Hey everyone, good evening. So my lecture, today is on, best practise within, the theatre suite, and how to maintain best practise. So we're gonna look at a variety of things.

So the outline for the lecture this evening is basically looking at the aims of infection control, in theatre. The environment, so talking a little bit about the layout, maintenance of environment and the instruments, so yeah, how do we maintain our environment and how do we maintain our instrument, the preparation of the patient and the surgical team. Monitoring infection control, specifically hand hygiene, and how do we maintain a high standard of patient care and organisation within theatre as a whole, and we'll be looking at lots of different aspects and and how we can manage patient care.

Really, the objectives from tonight's webinar is for you guys to be able to identify the ideal theatre design and implement it in practise, recognise routine protocols for maintenance of the theatre environment and materials, and praise the maintenance of high environmental standards within the theatre suite. Find techniques to achieve high standards of patient care and examine a range of methods to increase efficiency and organisation within theatre. Really, the aims of infection control in theatre, the main aim really is to avoid surgical site infections.

We also want to avoid the transmission of contagious diseases. We want to avoid nosocomal or hospitalised acquired infections. We need to protect our staff and our patients from any hazards and hospital acquired infections, and we need to prevent the spread of multi-resistant organisms.

Obviously, surgical site infections can have a risk to healing of wound, but it can also have a big impact on the patient's recovery. We need to avoid zoonotic transmission of disease. Obviously it's important to protect staff.

So therefore we need to make sure that we're not transmitting zoonotic diseases to staff. And obviously litigation as well. You know, if we're found to be negligent, and a patient doesn't recover, or we spread a disease or a zoonotic disease, then obviously we can be liable for litigation as well.

So if we look at the environment first, and if we concentrate on planning and design, so the plan with the theatre environment really is to promote asepsis. So the design of the theatre needs to be, easy, clean, so we need to have cleanable surfaces, electric sockets that can be cleaned. We need to have, an area where you can decrease traffic flow, so you haven't got high traffic flow areas.

So you need to have adequate space and obviously not all practises have the ideal design or the ideal environment. So sometimes it's just making The best that you can with what you've got. It's important to know what the ideal is because obviously if you ever have any scope for creating more space or extending or anything like that, then you need to have this knowledge in place to be able to do that effectively.

So ideally you should have a surgical preparation area for an anaesthetic induction in the patient preparation. So that's really important that the patient preparation is done away from theatre. Scrub area and changing areas, so specific changing areas for theatre staff so that you can get changed into scrubs and you can get changed into crops.

If you're changing your shoes, you can have higher levels of contamination in that area, so it's important to keep that area away from any theatres. And obviously everyone should be wearing scrubs where they're in theatre, so again you should be getting changed in an area away from theatre. Operating rooms, ideally if you can have a cleaner operating room, so an operating room for orthopaedics and maybe an operating room for soft tissue so that you try to keep them separate as much as you can.

I mean, At Lee Hurst we have 3 theatres, you do get you do get swapped around. We have, we do have the cleanest theatre if you like the orthopaedic theatre, which we use for orthopaedics and spines, total hip replacements and things. But on the odd occasion we have had to put say a septic abdomen in there or or something like that so.

As long as you are always planning your clean procedures first and you're always doing those first. And you're cleaning down your theatres thoroughly, then if you had to use an operating room for a dirty procedure, which is normally a clean, a cleaner room, then, you know, obviously you have to, but if you can separate them, then that, that's brilliant. And if you can have if you do have a room where you can use for infectious cases, so like a little mini theatre where you can clip and a patient or you know, even pre-medicate the patient, induce the patient, clip and prep the patient.

Recover the patient all in that one area, especially if they have a multi drug resistant organism or they've got some sort of infection, maybe MRSA or something like that, and that's really important to keep them isolated and away from the rest of the theatre area if you can. And obviously a recovery area, so it's important to have a recovery area where you've got patients recovering or coming into theatre for a procedure that is separate to the rest of the hospitalised patients. Nurses station, so you've got a central organisation point, maybe you've got a whiteboard up there, communication boards, a computer that you, you know, may need to work from.

You might need to have your housekeeping and your storage close by, and obviously your cleaning and preparing instruments and you'll have your cleaning preparing instrument room, with your autoclave and that's the ideal set up. Minimum really, the main thing is to make sure you have different areas to clip and prepare your patient. Effectively to perform in the surgery.

So like I've said, the arrangement of rooms is vital. Make sure you've got separate areas into clean, mixed, dirty or restricted semi-restricted areas. So we have double red lines, on restricted areas and we have signs up as well saying a sterile, sterile area, no admittance.

So the double red lines means you cannot cross into that area. So it's really important to have those clearly identified. Other thing that we have just recently started doing, which you can see from the picture of the theatre suite, so this is our operating suite, is we have the tachy mats, underneath the doors.

So we've got half the tacky map within theatre and half the tay map. On the outside of theatre doors and these tacky maps, because we wheel our patients on trolleys everywhere, we don't, we don't walk anywhere within theatre, they all go on trolleys apart from in recovery. And then they pick up any bits and from the trolley wheels and also from our scrub shoes as well.

