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Operating theatre etiquette, sterile technique and surgical site preparation
BASIC SKILLS
Operating theatre etiquette, sterile technique and surgical site preparation
performed. The use of surgical checklists is particularly useful and all theatre users should be familiar with the local protocols used. We will go on to describe the guidelines and latest evidence relating to sterile technique used in scrubbing, preparing the operation site and draping.
Theatre etiquette Preparing for a surgical list Every theatre session is a training opportunity, regardless of the seniority of the trainee. Trainees usually gain maximum benefit from a theatre session if they have looked at the cases on the list before attending. Meeting each patient, becoming involved in the consent process and looking up scans and test results prior to the list will all give a better understanding of the patient’s condition and the need for surgical management. It is also helpful to read about surgical techniques and procedures on a more practical level and to have an understanding of the anatomy that will be involved to further compound learning during each case.
Amanda Roebuck Ewen M Harrison
Abstract The operating theatre is an unusual environment and understanding the systems in place there is an important part of surgical training. ‘Non-technical skills’ is a term used to describe everything a surgeon does in the operating theatre, other than the technical aspects of the procedure itself. This includes communication, decision-making and leadership. Non-technical skills have become a vital aspect of the development of a surgeon and should form part of training programmes. A fundamental responsibility of the surgeon is the maintenance of sterility. The techniques of the surgical scrub and preparing and draping a patient only become second nature after good teaching and reflection by the surgeon. The purpose of this article is firstly to describe how a surgical trainee can get most out of an operating session. We will describe what non-technical surgical skills are and why they are important. We will focus on safety in the operating theatre and discuss worldwide strategies such as the ‘surgical safety checklist’ which aims to improve this. Finally we will present data on measures to reduce surgical site infection, such as which surgical scrub solution to use and whether drapes or wound protectors work.
Introducing the team Good communication in theatre is crucial. It is important that all members of the theatre team are introduced to each other prior to surgery commencing. When working in a new theatre department for the first time, always ensures that you are wearing correct surgical attire in line with hospital policy. Surgical ‘scrubs’, a theatre hat, and appropriate clean footwear that has not been worn outside are the essential minimum. Always wear an identification badge and on entering the department introduce yourself to the members of the team present that day. In particular, present yourself to the theatre sister, anaesthetist, and the operating surgeon if not a member of your usual team. Always ensure the theatre sister and scrub nurse know who you are e as well as being polite and respectful as a relatively new member in their environment, these colleagues can make life a lot easier when you start a new post, particularly for more junior trainees. They are likely to have worked with the consultant for a long time and will have a good knowledge of different surgeons’ preferences, suture and instrument choice.
Keywords Double gloving; facemask; handwash; non-operative skills; NOTSS; surgical brief; surgical safety checklist; surgical scrub; theatre etiquette; wound protector
Introduction The operating theatre can be an intimidating environment for the uninitiated. The purpose of this article is to describe the most appropriate behaviour for the operating theatre, particularly for those at the beginning of surgical training. As well as the technical aspects of surgery, modern training emphasizes so-called ‘non-technical skills’. These describe all aspects of operating theatre behaviour other than the technical aspects of the procedure itself. To maximize the educational value of time spent in the operating theatre, trainees should prepare themselves adequately. This will involve familiarization with the patients on the list, the staff in the theatre, and the procedures being
Surgical safety checklist As part of the World Health Organization (WHO) Safe Surgery Saves Lives initiative, in January 2007 the World Alliance for Patient Safety developed the WHO Safe Surgery Checklist.1 Most surgical departments have now implemented these checklists, and their aim is to identify and prevent the most common risks to patients having surgery. There are three main phases in which a checklist is used: before the induction of anaesthesia (‘sign in’), before the incision of the skin (‘time out’, also known as the ‘surgical pause’) and before the patient leaves the operating room (‘sign out’).1 Use of a checklist creates a culture which firmly focuses on safety. Checklist contents (Figure 1) can be adapted to local needs and WHO provides an implementation manual to guide users in the individual setting. The National Patient Safety Agency (NPSA) published a document in December 2010 entitled “Five steps to safer surgery”. This gives guidance on the implementation of the WHO
Amanda Roebuck MB ChB is a Clinical Research Fellow in Surgery at the Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of interest: none declared. Ewen M Harrison MB ChB PhD FRCS (Gen Surg) is a Senior Lecturer in General Surgery at the Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of interest: none declared.
