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Audit on operating theatres in Sri Lanka

Article in International Journal of Infection Control · June 2010

DOI: 10.3396/ijic.V6i2.010.11

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 International Journal of Infection Control
Audit on operating theatres in Sri Lanka Thevanesam

[Link] ISSN 1996-9783

original article

Audit on operating theatres in Sri Lanka

Vasanthi Thevanesam1, Jayantha Elwitigala2, LVC Liyanapathirana1

1
Department of Microbiology, Faculty of Medicine, University of Peradeniya, Sri Lanka.
2
Chest Hospital, Welisara, Sri Lanka.
doi: 10.3396/ijic.V6i2.011.10

Abstract
Design and behavior within a theatre is important in preventing infections at surgical sites. Protocols exist
for theatre infection control starting from the design stage. Compliance of theatres in the Sri Lankan public
health sector to such recommendations was assessed in this audit in a questionnaire based descriptive study
conducted in relation to a theatre infection control workshop.

Design, location, layout, ventilation and personal management in the theatres were assessed. Sri Lankan
theaters fall below the recognized standards in both theatre design and infection control practices and much
needs to be improved to bring up the standards of the theatres in the system to internationally acceptable
norms.

Introduction Guidelines on theatre design and policies on infection

The design of operating theatres has evolved in control in theatres have existed for many years now
complexity over the past decades with the development and most countries have adopted them as regular
of the surgical field. However, the basic principals of practice.5,6 Just as theatre design, the emphasis on
theatre design remain the same. Convenience, cost and infection control has also changed over the years with
infection control are some factors that are considered the emergence of new technologies such as positive
in designing and planning new theatres.1,2 pressure and laminar air flow.3

The design and behavior of staff inside operating Sri Lanka has no national policy on infection control;
theatres are both important factors that contribute to however the Sri Lanka College of Microbiologists with
the development of surgical site infections (SSI).1,3,4 the Ministry of Health Care and Nutrition has been

Corresponding author
LVC Liyanapathirana, Department of Microbiology, Faculty of Medicine, University of Peradeniya, Sri Lanka.
Email: vernjacl@[Link]

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Audit on operating theatres in Sri Lanka Thevanesam

successful in establishing Infection Control Units in Design and build of the operation theatres
hospitals and also published a Manual on Infection The design and build of the operating theatres varied
Control, which includes a section on operating (Table II) and when analyzing the actual plans of the
theatres, which was however published after the theatres brought to the workshop by the Theatre Sisters
study was conducted.7 The awareness of theatre staff or nurses who were involved in the study, it was noted
on such guidelines and adherence to it has not been that there was no uniformity in the actual layout of
assessed. The objective of this study was to assess the rooms or dimensions of space within the theatre
compliance of Sri Lankan theatres with international suites.
recommendations on theatre design and infection
control. Of the theatres that had no access to ICU or CSSD
facilities one hospital each did not have these two
Methodology units in the hospital premises at all.
The Sri Lanka College of Microbiologists in
collaboration with the Hospital Infection Society of The floor materials of the theatres were mostly terrazzo
United Kingdom conducted a workshop on infection (22), ceramic tiles (5) or a combination of the two (6).
control in operating theatres in September 2004. As Three theatres had carpet floors.
a part of this workshop, data on design and practices
in theatres in relation to infection control were Ventilation systems
collected by using a validated questionnaire. The Thirty seven theatres (92.5 %) were air conditioned.
questionnaire requested for details on the design Eleven hospitals had ventilation systems available. Of
of theatres, ventilation, maintenance, cleaning and the forty theatres participating in the study only 4 had air
personnel management and was prepared according changes but commissioning and regular maintenance
to international guidelines. They were sent by post to programmes were in place only in 3 theatres.
all hospitals with functional operating theatres with the
approval of the Ministry of Healthcare and Nutrition. The doors of the theatres were reported not to be
The questionnaires were completed by the sister or closed in 13 (32.5%) of the theatres.
nursing officer in charge of the theatre. Responses were
clarified at a workshop organized for the responding Cleaning of the operating theatres
theatre sisters and nurses as a part of the collaboration The cleaning protocols varied with the theatres (Table
mentioned earlier. III).