And when we started using them, it's amazing actually how much the hairs, fibres, it traps and stops coming into theatre. So The amount of dirt and hair and things you can get on your, on your crocs is quite unbelievable and these really do highlight that. So it does help to stop and dirt coming into theatre and there have been studies.

About tacky maps and I have, added, paper on the end of your extra reading on your, course notes as well. So you can have a look at that and look that up if you want if you're interested in Taki map. We have the Tay mats basically.

Outside all theatres, outside prep and recovery as well, and in between our main theatre corridor and the outside world as well, you can also put them, for you changing rooms and after you changing rooms as well to try just to try and limit how much dirt and debris you bring into the theatre area. Again, if you've got space to expand, then brilliant, and you can improve, improve the building, then that's great. And try to avoid lots of staff in central areas, so don't have too many workstations all in one area.

Again, try to limit traffic flow. So this is just a picture of our changing rooms. So we have colour coded scrubs, which is quite nice being a teaching hospital.

We have lots and lots of people in theatre, so we identify the students wear beige, the surgeons wear maroon, the anaesthetists wear teal, and the nurses and the staff. Wear blue. We do the same with the hat, so we have different coloured hats.

So anaesthesia students wear pink, . Theatre staff wear blue and visitors wear green, so you can really highlight, who's who in theatre at a visual glance just by looking at the hats or the scrubs. The anaesthesia or the surgical preparation room, so, Lee Hurst, we have two induction stations, so you should have, you know, an induction station, you should have all your prepping.

Items, hand, so your swabs, your chlorhexidine, etc. It's really important to have hand hygiene stations, in prep because obviously you're dealing with, hair in the skin for surgery. So, or you may be dealing with patients, you might be pre-med in patients or handling patients.

So it's really important to have plenty of hand hygiene, stations. Things like waste bins, normal waste and clinical waste, spins, sharp spins, etc. Storage for all your materials that you need.

So it's good to be organised, make sure you've got everything to hand. When we set up an induction station, we get all of our prepping things ready every. Thing that we'll need, obviously all your induction things, make sure your clippers are clean and that sort of thing, because again we'll talk about it a bit later, but it's so important to be organised to reduce that anaesthesia time that the animals are aren't under anaesthesia, .

Unnecessarily, so more organised you are, the more you've got things to hand, the quicker the whole preparation stage can can take place and obviously that is a point where they can really in their temperature as well. So scrub area we have automated scrub sinks, which is brilliant, so they're anti-touch no touch, we just wave or we point. For water and for soap, so they're really handy.

We also have a sterile corridor which is very limited in who can go through the sterile corridor, so it's only people who are loving and gowning or opening kits, and we have access to the theatre through the sterile corridor or the main corridor. And clean people, so people who just scrubbed, and gowned, opened the kits, go through the sterile corridor and once the procedure is finished, everybody else always leaves the other doors into the main corridor. So nobody should be going up and down the sterile corridor unnecessarily, and everybody should be wearing masks in that corridor because it's generally it's open or we've got the trolley drape which you can see there which is sterile and that's put on every morning and the gloves and gowns are stored underneath there, so.

Booking should be limited and everybody should be wearing masks and should be properly dressed within the sterile corridor. Instrument preparation area so it's ideal to have Clean area and a dirty area, and again it's handy to have two sinks so we fill one sink with me design so dirty instruments can be put straight into that sink or dirty items can be put straight into that sink. And then we have another area across the other side of the room where we pack instruments so that the city and the clean instruments are kept very separate.

We're very lucky because we have an instrument washer, which is brilliant, so we can put a large amount of kit in the washer. We can test the washer to make sure it's working properly, which we do every day with different indicators, so you can have protein indicators or you can have washer indicators that actually go in the washer, make sure that your, your equipment is functioning properly. Obviously teach you cleaning as well.

Laundry cleaning or scrubs should be laundered at 60 degrees. We have those all in the same room and it's important to have normal waste and clinical waste in there as well. Again, you shouldn't be putting, you should only be putting clinical.

Real clinical waste into clinical waste bins, no paper or anything like that should be going into clinical waste. So it's really important to have your waste bins there. And we also have recycling bins as well, plastic recycling as well in there.

Storage is really important, so storing some of your consumables that you need for packing kits, these shelf rackings are brilliant. I was trying to think of the company of where we got them from. I just can't remember, but I can find out if anybody's interested.

They are fantastic because you can wheel them around, you can clean underneath them, clear the clear trays, you can see what's in them, you can clearly label them, and it gets things off your side and you can just store loads of stuff, . Within a small space. So we use them for our sterile store as well.

So we've got two sides to our sterile store. We've got all our kits, on one side, and then we've got all our sterile consumables on the other. We've got a store guide as well.

So that's a reference. So people can try and find things because obviously there's, it's quite big there's a lot of stuff in there. And we use the instrument tins which I will talk about later.

