Policies and Procedures Manual Infection Control in Operating Room

POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN OPERATING ROOM

DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 1 of 13
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I. OBJECTIVES
1. To prevent the exposure of OR patients and staff to infections.
2. To ensure patient and employee safety.
3. To enhance infection control by controlling the movements of patient,
personnel and materials within the surgical suite
II. SCOPE
1. OR Personnel adhere to established infection control policies and procedures.
2. Supervisor, Operating Room and Senior Supervisor, Perioperative Nursing shall
2.1 Review and observe practices of OR personnel.
2.2 Ensure that all personnel adhere to infection control policies and
procedures.
2.3 Assist in infection control education programs for OR staff member.
2.4 Review, revise, and recommend infection control policies and

procedures.
3. Chief, Surgical Services Division reviews and concurs with all policies and procedures
for the OR.
4. Infection Control Supervisor shall:
4.1 Assist in the review and revision of infection control policies and
procedures.
4.2 Assist in infection control in-service education programs.
4.3 Review the infection control practices of personnel.
4.4 Act as a resource.
5. Infection Control Committee shall:
5.1 Review and approves all infection control policies and procedures.
5.2 Review data when potential and/or actual infection control problems
occur.
Prepared by: Reviewed by: Conforme: Approved by:
JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD
CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

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III. DEFINITION OF TERMS
1. Infection control-is the prevention of the spread of microorganisms which leads to

infections.
Operating Surgical Suite; OR Suite; A physically separate area that comprises

Suite operating rooms and
their interconnecting hallways and ancillary work areas such as scrub

sink rooms
Operating A room in an operating suite where operations are performed

Room
Surgical Any healthcare worker in an operating room during the operation who
Team has a surgical care role.
Member
IV. POLICIES
1. This policy describes the infection control measures and procedures for the prevention
of transmission of infections to or between patients, personnel and family members in
the Operating Room.
2. Strict surgical asepsis and sterile technique shall be observed by all staff in the
Operating Suite.
3. Members of the surgical team who have direct contact with the sterile operating
field or sterile instruments or supplies used in the field shall do a surgical scrub of
their arms and forearms immediately before donning sterile gowns and gloves.
4. OR personnel with active infections shall be prohibited in the Operating Room.
5. Disinfection & sterilization should follow the hospital wide policies recommended by the
Infection Control Committee. Please refer to Policies & Procedures on
Sterilization and Disinfection.
6. Gowning and gloving for an operative/surgical procedure shall only be
performed in the Operating Room.
7. All items that have come in contact with the patient and/or items outside the
sterile field shall be considered contaminated.
8. Environmental Cleaning of OR and Equipment
8.1 Each Operating Room shall be comprehensively cleaned before and after completion
of an operation.

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8.2 The Operating Suite/Rooms shall be cleaned according to established routine policies
and procedures.
8.3 Environmental culture or microbiologic air sampling of the OR suite shall be done if
foreseeing possible outbreak of infection/ after construction or renovations or as the
need arises.
9. Clean linen shall be transported daily to the Operating Suite in a clean covered cart at
designated delivery times by the Linen Department.
V. PROCEDURES
1. Traffic Pattern in the Surgical Suite
1.1 All personnel shall follow a well delineated traffic pattern observing limits
of the following zones:
1.1.1 Unrestricted Area (Outer Zone) – This zone shall include areas
where patients, patient’s families, other hospital personnel, physicians,
etc. are allowed in their street clothes (ex. dressing rooms, lounges,
holding area, hall areas that do not face OR suites).
1.1.2 Semi-Restricted Area (Clean Zone) – This zone shall include most
peripheral support areas such as storage areas for clean and sterile
supplies, work areas for storage and processing of instruments and
corridors of restricted areas for the OR suites. OR apparel shall be
required in these areas.
1.1.3 Restricted Area (Aseptic Zone) – This zone shall include areas where
sterile procedures are performed and requires appropriate scrub attire.
2. Environmental controls and surgical attire shall increase as progression is made from
unrestricted to restricted areas.
2.1 Semi-Restricted Area (Clean Zone)
 Movement of personnel from unrestricted areas to either semi or

restricted shall be through the Red line.
 Red line areas shall serve as a transition zone between outside
and inside of the Surgical Suite and may serve as a security
point to monitor people admitted.
2.2 Restricted Areas (Aseptic Zone)

