Abstract of the communication from the latest edition of the Journal of Hospital Infection, Vol. 140, October 2023
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.
Introduction
Surgical care is an essential part of health care, but it is also associated with a significant risk of complications, with post- operative infections being of particular concern. Guidelines and recommendations on the prevention of surgical site infections (SSI) generally focus on those aspects for which there is often some evidence, such as skin preparation and surgical antibiotic prophylaxis. However, there are certain behaviours and rituals that are commonplace in the operating theatre and are accepted practice, but for which the evidence may not be substantial. These are considered as part of traditional practice and regarded by some as assisting in maintaining discipline and professionalism in the operating theatre.
There are many risk factors for SSI, and the operating theatre environment is considered to be one of the modifiable factors. For this reason, throughout the decades, different ritualistic practices and behaviours evolved in the operating theatre with the aim of reducing environmental contamination and the subsequent risk of SSI. It is now acknowledged that some of these established practices may not have a sufficient evidence base. A modern operating theatre is provided with many technologies which control microbial contamination of the air, such that some of these rituals and behaviours probably have little impact on air contamination. At best, these rituals may be harmless and somewhat inconvenient. At worst, they are time consuming and expensive, wasting valuable resources that could be used elsewhere.
Some rituals, especially those associated with pre-operative preparation, may also be intimidating and embarrassing for patients, unnecessarily increasing their anxiety before surgery. To be able to abandon some of these rituals and staff behaviours, there is a need to demonstrate which do and which do not have a beneficial impact on patient outcomes and staff safety.
Previous guidelines on this topic were published 20 years ago, and more evidence has since emerged. Since then, some guidelines have been published on preventing contamination of the operating theatre, especially concerning operating staff attire, but none of these guidelines have considered whether some of the common practices contribute to the prevention of SSI. The purpose of these updated guidelines is to review the evidence for these practices, and to make clear recommendations on which rituals and behaviours in the operating theatre need to be retained to decrease the risk of SSI, and which can be safely discontinued. The guidelines have not addressed those areas for which there is a good evidence base (e.g. surgical antibiotic prophylaxis and avoiding hypothermia) as these are covered in other guidelines.
Definitions
The terminology used in relation to the operating theatre environment is sometimes ambiguous; therefore, to standardize some of the terms, the following definitions were used throughout these guidelines :
Operating theatre complex/operating theatre refers to the entire operating theatre facilities, which include, but are not limited to, the preparation room, the anaesthetic room, the operating room and the recovery area. The operating theatres which were considered for these guidelines are the standard operating theatres found in most European hospitals, which have specialized ventilation and undertake major surgical procedures. The Working Party agreed that other types of operating theatres exist (i.e. those for minor procedures, endoscopy or interventional imaging suites) but these were not considered in these guidelines. However, the Working Party also agreed that some of the recommendations may still be relevant to these settings.
Operating room refers to the room in which surgical procedures are undertaken.
Hand contact surfaces e refers to any surface that has or is likely to come in contact with staff or visitor hands in the preparation, anaesthetic, operating or recovery room. This term relates to any surface that was touched by staff/ patients/visitors during a procedure at least once.
Frequently touched surfaces implies that multiple individuals touch these surfaces multiple times.
Ultraclean ventilation (UCV) e refers to a type of ventilation which increases a dilution effect by providing a large volume of clean filtered air. This type of ventilation is sometimes referred to as ‘laminar flow ventilation’.
These guidelines are intended for healthcare workers in operating theatres; therefore, the Working Party believes that the terminology as well as other concepts (e.g. mechanism or risk factors for surgical infections) are familiar to most readers.
Reference :
Rituals and behaviours in the operating theatre e joint guidelines of the Healthcare Infection Society and the European Society of Clinical Microbiology and Infectious Diseases
H. Humphreys a, b, c, *, A. Bak b, E. Ridgway b, A.P.R. Wilson b, d, M.C. Vos c, e, K. Woodhead f, g, C. Haill b,
D. Xuereb h, J.M. Walker b, i, J. Bostock j, G.L. Marsden b, k, T. Pinkney l, R. Kumar j, P.N. Hoffman b
a Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland b Healthcare Infection Society, London, UK
c ESCMID Study Group for Nosocomial Infection, Basel, Switzerland
d University College London Hospitals, London, UK
e Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
f Association for Perioperative Practice, Harrogate, UK
g Royal College of Nursing, London, UK
h Infection Prevention Society, Seafield, UK
i NHS Grampian, Greater Aberdeen, UK
j Lay Member for Healthcare Infection Society, London, UK k Royal College of General Practitioners, London, UK
l University of Birmingham, Birmingham, UK