But as you can see from those pictures with the instrument tins, they all have indicators on. So it's very clear that the brown. Circle means that it's autoclaved and the white circle means that it's not autoclaved so it's easily identifiable when it's in those shelving racks.

You can see whether it's autoclaved or not before you take it off the shelf just by looking at the indicator. You can also see the dates on it and the initials of who packed it. It's, you can also have them colour coded, so you can see we've got blue lids, so they're all soft tissue kits and all the gold is, orthopaedic kits.

And again, then you can have the name with the the name engraved on them as well. So it's really that easy to see what everything is, which is great if you again, it's about being organised and if you need to quickly get something, you can just quickly run and find it. Recovery area.

So our recovery area now really isn't big enough, ideally it should be bigger and we don't have a separate cat and dog area, well, not as much as we would like to. So that's another thing to consider trying to keep the different species separate to each other as well. But again, that is deemed by space.

The main thing with recovery is making sure you've got kennels that are. Identifiable and making sure your patients are identified. So we use net collar tags so when a patient is admitted, we don't generally admit the collars and leads brought in with the via the owners because they go missing.

We do put like a sticky ID tag on them. With the patient sticker on or we just write the details on. And then they also get a clear day to day patient recovery form which has all the details of all their details, what they're in for, when they're pre-meded, did they have contrast, do they need fluids, if so, what rates, what medication did they have on recovery or the TPR Information and what time they're going home if they're a day patient or they have a hospital sheet put on if they're going to be staying in overnight.

So if they're having a procedure and staying in overnight and then the anaesthetist writes everything on the sheet or the hospital sheet. It's really important if you've got that, those neck collars on, that they stay on the patient because the day forms can easily be moved if you're cleaning out kennels or if they fall off the clipboard. So animals can get easily confused unless they've got a tag on.

So if you've got two boxes, the wrong, the wrong boxer might get pre-med, that has happened once before. That's why it's so important that they have the ID colour on and you can check their identification before you give any medication. Laminated, pennel sheets are also really good.

So the red ones for care, you can make up whichever ones you want really on different coloured cards, so they're really useful as well. Digital thermometers on the wall, they're really handy for doing TPRs. We also have a communication board in there, a white board, so we can do reminders of any patients that need medication or we can pass notes on to each other and that sort of thing for lunch cover.

Have a sink again, hand hygiene station really, really important. You should be infecting your hands before and after touching every patient and then a laundry basket as well. And obviously your warming devices as well and blankets and things like that.

So if we talk about maintenance of environment and instruments, most surgical site infections enter via bacteria from a wound. So it's really important that our environment, is kept as clean as possible and also the patient is kept as clean as possible and the wound is kept as clean as possible. So cleaning wise, obviously the, theatre should be cleaned daily.

You should have set routines. We have weekly and monthly routines, we have daily tick sheets as well. So all of our cleaning gets recorded, and it gets initialled, and we produce tick sheets for the whole of the month.

They all have their own place in the cleaning book and we all tick it off, whether it's a daily or weekly or a monthly and then that's kept as a record, which is really important for our CVS hospital accreditation and things like that. So it just, you know, shows that the Appropriate areas have been cleaned properly and we list exactly what we clean in those areas as well so that anybody coming into theatre and we clean a theatre and they know exactly what they should be cleaning. What we really concentrate on are the touch areas, so the door plates, the keyboards, anaesthesia equipment, etc.

Things that get touched regularly, like even you. Bundles and hoovers and things like that. We do environmental swabbing, so we know where we get most multidrug resistant bacteria and keyboards is a is a real number one for having multi-drug resistant bacteria on so are really important, they should definitely be wiped down at least once a day.

Floors, again, unless you're crawling around on the floor, they're not as important as touch areas. It's the touch areas that you really want to concentrate on cleaning. But obviously floors should be cleaned every day as well.

And with your weekly and your monthly routines, obviously you can do more deep cleaning, so we move, move equipment out of the way, take everything off the shelves, clean out any clubs, things like that. So you can do more intensive cleaning, every, every month as well. So we always have a bucket with the correct disinfection in the correct dilution again you can for all your dilutions that you have in theatre, you could just do like a little laminated sheet and have it in your cleaning cupboard or Somewhere on the wall, so you know exactly what dilutions you should be using.

It's really important for staff safety and it's really important to make sure you're getting rid of bacteria, so that they're at the right dilution, otherwise they may not be, effective. And now wipes they're brilliant for things like your anaesthesia equipment, so your SPO2 probes, you know, probes that are going to be used on mucous membranes of the patients, so they need to be safe for the patient, and all your anaesthetic. Like SPO2 probe should be disinfected in between each patient.

So if you just have a pack of Clinel wipes, next to your anaesthetic, or on your anaesthetic trolley next to your anaesthetic equipment, you can just give them a quick wipe down in between each patient. Obviously make sure you've got PPE to hand so you can wear gloves when cleaning. And like I said, we do bacterial swabbing which I'll talk about a little bit later, so we swab all of the environment within theatre, different areas, different we, we can just check to see if there's any multi-drug, or any bacteria we we need to be concerned about.