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Figure 1
checklist and also describes a briefing and debriefing stage as a time to discuss important information regarding the safety of the patient.2 In 2009 there were 155,000 reports of patient safety incidents from surgical specialties in England and Wales.2 Over 1000 of these incidents caused severe harm or death. In 2009 the NPSA issued a safety alert to NHS organizations and in 2010 a requirement was introduced in England and Wales for all NHS trusts to implement an adapted WHO Safety checklist and to record and monitor the use of this tool. The NPSA guideline describes a 5-minute briefing ‘before the start of the list that will enable the core team to meet to discuss the requirements of that list, including safety concerns, equipment and staffing’.2 This may also include special instructions for patient positioning and antibiotic prophylaxis. It also describes a debriefing stage during which any concerns or incidents can be discussed with team members to promote improvement.
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Non-technical skills for surgeons (NOTSS) The NOTSS project was developed by a team of surgeons, psychologists and anaesthetists and acts as a framework for training and assessment of ‘non-technical skills’ in the operating theatre. It is necessary for surgeons to develop these non-technical or non-operative skills in conjunction with their clinical and surgical skills. Four areas are included in the assessment framework: situation awareness, decision-making, communication and teamwork, and leadership (Table 1). It incorporates ideas from similar systems used in professional training elsewhere in industry and has been developed to enable surgical trainers to implement it in the operating theatre with minimal difficulty. The skills taxonomy shown in Table 1 can be used to assess key competencies including professionalism, interpersonal and communication skills, and systems-based practice.3 In a prospective observational study published in 2011, the NOTSS system was used to assess surgical trainees’ non-technical
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The surgical scrub is performed to remove as many resident hand flora as possible.5 The agents used in this scrub are broad spectrum and cover a range of bacteria and fungi. Studies comparing the efficacy of different scrubbing techniques and antiseptic solutions are limited e most practice is based on evidence from in vitro studies or in vivo trials outwith the operating environment. The common surgical scrub agents contain chlorhexidine or povidoneeiodine and although other agents available, these have fallen out of favour due to toxicity and lower efficacy.5 Chlorhexidine and iodine are comparable when considering initial reduction in bacterial count, however rapid regrowth of bacteria occurs after povidoneeiodine use but not with chlorhexidine.5 The povidoneeiodine solutions induce more allergic reactions and despite a lower efficacy, the solution is still widely used in practice today. When performing an aqueous handwash, the warm water is an essential catalyst facilitating the action of the scrub soaps and solutions. However, very hot water removes protective fatty acids from the skin and should be avoided.5 Health Protection Scotland (HPS) suggest a steady flow of warm or tepid water be used.6 The length of the surgical scrub has been the subject of much scrutiny over the years and in the past a 10-minute scrub was recommended. Initial studies showed no difference between 5and 10-minute scrubs, with subsequent work showing that 2 or 3 minutes were adequate.5 Alcohol hand rub techniques are also effective and require 3 minutes.5 Figure 2 outlines the recommended technique for application of an alcohol hand rub.5 HPS suggests that manufacturer guidance be adhered to in this decision to ensure efficacy.6 A number of studies have failed to show the benefit of scrubbing brushes as part of the surgical handwash.5 It has been suggested that vigorous scrubbing with a brush can damage and shed skin cells and so the WHO guideline recommends cleaning nails with a file. If a nailbrush is to be used, it should be sterile and single use. Box 1 shows the WHO recommended steps to prepare for and the procedure for performing an aqueous surgical scrub. A Cochrane review initially published in 2008 was reviewed in 2015. It compared methods