Results Both disinfectants and detergents are used in the

Questionnaires were sent to 53 hospitals and there cleaning of most of the theatres (25), only detergents
were 40 responses from 39 different hospitals in the are used in 7 hospitals while in 5 hospitals only
hospital hierarchy of Sri Lanka (Table I). One hospital disinfectants are used.
sent two replies for two different theatres at different
localities within the premises. Spill management policies were available only in
26 (65%) of the hospitals. Junior staff had no formal
There was no uniformity among the types of theatres; training on cleaning in 17 (52.5%) hospitals. In some
some housed only general surgical theatre units hospitals it was mentioned that either the theatre
whereas others were multipurpose theatres with more sister or a nursing officer gives verbal instructions on
than one type of surgery being performed in different cleaning.
rooms within the theatre. Certain hospitals had
different theatre suites located within the hospital at Personnel
different localities but had filled the questionnaire for The number of people present within a theatre room
only one such suite. varied from 6 - 35 during on going surgery and a
complete change of clothes were required in 32 (80%)
of the theatres.

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Audit on operating theatres in Sri Lanka Thevanesam

Discussion From an infection control point of view it is

Surgical Site Infections (SSI) are a major cause for recommended that theatres are located in a separate
post operative morbidity and results in additional area of the hospitals and away from busy corridors.1
expenditure to the health authorities. Though they are In our study it was found that 22 (55%) hospitals
mainly of endogenous origin, theatre personnel and have their theatres located in separate areas in the
environment also contribute to SSI.3 Thus, the infection hospitals but 19 (47.1%) theatres had their main
control team needs to be involved from the planning entrances opening to heavily used corridors. The latter
stage itself as the architects, engineers and administers demonstrates lack of proper planning in theatre design
lack expertise in these areas.1, 8 Though infection control and establishment.
as a concept has a considerable history in the world,
the history of it in Sri Lanka is relatively short. Hospital Thirty (75%) hospitals have horizontal surfaces in their
based clinical microbiology itself has a relatively walls which promotes deposition of dust. Guidelines
short history in the Sri Lankan health system. Thus, it recommend that such surfaces are minimized or
is unlikely that infection control teams were involved where impossible, to have them slanted to facilitate
in the design of the majority of existing theatres in Sri cleaning.1
Lanka and lapses in the design were anticipated.
Recommendations suggest that floors have an easily
The current audit found out that 80% of the theatres cleaned, non slip material that can withstand the
involved in the study are purpose built and 35% of impact of trolleys and heavy equipment.1
theatres are housed in renovated buildings. This
discrepancy may be explained by the fact that The majority of the theatres in the study have their
although the theatre rooms themselves are built on floors either tiled or covered with terrazzo, which is in
purpose, existing building may have been modified to keeping with the recommendations.
create them, leading to some misunderstanding of the
question. Twenty three (57.5%) hospitals have self sealing doors.
However 13 (32.5%) theatres did not keep the doors
Infection control is only one aspect that needs to be shut during an operation. In and out traffic of personnel
considered in designing new theatres. Easy access to X during surgical procedures promote air turbulence
ray facilities, CSSDs, ICUs, the accident and emergency which facilitate the spread of airborne infection. In
unit and surgical wards also needs to be considered.1 addition, frequent opening and closing of the doors
This is important in increasing the efficiency of theatre are distracting to the surgical team as well.3,4,6
function and indirectly to control infections. In our
study the accessibility of these units from theatres were
not satisfactory. Some hospitals do not have CSSDs Table I: Responding Hospitals
and ICUs within the hospital premises whilst others
do not have them within an easily accessible distance. Type of hospitals Number
Some theatres still clean their instruments within the
suite itself and the linen are washed by paid dhobis National 01
(traditional laundrymen) and then sterilized in the Specialized 05
theatres.
Teaching 06
Currently the trend is for multiple theatres to be housed General 08
in the same building as a theatre suite and certain
Base 17
facilities such as CSSD or scrub rooms to be developed
as common ones.2, 9 District 02
Total 39

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Audit on operating theatres in Sri Lanka Thevanesam

Table II: Design and layout of the theatres

Area assessed Yes No Not

responded

Purpose built theatres 32 (80%) 5 (12.5%) 3 (7.5%)

