Rituals and behaviours in the operating theatre - joint guidelines of the Healthcare Infection Society and the European Society of Clinical Microbiology and Infectious Diseases.

blood-borne viruses controlled before/after continuous environmental disinfection confidence interval continuing professional development European Society of Clinical Microbiology and Infectious Diseases ESCMID Study Group for Nosocomial Infections Grading of Recommendations Assessment, Development and Evaluation high-efficiency particulate air Healthcare Infection Society hazard ratio infection prevention and control incidence risk ratio interquartile range interrupted time series National Institute for Health and Care Excellence non-randomized controlled trial odds ratio personal protective equipment pulsed-xenon ultraviolet light randomized controlled trial risk ratio surgical site infection uncontrolled before/after ultraclean ventilation ultraviolet Prevention of surgical site infection (SSI) remains a main priority in operating theatres. This has previously led to the introduction of practices, often referred to as ‘rituals’ and ‘behaviours’ and sometimes labelled as ‘myths’, that are controversial and frequently disputed. Some of them are not underpinned by sound scientific evidence, but they are established in everyday practice and considered by many as traditional to help ensure discipline and professionalism in the operating theatre. Previous Healthcare Infection Society guidelines were published 20 years ago, and they aimed to debunk some of the practices. Since then, new technologies have emerged, and an update was required. These new updated guidelines, produced in collaboration between the Healthcare Infection Society and the European Society of Clinical Microbiology and Infectious Diseases, used methodology accredited by the National Institute for Health and Care Excellence (NICE) to provide further advice on which practices are unnecessary. The guidelines are intended for an international audience. Specifically, they discuss the current available evidence for different rituals that are commonplace in the operating theatre, and highlight the gaps in knowledge with recommendations for future research. Previous guidelines divided the operating theatre rituals and behaviours into essential, preferable (optional), and those that provide no clear benefit. In the light of new evidence and in line with the new NICE principles for recommendations, these have been updated and are divided into recommendations for use, good practice points, and recommendations against certain practices. These updated guidelines aim to minimize ritualistic behaviour without increasing the risk of SSI. The guidelines do not focus on those key prevention practices that are well researched and shown to be effective in preventing SSI (e.g. preventing hypothermia). These well-researched topics are addressed in other guidelines, and the Working Party has based their guidelines on an assumption that these evidence-based recommendations are followed. 1. (a) Does operating theatre cleanliness/disinfection have any effect on surgical site infection? (b) How important is operating theatre cleanliness outside the sterile field? (c) Does clutter matter? 1.1: All patient, staff and visitor hand and body contact surfaces must be cleaned between each patient. 1.2: In addition to cleaning between patients, clean and disinfect all patient and staff hand and body contact surfaces after dirty or contaminated procedures, as well as any areas contaminated by blood and body fluids. GPP 1.1: Clean and disinfect clinical care equipment, including anaesthetic machines, after each patient, and before the next patient arrives in the operating room. GPP 1.2: Clean and disinfect anaesthetic room hand contact surfaces before the next patient arrives. GPP 1.3: Keep the operating room tidy and devoid of clutter in accordance with local housekeeping practice. 2. If blood splashes and other forms of contamination with body fluids occur, can they be a source of blood-borne virus infection? 2.1: No recommendation, see good practice points. GPP 2.1: Wherever blood and body fluid splashes occur, clean and disinfect hand contact surfaces and floors immediately. GPP 2.2: Do not stop the use of the operating room to replace the ultraclean ventilation canopy screens or filters if they become contaminated with blood or body fluid splashes. 3. Does bringing beds and associated linen from wards and other clinical areas into the operating theatre result in increased bacterial counts or increased infection post-operatively? 3.1: No recommendation, see good practice point. GPP 3.1: Allow clean beds with fresh, clean linen to be brought into operating theatre complex directly from clinical areas. 4. (a) Does the order in which patients are operated on (i.e. patient with suspected or confirmed contact-transmissible multi-drug-resistant bacterial infection/colonization at the end of a list) reduce post-operative infection? (b) Should these patients recover separately from other patients before going to a ward? 4.1: There is no need to place patients with suspected or confirmed contact-transmissible multi-drug-resistant bacterial infection/colonization at the end of an operating list as long as the operating room is cleaned and disinfected to standard between patients, and the theatre ventilation is running without interruption. GPP 4.1: Allow patients with isolation/contact precautions to recover in the operating room or in a designated section of the recovery area. 5. What is the clinical effectiveness of pre-operative showering/bathing before elective surgical procedures using (a) non-disinfectant bath/shower and (b) disinfectant bath/shower? 