of surgical hand antisepsis on the rate of surgical site infections (SSIs) and the numbers of bacteria present after hand antisepsis.7 There were 14 studies included with four looking at SSI and ten reporting on colony-forming units (CFU) but not SSI. It concluded that: most studies used as an evidence-base to guide surgical antisepsis are regarded as poor in quality due to small numbers or poor data reporting and analyses there was no clear evidence that any one method of surgical antisepsis is superior alcohol rubs with additives were potentially more effective than aqueous scrubs to reduce CFUs there was some evidence for chlorhexidine to reduce colony-forming unit (CFU) number more effectively than povidoneeiodine There was limited evidence to suggest that the surgical scrub time of 3 minutes reduced CFU numbers more than a 2-minute scrub
Non-technical skills for surgeons (NOTSS) framework3 Category
Element
Situation awareness
C C C
Decision-making
C C
C
Leadership
C C C
Communication and teamwork
C C
C
Gathering information Understanding information Projecting and anticipating future state Considering options Selecting and communicating option Implementing and reviewing decisions Setting and maintaining standards Supporting others Coping with pressure Exchanging information Establishing a shared understanding Coordinating team
Table 1
skills.4 This study found that minimally trained assessors were sufficiently discriminating and consistent in their judgements of trainee surgeons’ non-technical skills to provide reliable scores based on an achievable number of observations.4 These assessors included scrub nurses, anaesthetists, and surgical care practitioners. Positioning the patient An important part of the surgical brief is the positioning of the patient and the responsible surgeon will clarify their preferences at this time. It is useful to assist the theatre staff in positioning the patient and to become familiar with the components of the surgical table and how they are assembled. When operating outwith working hours (evenings, overnight and weekends) operating theatre staff may be less experienced in certain procedures. It is often at these times that it is the responsibility of the surgical trainee to ensure proper patient positioning. Observing how this is done during the day will prove invaluable to avoid the difficulties that can be encountered operating on a patient not appropriately positioned.
Sterile technique The surgical scrub Before performing a surgical scrub ensure a gown and gloves are laid out. It is also polite to put out these items for other members of the surgical team. It is advisable to wear appropriate eye protection and a facemask to reduce the risk of exposure to contaminated fluids. The WHO document ‘Guidelines on Hand Hygiene in Healthcare’ provides extensive guidelines for hand hygiene to prevent healthcare associated infection. It describes the different antiseptic solutions used, the risk of allergies and skin reactions, and the surgical hand scrub procedure. It includes a discussion on religious and cultural considerations and provides solutions to practical barriers to implementation.
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Figure 2 Surgical hand preparation technique using an alcohol-based hand rub.5
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Figure 2 (Continued).
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and in high-risk procedures where double gloving is advocated it would be uncomfortable and potentially affect performance if accustomed to only one pair of gloves.
Key steps before starting surgical hand preparation and the recommended procedure for an aqueous surgical scrub with medicated soap5
Facemasks A Cochrane review first published in 2002 and reviewed in 2011 then 2016, looked at only three trials including a total of 2106 participants to assess the efficacy of surgical facemasks in prevention of surgical wound infections. With these limited data, there was no ‘statistically significant difference in infection rates between the masked and unmasked group in any of the trials’,9 but it was noted that this result was limited by low numbers included in the review. From a practical point of view, the facemask provides a physical barrier between the surgeon and the patient’s bodily fluids. As such many surgeons wear a facemask to prevent ingestion of such fluids in case of splash injury.