So instruments, well, it's a talk on its own, really. There's an awful lot I can talk about with regards to instruments, but obviously, It's vital that we maintain them. It's vital that we make sure that they are adequate for function and it's vital that we clean them properly as well.

So all gross contamination needs to be removed first. However you do that, whether it's an instrument washer or you're scrubbing them manually, it needs to be, they need to be properly contaminated, and they also need to be rinsed properly and they need to be cleaned in the correct solution. There are solutions that are not designed for instruments that will cause pitting and damage to your instruments as well.

So it's really important that you're using the correct solutions at the right dilution, and it's really important that they get rinsed and dried before they go in the autoclave. Preparation, so it depends on what sterilisation method you're using. So you might be using cloth, you might be using the paper, or you might be using the instrument bins.

Now we moved over to instrument bins quite a few years ago now, and when we looked into it, the advantage really was that they protect your instruments, they are. Mhm. You're less likely to break a sepsis because you don't have the concern of the cloth being perforated or the rat becoming perforated during storage or getting caught on something and then contaminating the whole pit or the whole sterile field.

So they're very hardware in. So a lot less contamination risk as well. And also, if you think about the environment, you're not having to wash all the cloths, you're not having to put it all into clinical waste, all the paper.

So they do save a lot on waste and therefore the environment as well. . And you can colour code them they're easily identified, easily labelled, so yeah, we really, really like the instrument tints and over time, over years, wrap is actually the double layer wrap is actually really quite expensive or the one we were using was and it say over years it will save us thousands and thousands of pounds, so it is cost effective as well over time, long term it is.

So 6 months, sterilisation wise, if you've got something single wrapped, then that will last 6 months. Or if it's double wrapped, then it should last 12 months, or if it's in the tin, like I say, it will last 12 months as well. So you don't need to re-sterilize, you only need to re-sterilize them every 12 months.

. The SOP guides are really good. So having, we have 3 Bibles, we have one for SOPs for how to clean, drills and specialist equipment and things like that. So make sure that everything gets cleaned properly as it should be, how to lubricate bills, how to maintain them.

And then we have another bible for setting up. So, how to set up for a total hip replacement, everything that you would need, which surgeon likes what so that when we get in and prepared for the total hip replacement, replacement, we've got. List and we we know we're not going to miss anything.

Everything's going to be set out. And then we also have another Bible which has got pictures in of every kit and every instrument is labelled and how to pack that kit. And we correlate those with our inventory lists, which you can see in the tin there, we've got an inventory, list, and that basically is a list of every instrument that should be in it.

And then whoever washes it ticks it off to say they've washed it and then packed it and then we get another member of staff to come along and just double check that all the instruments are clean because it's human error, we all miss stuff, it can happen. It's always good to have a second set of eyes, just have a look over the instruments and to make sure, yes, they're all there, so they can tick off the list, all the instruments are there, and then the can get packed. .

Also, obviously we have the TST strips in there for make sure that it is properly sterilised when we then open the kit. So double checking. Saves a lot of time because if you have got packs that don't have that have instruments missing and you need to then find them obviously it causes a delay for the surgeon, it causes a delay for the procedure because you then having to find that instrument or having to come out of theatre and go and find it as an extra.

So I do think inventory lists are brilliant. Again, the TST strips, talking about the main maintenance of the autoclave first. Cycle of the day when the auto clo is cold is likely is the cycle where you will get the most, if you're going to get any issues you're gonna get it with that cycle.

So these TST strips are brilliant. You just put them in with the first load and then it's just a TST strip in the middle of lots of drapes or lots of bits of paper, so it makes sure that it's penetrating all those layers of paper and . It's indicating that the sterilisation method has happened at the correct temperature for the correct amount of time.

So we then keep that as a record, and that's our check that the autoclave is functioning as it should be every day, so we do that every day. So if we now look at the preparation of patients and the surgical team, so with regards to patients, obviously, We need to clip away the hair, we need to prep prepare the skin, we need to position them, we need to drape them. We need to think about dietary restrictions, and we also need to think about excretion, so expressing the bladder before we start prepping, if we need to do a purse string, do we need to empty any faeces and that sort of thing.

And the surgical team, obviously we need to think about their attire, they're thinking about scrub suits, footwear, head covers and face masks. Obviously they need to scrub up, they need to glo and gown, and they need to maintain sterility during surgery, which again we'll focus on all of these and I'll talk about all of these individually. So if we talk about the patient first, obviously with regards to preparing the patient for theatre for surgery, we need to remove the hair, and we need to hoover away the hair, so that it's not going all over the patient to try and limit as much hair taking theatre as possible.

Clip with a 40 blades, so make sure that the blades are clean, make sure they're functioning, . The last thing you want is to have skin abrasions when you're prepping a patient. If they have cuts or skin abrasions, then you've broken the surface of the skin and that means bacteria can get into.