Housed in renovated buildings 14 (35%) 24 (60%) 2 (5%)

Part of a theatre suite 20 (50%) 12 (30%) 8 20%)

Different theatres are found in different

places in the hospital 15 (37.5%) 24(60%) 1 (2.5%)

Theatre located in a separate area of the hospital 22 (55%) 17 (42.5%) 1 (2.5%)

Situated off a heavily used corridor 19 (47.1%) 18 (45%) 3 (7.5%)

Easy access to X ray facilities 09 (22.5%) 29 (72.5%) 2 (5%)

Easy access to CSSD (Central Sterilization and supplies division) 13 (32.5%) 26 (65%) 1 (2.5%)

Easy access to ICU 20 (50%) 19 (47.5%) 1 (2.5%)

Adequate storage facilities are available 12 (30%) 26 (65%) 2 (5%)

Storage facilities are available within the theatres 20 (50%) 17 (42.5%) 3 (7.5%)

Self sealing doors are available 23 (57.5%) 16 (40%) 1 (2.5%)

Walls have horizontal surfaces 30 (75%) 6 (15%) 4 (10%)

Thirty seven theatres (92.5 %%) were air conditioned;

air conditioning is mainly for operator comfort and is Table III: Summary of cleaning procedures
not important in maintaining air quality. However, as
discomfort of the operator hinders surgical technique, Cleaning programme Number
air conditioning is part and parcel of theatre
ventilation.5 Once daily 5

Twice daily 17
The main function of a theatre ventilator system is to
After each theatre list 3
prevent micro organisms from depositing on clean
surgical wounds and causing SSIs.3 Only 11 theatres After each case 6
participating in the study were equipped with ventilator
Once daily and after each case 2
systems, but the frequency of air changes was erratic.
Regular maintenance of air conditioners too was not Twice daily and after each case 4
in practice. They were looked into only if there was
No response 3
detectable change in temperature.
Total 40
The concept of pre use commissioning of a theatre
prior to use or after a major modification8,10 that would
affect the airflow pattern of the theatre, is virtually non
existent according to the current study.

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 Audit on operating theatres in Sri Lanka Thevanesam

Though the complete cleaning protocols for cleaning importance of involving infection control teams from
of theatre equipment was not analyzed as a part of the initial designing of a theatre to the day to day
the study, it is obvious that there is no uniformity in practices.
the theatre cleaning protocols. Detailed guidelines are
easily accessible and freely available and the Hand Acknowledgements
Book on infection control published by the Sri Lanka Sri Lanka College of Microbiologists, Sri Lanka College
College of Microbiologists also includes these.7 It is of Surgeons and Hospital Infection Society of UK for
mandatory that spill decontamination protocols are being stakeholders for the workshop on infection
available at the theatres. The sanitary staff members control in theatres, as a part of which this study was
who do the actual cleaning work needs to be given conducted.
organized, structured training on managing these
procedures. As evident from the study, there is a lack Ministry of Healthcare and Nutrition, Sri Lanka for the
of such programmes in the Sri Lankan theatre system. support given in organizing the workshop.
The number of people within a theatre at a given time
influences the microbial load in the theatre and thus The Theatre sisters and nursing officers of participating
influences the SSI rate. Unnecessary movements and hospitals.
conversations during a procedure further increase the
chance of dispersion of organisms.1,3,4,5 There is no References:
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theatre suite. Journal of Hospital Infections 1993; 23: 61-67.
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3. Ayliffe GAJ and Lowbury EJL. Airborne infection in hospital.
teaching units for undergraduate and postgraduate
Journal of Hospital Infections 1982; 3(1): 217-237.
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as the majority do not conform to the international and control of hospital Associated infections. [Link].
[Link]/LinkFiles/Publications_hlm-[Link] (Accessed on
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facilities need to be used in such a way that the rate of Theatre Infection Control Policy February 2005. Accessed on
18/11/2009.
infections is kept to the minimum possible level. The 7. Hospital Infection Control Manual. Sri Lanka College of
data in this study is 4 years old, more theatres have Microbiologists. 1st edition. Colombo.111-124.
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Medical Microbiologists’ New Hospital Developments Project
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in this study. Officials need to be informed about the

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