it is

located to the entrances to both

Hacettepe University Hospital-after renovation- Thanks to Y. Çetinkaya ardan

Guidelines for design and construction ofhealthcare facilities2006
 Operating Room Design
• Medication distribution station

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• Equipment and supply storage

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• Soiled workroom

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• Fluid waste disposal facilities

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Guidelines for design and construction of healthcare facilities-2010

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Ventilation Requirements for

Sterilization Facilities
Operating Rooms
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• Room temperature: 20-23°C

C

• Relative humidity:<%68 (%30-60)

• Maintain positive-pressure ventilation with respect to

ES

corridors and adjacent areas

• Maintain 15 ACH, of which 3 ACH shoud be fresh air

• Air filters: All recirculated and fresh air should be filtered

with 90% efficiency at a minimum

• Introduce air at the ceiling and exhaust air near the floor

Guidelines for Environmental Infection Control inHealthCare Facilities

Erciyes University Hospital-Operating Rooms-2010 MMR2003;52(RR10);142
 Ventilation Requirements for
Operating Rooms

• Do not use ultraviolet (UV) lights to prevent

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surgical-site infections

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• Keep operating room doors closed except
for the passage of equipment, personnel,

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and patients, and limit entry to essential
personnel

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Guidelines for Environmental Infection Control in Health-Care Facilities Erciyes University Hospital-Operating Rooms-2010
MMR 2003;52(RR10);1-42

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Erciyes University Hospital-Operating Rooms-2010

Erciyes University Hospital-Operating Rooms-2010
 Ventilation Requirements for
Operating Rooms
Surgery of tuberculosis patient

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• Use an N95 respirator in the operating room

• Intubate the patient in either the airborne infection isolation; if

intubating the patient in the operating room, do not allow the doors open

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until 99% of the airborne contaminants are removed

• When anesthetizing a patient with confirmed or suspected TB, place a

bacterial filter between the anesthesia circuit and patient’s airway to

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prevent contamination of anesthesia

• Extubate and allow the patient to recover in an airborne infection

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isolation

• If the patient has to be extubated in the operating roo, allow adequate

time for ACH to clean 99% of airborne particles from the air

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Guidelines for Environmental Infection Control in Health-Care Facilities
MMR 2003;52(RR10);1-42

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Ventilation Requirements for Ventilation Requirements for

Operating Rooms Operating Rooms
M

Surgery of tuberculosis patient

C

• No recommendation is offered for

performing orthopedic implant operations
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• Use portable HEPA filters for supplemental air cleaning

during intubation and extubation for TB patients who in rooms supplied with laminar airflow-
require surgery Unresolved issue
• If possible, schedule TB patients as the last surgical
cases of the day to maximize the time available for
removal of airborne contamination

Guidelines for Environmental Infection Control in Health-Care Facilities Guidelines for Environmental Infection Control in Health-Care Facilities
MMR 2003;52(RR10);1-42 MMR 2003;52(RR10);1-42
 Surgical Smoke

• Electrocautery • Acrylonitrile

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• Carbonmonoxide
• Laser systems
• Hydrocarbons
• Ultrasonic scalpel

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• Phenols
• Nitriles
• Fatty acids

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• Benzene
• Formaldehyde

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• Acrolein
• Hydrogen cyanide

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Alp E, et al. J Hosp Infect 2006; 62(1):1-5.

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Surgical Smoke Risk Ventilation Requirements for

Operating Rooms
M

• Acute and chronic • Carcinoma

inflammatory changes • Dermatitis • In settings where surgical lasers are used, wear
C

in respiratory tract • Cardiovascular dysfunction appropriate personal protective equipment including

• Hypoxia/dizziness • Throat irritation N95 or N100 respirators, to minimize exposure to
• Lacrimation laser plumes
ES

• Eye irritation
• Colic
• Nausea/vomiting
• Anxiety • Use central wall suction units with in-line filters to
• Headache • Anaemia evacuate minimal laser plumes
• Sneezing • Leukaemia
• Weakness • Nasopharyngeal lesions • Use a mechanical smoke evacuation system with a
• Lighteadedness • HIV high-efficiency filter to manage the generation of
• Hepatitis large amounts of laser plume, when ablating tissue
with human pappiloma virus or performing procedures
on a patient with extrapulmonary TB
Alp E, et al. J Hosp Infect 2006; 62(1):1-5. Guidelines for Environmental Infection Control in Health-Care Facilities
MMR 2003;52(RR10);1-42
 Environmental Cleaning

• Disinfection is required for blood

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and secretion spills

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• Tacky mats are not recommended

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• Vacuum cleaners are recommended

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at the end of the day

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Guidelines for Environmental Infection Control in Health-Care Facilities
Alp E, et al. J Hosp Infect 2006; 62(1):1-5.
MMR 2003;52(RR10);1-42

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Environmental Sampling Asepsis-Antisepsis

M

• Do not conduct random, undirected, routine

microbiologic sampling of air, water, and
C

environmental surfaces in OR
ES

• When indicated, conduct microbiologic

sampling as part of an epidemiologic
investigation

Dharan S, Pittet D. J Hosp Infect 2002;51:79-84 Joseph Lister (1827-1912)

 Surgical Hand Disinfection
Surgical Hand Disinfection

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No jewellery Clean under finger nails Wash for 3-5 minutes

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1860 2010
Wash forearm up to elbow Use sterile towel When the hands are dry,

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sterile surgical clothing and
gloves can be done
Widmer AF. Surgical hand preparation: state-of-the-art. J Hosp Infect 2010;74:112-22

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Water Quality Surgical Hand Rub

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• Purified water
C
ES

• Sterile water ???

Dharan S,Pittet D.JHosp Infect 2002;51:7984 Widmer AF.Surgical hand preparation:stateoftheart.JHosp Infect 2010;74:11222
 Surgical Antisepsis Covering materials
• Sterile

• Mask • Moisture-repellent

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• Impermeable to
• Gown moisture and

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microorganisms

• Supple and strong

• Hair covering

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• Very low particle
emitting

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• Sterile gloves
• Easy to secure

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• Consistent in quality

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DISCIPLINE IN OPERATING ROOMS What is the Future in Operating

Rooms?
M

• Standart infection control measures

• Appropriate clothing of staff in operating room

C

• Asepsis- antisepsis rules

ES

• Appropriate ventilation of OR

• Limiting the number of people in OR

• Traffic control

• Appropriate cleaning-disinfection
ES
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