It because a skin barrier has gone, so, they are more likely or more at risk of surgical site infections. So it's really important you clip with the correct blades, your clippers and your blades are in good working order and to avoid skin abrasions. Little hairdressing clippers can be brilliant for Really delicate areas as well, you get much less abrasion abrasions with those, so they can be really good and we use those a lot for very delicate areas.

And make sure you clip in the hair in a separate area to the operating room as well. So again with relation to hair, if we're talking hind limb surgery, then maybe wrap the tail if it's very hairy, wrap wrap it in wrap to keep the hair out of the way before you start wetting the skin, and with any, feet, then it's important that you prevent strike through. So again, a glove, over the hair, over the whole of the foot and then vet wrap.

Hole of the foot. And just to say with regards to whoever is prepping, a person should wear an appropriate PPE. So we always wear a plastic apron and gloves for prepping a patient and we remove the plastic apron before we go into theatre.

It just stops. Too much hair on your scrub. The more hair you've got on your scrubs in the afternoon, the more bacteria you've got on your scrubs, so the more bacteria you're carrying around with you.

So plastic aprons can be really useful for, again preventing too much hair and every contaminating your scrubs. So again, that's just showing, vet wrapping the hair, and again, either purse string sutures or book plugs, we use plugs, just like a little tampon really, very human thing. Obviously they're less traumatic than doing the, purse string suit, so they can be really useful.

So with regards to prepping the skin, it's really important you use the correct solution at the correct dilution. Now skin preparation, gold standard skin preparation, you should be using chlorhexidine at 50/50 dilution. You should be storing it in a clean bottle, and these should be discarded after 2 days really.

So what we do is we use our empty sterile saline bottles and we make it up every day and we label it with taste and what it is on it and we keep them in prep at hand ready. And then you can get a stainless steel, sterile right because we sterilise these every day, in the autoclave, so they're sterile, and we use to swabs. So we use swabs instead of cotton wool, so you don't have many fibres, you don't have lots of fibres left on the skin.

And they're really soft as well, so they're not abrasive, which is another really important thing. So it's important to clean the skin and it's important to get rid of the dirt, but it's also really important not to be so rough that you create inflammation and you create abrasions. So the more, abrasive the swabs or the more abrasive you are with scrubbing, the more inflammation there is, the more bacteria you can bring to the surface of the skin.

Through that inflammation reaction. So that's another really important thing to consider with patient preparation. Contact time is important, but if you are properly cleaning until your swabs are clean, you should be checking your swabs.

By the time you've done that and you've moved into theatre, you should have easily done the 5 minute contact time. And for our final prep, once we've moved into theatre and we've positioned the patient, if we're happy that we haven't touched the site and we're happy that we haven't . You can, our sterility of our, of our prep, and we will go on and do the final prep.

If in any doubt, we'll take a little bit of prep solution through with the top swabs and we'll just do an extra. An extra prep in theatre just in case and then we'll finish with the lora prep and again it's an anti-touch technique, it's a method in the NHS. We've been using them for years now, and they're great and they rely on the back and forth technique.

So the circular motion of with your swabs is. Old fashioned now, it should just be the back and forth technique and you should just be cleaning it until your swabs are clean. And with the chloro prep again, it's back and forth technique, 30 seconds concentrating just on the incision site, back and forth, and then take it round the rest of the area and then discard it.

Again, there's there's a paper I've included in your Additional reading, which you can read about if you wish to. Again, this is just demonstrating the preparation of the skin with the stainless steel tray, the top swabs, and the fifty-fifty hippie scrub. So again, patient positioning, really important to keep those patients warm, always have a hot dog, which I'll talk about a little bit later, .

At induction and we have it warm before we even induce the patient so that the station's nice and warm and it's on throughout induction and throughout prep. We'll cover the patient as much as we can during the prepping . In in prep, and then when we move into theatre, we'll also try and, for the patient as well.

So it's really important to get the position right for the surgeon, not to touch the sterile site and not to touch the sterile field, but it's also really important to make sure the animals can still breathe and then not be restricted. Again, draping at Lee Hurst nurses generally do the draping, so we, we, again I'm going to talk about this a little bit later. We have different nurses in different roles and the scrub nurse will scrub up, open the kit and then drape the patients.

So the prep nurse and the scrub nurse. Communicate with each other as to when is it best for the grub nurse to go and scrub and open kit. The nurse will let her know and then the idea is that the prep nurse brings the patient through into theatre.

The final prep and the scrub nurse is ready waiting in the sterile corridor with the kit open, all organised, all ready, got everything that we need, and they come in and then they drape the patient so there's no delay, so the patient doesn't get cold, it doesn't increase the anaesthetic time, and it saves the surgeon some time as well because they come in and the patient's draped and all ready to go all instruments and equipment is ready, and they're at hand. So again, scrubhos scrub suits should be worn, you shouldn't have anything . Low elbow, so you shouldn't have anything on underneath your scrubs, footwear, is a bit controversial, it does little really to to reduce bacterial loads, and actually.