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 Patients entering the surgical suite shall wear clean gowns, be

covered with clean linens and have their hair covered to contain
debris and dead cells that can shed off the patient.
 Patients shall not be required to wear masks while in the surgical
suite. While in the restricted area, the mask would hinder access
to the face and airway and might increase the patient’s anxiety.
 The sterile field shall be kept away from the head of the surgical
bed until the patient is draped to minimize possibility of
contamination.
 All doctors and personnel shall change their street clothes to
scrub suit when entering the semi restricted and restricted zone.
Scrub suit shall not be worn outside the OR Suite. If doctors and
other personnel will leave the OR Suite (ex. to do rounds on
patients) and subsequently return to the OR, such personnel
shall be required to put on a new set of scrub suit if they are to
operate again.
3. OR Personnel should:
3.1 Not eat, drink, or smoke in all patient care areas.
3.2 Follow the hand washing technique in the OHHC Infection Control
Manual (refer to Hand Hygiene).
3.3 Use Personal Protective Equipment/ barrier techniques to minimize

contact with blood and body fluids, secretions, and excretions. Infection
control barriers in the OR include: Gowns, plastic aprons, masks, goggles,
shields, plastic boot covers, and water-repellent cover gowns.
3.4 Wear the appropriate surgical attire when entering restricted and semi-
restricted areas
3.4.1 OR attire should not be worn outside the OR suite, such as for
lunch breaks.
3.4.2 OR attire should not be hung or put in a locker for use at

another time. It should be discarded in trash or put in a laundry
hamper, as appropriate.
3.5 Handle and dispose of sharps according to Needle stick and sharp injury.

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3.6 Report Blood/body fluid exposures to the OR Supervisor or Charge Nurse

immediately (refer to Blood and Infectious Fluid Exposures).
3.7 Promptly clean blood and body fluid spills according to Housekeeping
Policy Manual (refer to Cleaning Blood and Body Fluid Spills).
3.8 Place contaminated solid waste only in covered trash bins with yellow
liners.
3.9 Handle all linens according to Handling of Soiled and Clean Linen.
3.10 Handle all laboratory specimens according to Specimen Collection and

Transport.
4. Hand and Forearm Antisepsis:
4.1 Fingernails must be kept short, clean, and healthy. Artificial or acrylic
nails are not allowed.
4.2 Arm or hand jewelry (except small wedding band) is not allowed.
4.3 Perform a preoperative surgical scrub with an approved antimicrobial

agent or alcohol based brush-free surgical scrub solution.
4.4 Subungual areas should be cleaned under running water using a nail
cleaner.
5. Infectious Cases required additional precaution:
 Contact transmission: (MDROs. C difficile and RSV)

 Droplet Precaution (Meningities, Influenza Virus and Mumps)
 Airborne Precaution: (Pulmonary TB, Chicken Pox)
5.1 Scheduled as the last case of the day.
5.2 Treated according to approved policies and procedures in the OHHC

Infection Control Manual (refer to Isolation Precaution).
5.3 Elective operative procedures on patients who have TB should be delayed

until the patient is no longer infectious (Refer to the policy Management of
patients with infectious TB in the operating room)

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6. Traffic Control:
6.1 The OR is divided into three designated areas that are defined by the
physical activities performed in each area:
6.1.1 Unrestricted Areas include the OR front desk, the Holding area,
locker rooms and staff lounge. Street clothes are permitted in these
areas and traffic is not limited.
6.1.2 Semi restricted Areas include the peripheral support areas of

the surgical suite, including storage areas for clean and sterile
supplies, work areas for storage and processing of instruments; and
corridors leading to restricted areas of the surgical suite. Traffic in
this area is limited to authorized personnel and patients. Persons
entering in this area must wear surgical attire. All head and facial
hair should be covered by a surgical cap, headscarf, and or hood.
6.1.3 Restricted Areas include operating and procedure rooms, the

