Operation theatres (OTs) are highly controlled environments designed to prevent infections during surgical procedures. Despite stringent protocols, surgical site infections (SSIs) remain a significant concern, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Reducing OT infection rates requires a multi-pronged approach involving evidence-based practices, modern technology, continuous monitoring, and collaboration among surgical teams, infection control personnel, and hospital management.
This essay discusses the key strategies for decreasing OT infection rates, focusing on preoperative, intraoperative, and postoperative interventions, as well as infrastructure design, personnel hygiene, and emerging technologies.
1. Preoperative Measures
a. Patient Screening and Optimization
Effective infection control starts before the patient enters the OT. Preoperative assessments should identify and address modifiable risk factors such as:
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Diabetes: Poorly controlled blood sugar increases SSI risk.
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Malnutrition: Affects wound healing and immune function.
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Smoking: Delays healing and impairs tissue oxygenation.
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Existing infections: Must be treated or managed before surgery.
Screening for methicillin-resistant Staphylococcus aureus (MRSA) and administering decolonization protocols (e.g., nasal mupirocin and chlorhexidine washes) have shown to reduce postoperative infections.
b. Preoperative Bathing and Skin Antisepsis
Patients should bathe with chlorhexidine gluconate (CHG) before surgery. Proper skin preparation with antiseptic solutions such as povidone-iodine or alcohol-based chlorhexidine immediately before incision is essential. These agents reduce the skin flora that are the primary sources of SSIs.
c. Antibiotic Prophylaxis
Administering prophylactic antibiotics within 60 minutes prior to incision significantly lowers the risk of SSIs. The choice of antibiotic depends on the surgical procedure and local microbial resistance patterns. Timing, correct dosing, and redosing during prolonged surgeries are crucial.
2. Intraoperative Measures
a. Aseptic Technique and Surgical Team Discipline
Strict adherence to sterile technique is fundamental. This includes:
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Proper surgical scrubbing
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Sterile gowns and gloves
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Avoiding unnecessary traffic in and out of the OT
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Minimizing talking and movement during surgery
Surgical teams must be trained regularly to maintain vigilance and consistency in aseptic practices.
b. Proper Ventilation and Airflow
Maintaining positive pressure ventilation and laminar airflow systems helps prevent airborne contamination. High-efficiency particulate air (HEPA) filters can capture microorganisms and particulate matter. OTs should meet the required air exchange rate (at least 15–20 air changes per hour) to maintain air purity.
The use of ultraviolet germicidal irradiation (UVGI) systems and plasma air purification technologies is also increasing in modern OTs to reduce microbial load in the air.
c. Instrument Sterilization and Handling
All surgical instruments must undergo rigorous sterilization using autoclaves or low-temperature sterilization systems. Proper handling and packaging techniques must be followed to maintain sterility until use. Sterile storage conditions and inventory rotation help prevent contamination from outdated or improperly stored equipment.
d. Environmental Cleaning and Surface Disinfection
Surfaces in the OT—including operating tables, lights, and anesthesia equipment—must be disinfected before and after every procedure using hospital-grade disinfectants. Focus should be placed on high-touch areas. Use of ATP bioluminescence systems can validate cleaning efficacy.
3. Personnel Hygiene and Practices
a. Hand Hygiene
Hand hygiene remains the single most effective method of infection prevention. All OT staff should follow WHO’s Five Moments of Hand Hygiene using alcohol-based hand rubs or soap and water. Compliance should be monitored, and feedback provided.
b. Proper Use of Personal Protective Equipment (PPE)
OT personnel must wear appropriate PPE, including sterile gloves, gowns, masks, and eye protection. Use of surgical helmets or space suits is recommended during high-risk procedures such as orthopedic joint replacements.
c. Limiting OR Traffic and Access
Each entry and exit increases the risk of airborne contamination. Establishing restricted access protocols and minimizing unnecessary staff movements help maintain sterility. Access control systems and signage can support compliance.
4. Postoperative Measures
a. Wound Care and Dressing Protocols
Postoperative wound management should involve the use of sterile dressings, regular monitoring for signs of infection, and early intervention if complications arise. Some surgeries benefit from negative-pressure wound therapy (NPWT) to enhance healing and reduce infection risks.
b. Antibiotic Stewardship
Avoiding unnecessary postoperative antibiotics is essential to prevent resistance and secondary infections. Clear guidelines on antibiotic duration and spectrum should be established and followed by all departments.
5. Training and Audit Systems
a. Education and Continuous Training
Ongoing education programs for OT staff regarding infection prevention protocols, hand hygiene, and sterile techniques help reinforce best practices. Simulation-based training can improve compliance and team communication.
b. Regular Infection Surveillance and Feedback
Hospitals should maintain a robust infection control surveillance system that tracks SSI rates, identifies trends, and prompts corrective actions. Root cause analysis of infection cases helps pinpoint gaps in protocol adherence. Data transparency and regular feedback to OT teams encourage accountability.
6. Innovations and Emerging Technologies
a. Antimicrobial Coatings and Drapes
New materials are being developed for surgical drapes, gowns, and instrument handles that are impregnated with antimicrobial agents such as silver or chlorhexidine to reduce bacterial colonization.
b. Smart Sensors and Automation
Automation of infection control checklists and use of sensor-based hand hygiene compliance systems can improve adherence. AI-based monitoring tools are being introduced to track OT traffic, sterilization compliance, and environmental cleanliness.
c. Robotics and Minimally Invasive Surgery
Minimally invasive and robotic surgeries typically result in smaller incisions, reducing the exposure of internal tissues and lowering the risk of infection. These techniques also shorten recovery times and reduce hospital-acquired complications.
7. Design and Maintenance of OT Infrastructure
a. Zoning and Layout
OTs should be divided into sterile and non-sterile zones to control contamination. Properly designed layouts minimize cross-contamination by streamlining the movement of personnel and equipment.
b. Maintenance of Ventilation Systems
Regular servicing of HVAC systems and air filters is essential. A maintenance schedule should be strictly adhered to, with microbiological monitoring of air and surfaces conducted periodically.
Conclusion
Decreasing OT infection rates is a complex but achievable goal that requires a combination of stringent protocols, technological advancements, and continuous education. Preventing infections not only saves lives but also reduces the burden on healthcare systems. As surgical techniques and hospital environments evolve, so too must our infection control strategies. A culture of safety, vigilance, and collaboration is essential to maintaining sterile operating environments and ensuring optimal outcomes for all surgical patients.
Dr. Ramjee Bastola @2025
Surgeon , Nepal