If you are changing your footwear regularly in theatre, then it's not always a good thing in relation to hand hygiene. So if you shouldn't really be handling your footwear at all, whether it's crocs or your normal shoes, but we were changing our footwear to go from theatre to imaging, but there are studies that show that by touching, And changing shoes, you're touching shoes are dirty and then you're not necessarily immediately disinfecting your hands. So, again, and that's the same with shoe covers.

Are you just increasing your contamination on your hands. We do have dedicated crocks we put on in the changing rooms with our scrubs and then we keep them on all day. It covers so hair, there is a lot of bacteria in hair, so it is really important to make sure all hair is covered, in, in a hat, masks, there's not a great, there's not great evidence that they decrease bacterial load and after 15 minutes they can become heavily saturated with bacteria, especially if you're doing a lot of talking, .

So the problem then is they've become saturated and then they're not as efficient and also if you are inclined to touch the mask, obviously not if you're scrub up in the sterile field, but if you're circulating staff and you end up handling your mask, you're touching your face more, then not disinfecting. Hands and you've got bacteria on your mask. So and masks can be seen as a contamination on your hands as well.

And they have to be regularly changed if they saturate after 15 minutes, and you obviously you definitely need to be changing them for every single surgery. You shouldn't be having them around your neck or left. In a pocket and reuse them for the next surgery.

So it does mean that with masks, if you don't have full staff compliance with using them properly, they can actually transfer more bacteria around the hospital and the theatre, than if you didn't have them. We do have them in theatre and we wear them because we're a teaching hospital and we we do probably do more talking, really the circulating staff unless you're over the sterile field, it probably there's no real great evidence that that needed for circulating staff. Scrubbing hands, so again it's changed over the years.

So the idea really is that again, you don't want any abrasions, you don't want to be scrubbing your hands with an abrasive brush because again the more abrasions, the more trauma you cause to your hands, the more inflammation you'll have, and then the more bacteria, the higher bacteria flora you'll have on your hands as well. So we use the alcohol, rub, the sterilium, it cuts, scrub time down by a lot. It looks after your skin, so it's less traumatic, so you don't get the inflammation and the abrasions and therefore the increased bacterial load on your hands.

And again, there's some papers in your additional reading on your course notes about alcohol drugs versus the traditional method, so you can have a look at those as well. Obviously maintaining sterility, you've got to be vigilant once you're scrubbed, you don't touch anything that is not in the sterile field. You always face the surgical field, you hold hands in front and above your waist and below your shoulder.

You don't lean over the non-sterile area. Anything below the waist is deemed unsterile and your back is deemed unsterile as well. So you need to avoid changing position if if possible.

I mentioned bacterial swabbing. So, basically we just take samples throughout the hospital, we rotate it, so we take different samples every week and we analyse them for multi-drug, resistant bacteria, MRSA, MRSP, and we look for signs, . Any of any of those bacteria in the hospital.

And basically it gives you a good indication of what your hand hygiene is like. So we had a case of a patient that had a specific E. Coli and we tracked E.

Coli throughout the whole of the hospital. And that just showed that people were touching this patient, not disinfecting their hands properly and then going away and doing something, touching a keyboard, and then obviously someone else was picking that up and it was transferring and it transferred around the whole of the hospital, so. We use it basically as an educational tool, so it, highlights to people the importance of hand hygiene and what can happen if you don't, disinfect your hands in between patients and how easily bacteria can spread.

And then obviously if you know that you get a lot of multi-drug resistant bacteria on keyboards, you know that you need to concentrate on cleaning those regularly. And you also need to concentrate on promoting hand hygiene with with among the staff. So, another way of, having surgical site infections is through hypothermia.

So hypothermia can increase the risk of surgical site infections. So it's really important to try and prevent it as much as possible. The warming devices, we use hotdogs, and again I'll speak to you about why we use hotdogs instead of huggers, .

We cover the patients as much as we can, and we get the patient draped as much as, as soon as possible as well. The sooner they draped, the less likely they are to, become hypothermic. And if you warm them, keep them warm from induction, again, you're much more likely to prevent hypothermia if you're keeping them warm from induction.

HMEs are really good, moisture exchanges, so they just go between the ET tube and the breathing, circuits and they basically it's an antibacterial philtre, it also warms. So if you think oxygen. It is cold.

You've got cold gases going into the patient, so these philtres help to warm the cold gas. If you use less oxygen as well, so use lower oxygen rates and that will help reduce hypothermia because you've less cold gas going into a patient as well. And obviously a high standard of prepping, maintaining your sterile field, wearing PPE all of these things will help to prevent surgical site infections.

So just relating to warming devices then air huggers basically they force warm air around the patient with a blanket. Now that's OK, but if you have bacteria sat in your bear hugger, so in the sleeve, in the little bit that connects to the blanket, you can potentially be transmitting bacteria around the patient and around the sterile field. So, It's really important if you do have bear huggers that you clean them really regularly, especially the nozzle and especially the sleeve where bacteria could could sit, and you don't use your blankets, so you do use a new blanket for every patient where possible.