clean core, and the scrub sink areas. Persons in this area are
required to wear full surgical attire and cover all head and facial hair.
Masks are required when open sterile supplies or instruments are
present or scrubbed persons are located.
6.2 Persons from other departments entering the semi-restricted areas of

the surgical suite for a brief time for a specific purpose, and authorized by
the Unit Supervisor (i.e., Maintenance or Clinical Engineering), may wear a
disposable white coverall suit over their outside clothes.
6.3 Doors to the operating rooms should be closed except during movement
of patients, supplies, and equipment.
6.4 Supplies prepared for surgical procedures outside the surgical suite in
the CSS Sterile Processing and Supply Unit (SPS) should be transported to
the surgical suite via the OR Clean Elevator in closed case carts to maintain
cleanliness and sterility.
6.5 Soiled supplies, instruments, and equipment should not re-enter the
clean core area. They should be contained in closed bags or covered carts
and containers for transport via the OR Dirty Elevator to the SPS
Decontamination area.
NOTE: The clean and dirty elevators in OR should not be used by any personnel to
prevent contamination in the OR.

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6.6 Personal protective equipment (PPE) like gloves, gown, mask, head cover
and shoe cover, etc. should be removed at the point of use and should not
be worn outside the Operating Room. (Refer to Standard Precautions)
6.7 No closets are built inside theaters.
6.8 Minimal items are stored in Operating Room.
6.9 Maintain ≥ 15 air change per hour
6.10 All re-circulated or fresh air should be filtered through filters that
provide 90% efficiency HEPA filters.
6.11 Operating Room is maintained at positive pressure with respect to

corridors.
6.12 All clean and sterile supplies shall be stored on shelves or pallets at
least 8-10 inches of the floor. Clean and sterile supplies shall be dust free.
6.13 Temperature should be maintained between 68°F to 73°F (20°C to

23°C) within the operating room suite and general work areas in sterile
processing
6.14 All refrigerators shall contain thermometers and the temperature

recorded daily.
7. Immediate Use (Flash) Sterilization
7.1. Procedure:
7.1.1 Immediate Use (Flash) sterilization should be used only when time
does not permit sterilization by the preferred wrapped procedure.
7.1.2 The unwrapped method may be used in emergency situations for

individual items (i.e., dropped instruments). Complete sets or trays of
instruments may be immediate use sterilized/flashed if the following
conditions are met:
7.1.2.1 There is an urgent need.
7.1.2.2 Proper decontamination, cleaning, inspection, and

arrangement of instruments prior to sterilization.
7.1.3 All contaminated instruments to be immediate use sterilized/flashed

will be manually decontaminated prior to placement in the steam sterilizer.

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7.1.4 Don protective gear (i.e., eye protection, gloves, apron if appropriate).
7.1.5 Rinse items under cold water.
7.1.6 Spray instrument with enzymatic solution.
7.1.7 Clean items with scrub brush under water to avoid aerosolization.
Inspect for cleanliness.
7.1.8 Place items in immediate use/flash sterilization pan with chemical

indicator. Metal or nonporous items are sterilized for 3 minutes at 270° F
(135° C) in either the gravity or prevac cycle. Items with lumens or complex
items require a 10 minute 270° F (135° C) gravity cycle or 4 minute 270° F
(135° C) prevac cycle.
7.1.9 If time permits, all instruments needed for another scheduled case
should be taken to CSSD for decontamination and returned to OR for
immediate use sterilization/flashing. This will take approximately 1 hour.
Notify CSSD in advance for prompt service.
7.1.10 Immediate Use (Flash) sterilization should not be used for

implantable devices except in cases of emergency when no other option is
available. In an emergency a rapid-action (1 hour blue top) biological
indication will be run with the load. Following sterilization, the implant
should be quarantined until the rapid-action biologic provides a negative
result.
7.2 Documentation:
7.2.1 Documentation of cycle information and monitoring results will be

maintained in a file to provide tracking of the flashed item(s) to the
individual patient.
7.2.2 Documentation allows every load of sterilized items used on a patient

to be traced.
7.2.3 Sterilization records should include information on each load,

including:
7.2.3.1The item(s) processed;
7.2.3.2 The patient receiving the item(s)

