Operating Theatre staff
The presence of an infected skin lesion, such as a boil, paronychia or carbuncle, known carrier state, particularly in the nares and the presence of an acute bacterial infection, particularly an upper respiratory tract infection, must lead to the exclusion of such a person from the team. There is good microbiological evidence to show that failure to do so will lead to an increasing number of infections.
Showering is preferable to bathing and the utilisation of a 4 per cent chlorhexidine gluconate soap by the surgical team is of benefit before the start of an operating list, and has been recommended for the operating surgeon between cases when the procedure is long.
Clothing and gowning
Desquamation principally occurs from the lower half of the body and the changing from normal clothes to clean linen reduces the bacterial count; cotton pores are 100 pm in size whereas skin scales are 5—60 pm, and thus cotton clothing
will not serve as a barrier. Cotton suits worn below cotton gowns results in a decrease in bacterial count in air by 30 per cent. The newer bacterial impermeable fabrics further reduce the count but are of no value when worn over cotton pajamas because the desquamation process continues and bacteria still escape, particularly at the ankles but also at the neck. The wearing of elastic anklets on trousers will reduce bacterial counts by 47 per cent. The most effective reduction of airborne bacteria is obtained by using the Charnley exhaust gowns — this is particularly important in orthopaedic procedures, but probably not significant in general surgery.
Caps are usually worn, although the amount of pathogenic bacteria dispersed is unlikely to be of any significance in general surgery, but may again be significant in implant surgery.
• Pajamas with elasticated ankles and wraparound breathable membrane fabrics will reduce the bacterial count.
• In orthopaedic surgery, use of the Charnley exhaust gown is optimal.
The oropharynx is a low-level source of bacteria (36 bacteria per 100 words spoken are generated), the number of bacteria that settle on culture plates is not affected by wearing a mask and several studies exist to show that the wearing of masks in general surgery does not affect the wound infection rate, although the wearing of masks in implant surgery is appropriate as their use has been shown to decrease the number of bacteria detected at the operating site.
• Their use is indicated in implant and orthopaedic surgery.
• They offer protection to the wearer.
• Reduction of speech at the operating table is important.
Although gloving or double gloving is widely practised there is little evidence that wound infection is related to glove puncture. This would suggest that disinfection of the hands is important in keeping the incidences of wound infection low.
Brushes should only be used for cleaning finger nails. A scrub-up time of 3—S minutes with chlorhexidine soap or povidone iodine soap is utilised; the former is a broad-spectrum rapidly active agent with persistent activity, whereas the latter has a relatively short duration. The technique should include thorough washing of the hands to the elbows, with removal of the soap in the direction hand to elbow.
Excess soap is not required but a steady and methodical method of massage is important, and adequate drying is again essential, the preferred technique using paper towels in the direction hand to elbow. Jewellery should.be removed
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