And really you shouldn't really be turning them on before draping because you again contaminate your your prep sites. If you do that, so we always used to switch them on after draping, which means your patient isn't on any heat source, until they're draped. You do have different size blankets for small or large patients.

The blanket goes either underneath or top of the patient. We do use them in recovery. So if we have a really hypothermic patient, we might use a hotdog underneath them and a bear hugger over the top, but then a blanket over the top, but the wound is covered, so there's less contamination risk.

Hotdog is basically a conductive fabric electric warming devices, different temperature settings. It doesn't rely on weight, you can put it on straight away so you can have it on and it can be nice and warm in theatre or at your induction station ready to place. Animal on.

They're easy to clean. There's no waste, so you're not putting any blankets into, into the waste. So it's more environmentally friendly.

It's probably more cost effective, to be honest. I mean, they're not cheap to buy. If you look after them, and they're probably more cost effective compared to going through all the different blankets you go through with the hookers.

And in some studies, it's shown to be more effective as well, at actually actively warming the patient. And the blankets can be wrapped around or go underneath the patient. So, Augustine, who produced the hotdog have produced a, study, a summary of research basically supporting the air free hotdog.

So I've just done a screenshot so you can have a look at the PDF, if you want, and you can have a look at the research study, and see what they found basically. Again, I spoke about this earlier, about the recovery patients. So we have a dedicated recovery patient nurse, which I think is vital, really, probably one of the most vital roles really in theatre because recovery is your highest risk.

It can be your highest risk phase of an anaesthetic. So it's really important that we are monitoring these patients really carefully, and it's really important that you've got a good. Monitoring sheet to be able to do that.

And the better filled in it is, the easier it is for other people to see if there's any identify any problems or to see what's happening with that patient. See if it needs a TPR if it's hypothermic, etc. So chemical labelling and I think the recovery sheets or the hospital sheets are really, really important to be filled out correctly.

So, if we have a think about again, maintaining a high standard of patient care, and the biggest way you're going to maintain your, your high standard of patient care really is through your personnel. So your staff for everything, you really, you know, as much should be done as much work should be put into your team as possible. The better team you have, to a high standard of patient care and organisation you you will get.

So to achieve this, all personnel should have and know their responsibilities and functions. Ideally they should have written job description or role descriptions and, should have appraisals at least once a year, ideally twice a year if possible, and those appraisals should be nice and positive, you know, which is vital for a motivated team and an effective motivated team means you're gonna get a high standard of work. And during those appraisals, you can go through the job description, you can go through the role description, you can discuss what the team responsibilities are, what the role, of that specific person is, all sorts of things that you can discuss, and set appraisals and .

We all need to have provision for training and access to books online and resources, etc. And I think the individual roles really help with this. So we have a scrub nurse, an anaesthesia nurse, a prep nurse and a recovery nurse.

So the scrub nurse is responsible for scrubbing up and opening all the kits in the sterile corridor, making sure they've got everything they need for that surgeon, and again, we use the kit lists, the Bibles, for this as well. And then, . They will drape the patient and then they will stay in assist and assist if needed, or if they're just interested in the procedure, they might stay in and assist.

So it depends how busy we are as well. But yeah, for the whole week they are just scrubbing and assisting in surgery and the anaesthesia nurse just specialises and does anaesthesia for the week, the prep nurse preps all the patients and the recovery nurse just concentrates on recovery. So it means, and then we swap.

So it means that those nurses get for a whole week, they'll be able to specialise in one area which I think is motivating, and they can learn, a lot of skills and knowledge as well, and they, they all seem to enjoy it, so I think that's great. Having to do lists is really important as well. We have AM and PM to do lists, so everybody works as a team.

Everything gets cleaned and stocked properly for the day, and we also plan for the day, the day before, so we do a plan. And we do it the day before, so we know exactly what we do in the next day. And we also get the kits and everything ready as much as we can for the next day as well.

So we're ahead of the game and we're ready to go. Message, whiteboards can be really good, for planning and organising, or laminated sheets with AM and PM to do lists on as well. But like I said about theatre planning, we use an Excel spreadsheet which I'll show you in a minute, but we also have a whiteboard for the nurses so we can tick off when something's gone into theatre or we can write notes or we can say we need fluoro for this or we need this setting up.

So we've got a go to board to communicate between ourselves as well. But you might have one that includes bloods, has the pre-op bloods been taken, . Etc.

Has the animal been pre-medded, etc. We always prepare the instruments and the equipment the night before, so we got a reference bible that we all adhere to, and use that to prepare for the next day. And we have the cleaning lists as well to make sure all the cleanings done, and we have to do lists to make sure all the daily and the weekly jobs get done.

So we have like a Monday list and a Friday list. So like we'll clean all the hoover on a Monday or something that needs doing weekly. We have lists for that as well.

So our Excel spreadsheet, is basically, we have a pre-med time, then we have the animal's name and then we have the induction time. So we try and stick to that time as much as possible, and we try to stick to the plan as much as possible. So it just sees how many cases we can fit in that day, and we can look back on it and see how many cases we're doing as well, and everybody knows what time the animal should be induced and what time it should be in theatre.