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7.2.3.3 The cycle parameters used (eg, temperature, duration of

cycle)
7.2.3.4 The date and time the cycle is run
7.3 Cleaning and Disinfection Anesthesia Machine
7.4 Anesthesia Machine Surfaces and Carts
7.4.1 Clean, then spray or wipe anesthesia machine surfaces and knobs with
an appropriate germicide between cases and at the end of each day.
7.4.2 Take protective measures to prevent materials stored on the

anesthesia machine from becoming inadvertently contaminated by airborne
debris (e.g., blood).
7.4.3 Remove equipment from drawers, clean and disinfect drawers

regularly.
7.4.4 Place a clean covering on the top of the anesthesia cart at the
beginning of each case.
7.4.5 Wipe small surfaces with 70 percent isopropyl alcohol to reduce

bacterial contamination.
7.4.6 Clean carbon dioxide and soda lime absorbers when the absorber is
changed and remove debris from the screens.
7.4.7 Breathing system filters are single-use items that are disposed
immediately.
7.4.8 Follow the manufacturer instructions for disassembly, cleaning, and

sterilization of carbon dioxide absorbers.
8. Environmental Cleaning of OR and Equipment
8.1 Each Operating Room shall be comprehensively cleaned before and after
completion of an operation.
8.2 The Operating Suite/Rooms shall be cleaned according to established routine

policies and procedures.
8.3 Environmental culture or microbiologic air sampling of the OR suite shall be

done if foreseeing possible outbreak of infection/ after construction or
renovations or as the need arises.

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8.4 Clean linen shall be transported daily to the Operating Suite in a clean
covered cart at designated delivery times by the Linen Department.
9. Managing Infectious Patient
9.1 Precautions for Managing Patients on Airborne Precautions in the Operating

Room
9.1.1 In patients with active MTB, only emergency procedures are

recommended
9.1.2 Elective procedures on patients who have MTB should be postponed

until the patient is no longer infectious.
9.1.3 If possible, perform procedures in operating rooms that have

anterooms. The doors to the operating room should be closed, and traffic
into and out of the room should be made to perform the procedure at a
time when other patients are not present in the operative suite and when
the minimum number of personnel are present (e.g., at the end of
the day).
9.1.4 OR personnel should wear the N95 masks throughout the procedure.
9.1.5 Let the patient recover in the operating room, if a negative pressure
room is not available, or alternatively, in a private room with a portable
HEPA filter.
9.1.6 Follow cleaning and disinfection process of the room and equipment
based on Housekeeping
9.1.7 Refer to Transporting Patients on Isolation Precautions.
9.2 Precautions for managing patients on Droplet Precautions
9.2.1 Elective procedures on patients who are under droplet precaution

preferably to be delayed until no longer infectious or schedule the
procedure at the end of the day.
9.2.2 Initiate and maintain droplet precautions when there is suspected or

confirmed diagnosis of an infectious disease that is transmitted by the
droplet route.
9.2.3 Wear a surgical mask within 3 feet of the patient. Refer to Droplet
Isolation Precautions for managing patients needing droplet precaution.

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9.2.4 Clean and disinfect the operating room and equipment used after the
surgical procedure based on Housekeeping.
9.2.5Utilize the operating room for the next procedure after the
recommended housekeeping cleaning process has been completed.
9.2.6 Refer to Transporting Patients on Isolation Precautions back to the

wards.
9.3 Precautions for managing patients on Contact Precautions
9.3.1 Schedule elective procedure preferably at the end of the day.
9.3.2 Place patient in isolation in a single room in the recovery. Refer to