5.1: No recommendation, see good practice points. GPP 5.1: Encourage patients to shower/bathe before surgery for personal hygiene reasons. Consider using alternatives (e.g. wipes) immediately before surgery for patients who are not able to shower or bathe before surgery. GPP 5.2: Do not delay operations for patients who are not able to shower or bathe before surgery. GPP 5.3: Instruct patients not to shave their surgical area in the days before surgery. Include this in any written patient information that is supplied to patients/carers in advance of surgery. 6. What is the most effective pre-operative skin antiseptic? 6.1: Refer to Recommendations 1.3.7, 1.3.8, 1.3.9 and accompanying Table 1 in the NICE guidelines (NG125) for advice on choosing appropriate skin preparation solution. 7. (a) Should surgical instruments be laid up (unpacked, inspected and exposed) as close as possible to use? (b) Should surgical instruments used in ultraclean ventilated theatre procedures be laid up under the canopy or in the preparation room? 7.1: For all surgical/operative procedures, lay up the instruments and prosthetic materials as close as possible to when they are needed. GPP 7.1: For ultraclean ventilation operating theatres, lay up the instruments/prosthetic materials under the canopy unless there happens to be ultraclean ventilation in the preparation room, which is an alternative. 8. What is the most effective surgical scrub procedure for scrub staff? 8.1: Refer to Recommendations 1.3.1 and 1.3.2 in the NICE guidelines (NG125) for advice on choosing appropriate hand decontamination solutions. 9. Does the movement of theatre staff in and out of the operating room impact air counts of bacteria and infection rates? 9.1: Minimize non-essential staff movement and hence door openings during surgical procedures to minimize bacterial air counts. 10. Should the surgical team remove jewellery, false nails and nail polish before entering the operating theatre facilities? 10.1: Do not allow scrubbed staff to wear jewellery below the elbow. Where jewellery cannot be removed, the area around and underneath any item of jewellery must be carefully cleaned as much as possible during the scrubbing process. 10.2: Do not allow scrubbed and unscrubbed staff to wear artificial or polished nails in the operating theatre. 11. (a) Should staff cover their hair? (b) Should staff use face masks? 11.1: No recommendation, see good practice points. GPP 11.1: Ensure that all staff working in the operating room wear a head covering and a face mask in accordance with local policies. GPP 11.2: When face masks are worn, ensure that they are changed periodically. 12. What is the impact of wearing operating room attire outside the operating theatre complex? 12.1: No recommendation, see good practice point. GPP 12.1: Change or cover operating theatre attire (e.g. with a single-use disposable gown) and change footwear if leaving the operating theatre complex with the intention of returning. 13. Should patients remove jewellery, false nails and nail polish before being brought into the operating theatre? 13.1: No recommendation, see good practice points. GPP 13.1: Refer to current hospital policy for pre-operative patient management. GPP 13.2: If patients are asked to remove jewellery, artificial nails or nail polish before they arrive in the operating theatre, include this in written (paper or digital) patient information supplied in advance of surgery while preparing at home. 14. Should patients cover their hair before entering the operating theatre facilities? 14.1: No recommendation, see good practice point. GPP 14.1: Refer to current hospital policy for pre-operative patient management, although be aware that covering patients' hair is not required for infection prevention reasons. 15. (a) What should parents/carers/accompanying person wear when accompanying the patient to the operating theatre? (b) Do patients or other individuals dressed in ordinary (street) clothes in the operating theatre result in increased bacterial counts or increased infection post-operatively? 15.1: No recommendation, see good practice points. GPP 15.1: Ask parents and carers to wear scrubs or equivalent (e.g. single-use coveralls), along with head coverings and face masks, on entering the operating room as per local policy. Changing shoes is not necessary. GPP 15.2: Ensure that visitors (e.g. technicians or company representatives) comply with local departmental policy on theatre attire. Prevention of surgical site infection (SSI) remains a key priority in operating theatres. This has led to the introduction of practices, often referred to as ‘rituals’ as some of these practices are not based on real or sound scientific evidence, that are now established in everyday practice. Previous Healthcare Infection Society guidelines were reviewed and published 20 years ago, and they aimed to improve some of the practices. However, new technologies and evidence have emerged, which requires these guidelines to be updated. These new and updated guidelines are published in collaboration with the European Society of Clinical Microbiology and Infectious Diseases. Using methodology accredited by the National Institute for Health and Care Excellence (NICE), they aim to give guidance on which practices are unnecessary. They identify currently available evidence for different practices which are commonplace in the operating theatre, and highlight gaps in knowledge with recommendations for future research. Previous guidelines rated the operating theatre rituals and behaviours as essential, preferable (optional), and those that provide no clear benefit. With new evidence and in line with the new UK NICE principles for recommendations, these guidelines have been updated and divided into recommendations for use, good practice points, and recommendations against certain practices.