These are our Bibles. So again, I said we had the instrument Bible with the pictures in every single instrument is labelled, and it tallies with the inventory list that everybody can pack a kit because they can learn what all the different instruments are, so it's a good learning exercise as well. And then we have our setup lists as well, so everybody can.

Organise and get set up for the next day and we don't miss anything either. So we've always got everything surgeon's going to need, which is good because you're limiting the traffic in and out of theatre, you're not delaying anything, you look like you're ahead of the game, you're on top of things, you're organised, which, you know, it's always good if you, if you look, organised and on top of your game, I think. And then we have a whiteboard, which we've had.

You can get them specially made, so you can have them made and have whatever you want on the whiteboard, which I think is really good. So it means that you're not constantly having to rub them off and rewrite them and things like that. And we just put little information notes, on it, make sure that we're communicating with each other as best as we can.

And then surgical safety checklists, this is another thing that we also do, which is really, really important, and they're a lot more common now. A lot more people know about them and a lot more people use them. So they're a really good patient safety checklist.

So you can tailor make them to your own practise. So we've got this is ours and we have a before induction, before first incision and then before leaving theatre checklist. So.

It makes sure you've got the right patient, you've got consent for the procedure, you know the site of the surgery, so you're not going to clip the wrong leg, because this is all done for induction. So everybody knows which leg it is. You're not going to get it wrong.

And it has happened before. We have clipped the wrong leg before since doing the surgical safety checklist, we haven't, it, it, it's eradicated completely. .

And then you can make sure the anaesthetic machine's been checked. Has the patient got an unknown allergy? Have you got any concerns?

Have you checked the medications? And then before first incision, so again it opens up communication. It's good for the anaesthetists and the surgeons to communicate, if they've got any concerns or anything like that or anything that needs to be done on recovery, anybody new into theatre can introduce themselves.

Nurses can confirm that the final prep's been done. We can also confirm that TST strips have been checked, so we know that this this instruments are definitely sterile. That's another important thing as well.

And we can discuss if antibiotics have been given and how often they want to be given. And do they need any imaging displayed as well. So there's loads of different checklists you can do and you can tailor make it to your own practise.

And then we do a sign out, so we do have you done a swab and equipment count? Have you labelled your specimen, sorry I can't, were there any equipment problems and also sharps have sharps been removed. So we added this because we're having so many issues with surgeons, leaving sharps on, which is obviously.

Big health and safety hazard for the staff who are cleaning the instruments. But we made it as part of the safety checklist that at the end, we could always check that the sharks have been removed before the kits removed from the theatre. And then it's got the date, it's got the procedure on, it's got the patient name and the owner on, and we keep that then as a record in the patient file so we can prove that all the necessary safety measures were taken with that patient.

And then our to do lists, so again, we have an 84 to do list and a 106 to do list. It's all stocking and cleaning, making sure things are put on charge, making sure we've got fresh solution for that day, make sure the autoclave's been put on a warm up. That sort of thing, just a checklist and then below you can see our cleaning checklists so you can see the date and the initials and all the different areas that should be cleaned.

So that's it. That is the end of my presentation, a one minute, one minute over. Thank you very much for listening.

Louise, that was fabulous you forgiven for. Yes, I, I think I did quite well. I thought .

I thought, I thought I'd go over even more. You did fantastically well. So we do have a couple of questions.

The first one comes from Hillary and says, we have very dirty dogs. For these, I do a pre-prep wash with Clawhex alcohol. Leave it on for one minute, wipe it off, and it seems to lift off the grease and dirt quite well without rubbing.

Is that OK? Yeah, that's, I mean, You just, is that you just do that and then you can do another after that or thinking about contact time? I think the the the the way I understood it, that was like a pre-scrub just to get the dirt off, you know, come in and they're black and you start prepping them for theatre out.

Yeah, yeah, that's a good idea, yeah, definitely. Another question, the 02 inflow devices that you were talking about, are they disposable? Or is it one per patient or do you reuse them?

Yeah, the disposable, it's one per patient. The HME I think it is, isn't it? Yeah.

Yeah, yeah, they're disposable, it's one per patient. Excellent. Just to folks to let you know that Louise has very kindly provided, a lot of documents for us and supporting documents and copies of all the stuff that you referred to.

So, those are all up on the website and the Q and A and everything else will be on the website tomorrow. And then of course, the recording of this will also be up on the website. So if you've missed something or if you want to go back and listen to something again, the recording is there and all the fabulous documents that Louise has provided for us.

Louise, thank you very much for your time and for coming on and sharing these, these tips with us. And it certainly looks like your team are having a great time there with the munchies, which is. Yeah, absolutely.

If you want to win a practise over, you just nurses and all the way. Folks, thank you for joining us tonight. Thank you once again to Louise for the presentation and the time.

And to Dawn, my controller in the background. Thank you very much for making everything happen seamlessly as always. From myself, Bruce Stevenson, it's goodnight until the next time.

Bye-bye.