Contact Isolation Precautions.
9.3.3 Clean and disinfect the operating room and equipment used after the
surgical procedure based on Housekeeping.
9.3.4 Refer to Transporting Patients on Isolation Precautions.
V. REFERENCES
1. Association of Perioperative Registered Nurses. Standards, recommended practices and

guidelines, 2012 edition. Denver, CO: AORN,
2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical
site infection. Infection Control and Hospital Epidemiology2013 Apr; 20(4):247278. In:
Division of Healthcare Quality Promotion (DHQP). Guidelines and Recommendations
[Internet]. Atlanta: Centerfor Disease Control; Available from:
http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html.
3. APIC 2014.
4. The GCC Infection Prevention and Control Manual 3 rd Edition 2018
VI. SIGN-OFF AND REVISION HISTORY
Owner

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INFECTION CONTROL
Initiator
JAN MARVIN M. PALIJO, MSN, RN – CHIEF NURSING OFFICER
Reviewer
GINA M. GARCIA, MD – CHAIRMAN, DEPARTMENT OF MEDICINE
Approvals:
ARGYLL T. ARCIGAL, MD
CHIEF OF CLINICS
CHERRY PINK D. ORDINAL, MD
QMD Head
RICO M. RAYOS DEL SOL, MD
Chief Medical Officer

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NEIL ANDREW S.J. DE LUMEN, MD
President
Revision History
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POLICIES AND PROCEDURES MANUAL

INFECTION CONTROL IN OPERATING ROOM

2.1 Review and observe practices of OR personnel.

2.3 Assist in infection control education programs for OR staff member.

2.4 Review, revise, and recommend infection control policies and

4. Infection Control Supervisor shall:

4.2 Assist in infection control in-service education programs.

4.3 Review the infection control practices of personnel.

4.4 Act as a resource.

5. Infection Control Committee shall:

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

III. DEFINITION OF TERMS

1. Infection control-is the prevention of the spread of microorganisms which leads to

Operating Surgical Suite; OR Suite; A physically separate area that comprises

their interconnecting hallways and ancillary work areas such as scrub

Operating A room in an operating suite where operations are performed

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1. Traffic Pattern in the Surgical Suite

2.1 Semi-Restricted Area (Clean Zone)

 Movement of personnel from unrestricted areas to either semi or

2.2 Restricted Areas (Aseptic Zone)

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 Patients entering the surgical suite shall wear clean gowns, be

3.1 Not eat, drink, or smoke in all patient care areas.

3.3 Use Personal Protective Equipment/ barrier techniques to minimize

3.4.2 OR attire should not be hung or put in a locker for use at

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

3.6 Report Blood/body fluid exposures to the OR Supervisor or Charge Nurse

3.10 Handle all laboratory specimens according to Specimen Collection and

4. Hand and Forearm Antisepsis:

4.3 Perform a preoperative surgical scrub with an approved antimicrobial

5. Infectious Cases required additional precaution:

 Contact transmission: (MDROs. C difficile and RSV)

5.1 Scheduled as the last case of the day.

5.2 Treated according to approved policies and procedures in the OHHC

5.3 Elective operative procedures on patients who have TB should be delayed

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

6.1.2 Semi restricted Areas include the peripheral support areas of

6.1.3 Restricted Areas include operating and procedure rooms, the

6.2 Persons from other departments entering the semi-restricted areas of

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

6.7 No closets are built inside theaters.

6.8 Minimal items are stored in Operating Room.

6.9 Maintain ≥ 15 air change per hour

6.11 Operating Room is maintained at positive pressure with respect to

6.13 Temperature should be maintained between 68°F to 73°F (20°C to

6.14 All refrigerators shall contain thermometers and the temperature

7. Immediate Use (Flash) Sterilization

7.1.2 The unwrapped method may be used in emergency situations for

7.1.2.1 There is an urgent need.

7.1.2.2 Proper decontamination, cleaning, inspection, and

7.1.3 All contaminated instruments to be immediate use sterilized/flashed

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

7.1.5 Rinse items under cold water.

7.1.6 Spray instrument with enzymatic solution.

7.1.8 Place items in immediate use/flash sterilization pan with chemical

7.1.10 Immediate Use (Flash) sterilization should not be used for

7.2.1 Documentation of cycle information and monitoring results will be

7.2.2 Documentation allows every load of sterilized items used on a patient