Key steps C Keep nails short and pay attention to them when washing your hands e most microbes on hands come from beneath the fingernails C Do not wear artificial nails or nail polish C Remove all jewellery (rings, watches, bracelets) before entering the operating theatre C Wash hands and arms with a non-medicated soap before entering the operating theatre area or if hands are visibly soiled C Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of cells. If used, nailbrushes must be sterile, once only (single use) Reusable autoclavable nail brushes are on the market
Approaching the table After gloving and gowning it is important not to contaminate the sterile field created. Gloved hands should be held in front of the body above waist height and not underneath arms or behind the back. Care should be taken to move around the theatre environment with your back to non-sterile surfaces and people, especially if in close proximity or limited spaces. Ask for help if a piece of equipment could be moved to make your route to the operating table easier to avoid contaminating yourself. When you approach the table, it is obviously safe to touch sterile drapes and the sterile operating field. Take care to ensure that light handles and cables are sterile if uncertain before touching them, and never be afraid to ask for new gloves or to completely re-scrub if you feel you have been contaminated. It would be much more embarrassing to be linked to a surgical wound infection. When passing cables and equipment to un-scrubbed theatre staff take care and time to keep essential parts sterile. This may require communication with team members when unfamiliar equipment is being used, or inexperienced staff are handling equipment.
Procedural steps C Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes C Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands C Wash each side of the arm from wrist to the elbow for 1 minute C Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated C Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water C Proceed to the operating theatre holding hands above elbows C At all times during the scrub procedure, care should be taken not to splash water onto surgical attire C Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and gloves Box 1
Surgical site preparation
Double gloving Wearing a protective outer glove in theory reduces the risk of tears to the inner glove and thus protects the patient from surgical site contamination and the wearer from exposure to body fluids. In specialties where sharp structures are encountered, such as in orthopaedics and dentistry, this practice is already widely adopted. A Cochrane review updated in 2009 showed that an outer glove had a protective effect, reducing the number of tears to the inner glove in comparison to a single glove.8 It also looked at the use of coloured indicator gloves, which made perforations in the outer glove more apparent, use of a cloth outer glove which reduced perforations to the inner glove. There was no evidence that an additional glove protected the patient from SSI. From a more practical point of view, as a trainee, it is good practice to become accustomed to the practice of double gloving. The tactile feedback when wearing two pairs of gloves is reduced
Preparing the skin Before applying drapes to surround the surgical field, the skin must be prepared with a sterile solution to minimize risk of contamination of the surgical field with the patient’s skin commensal organisms. As with the surgical scrub, the main agents used to sterilize the skin are chlorhexidine and povidone eiodine containing solutions. A Cochrane review of preoperative skin antiseptics updated in 2015 found that use of chlorhexidine in alcohol led to a reduced rate of SSI in comparison to a povidoneeiodine in alcohol solution,10 However, this study did not report important details such as strength of iodine solution and as such bias may have influenced the result. There are a few practical considerations depending on which solution is chosen and this usually depends on the responsible consultant or departmental preference. Chlorhexidine is usually prepared with alcohol and is therefore highly inflammable. Care should be taken not to allow pools of the liquid to form. Skin should be dried with sterile swab, paying particular attention to
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Examples of surgical drape techniques Incise panels of clear plastic along inner legs
Abdomen Leg drapes
1. Draping of abdomen – drapes applied to make a ‘square’ to allow variety of approaches for abdominal access incisions
Panel over middle chest
Perianal area
2. Lithotomy position for perianal procedures – use of leg drapes
3. Cardiothoracic surgery – incise panels on chest and inner legs to allow sternotomy and harvesting of long saphenous veins during coronary artery bypass grafting
Figure 3
cover the patient and secured carefully without contaminating the sterile drape surface or the sterile field. There are different types of drapes and set-ups depending on the type of procedure. For example, abdominal and breast surgery use square-draping technique, where four drapes are applied overlapping in a square to expose the surgical field centrally. In perianal surgery, the patient will likely be placed in the lithotomy position where the legs are held elevated in stirrups. This requires draping of the legs to prevent contamination of the operator sitting between the legs. In coronary artery bypass grafting, access is often needed to the legs to obtain long saphenous vein. Pre-formed drapes are available with incise panels over the chest and legs which cover the whole patient. The trainee should ensure they are able to prepare the patient depending on the responsible surgeon’s preference or department policy. The theatre nursing staff are a very useful resource when learning these techniques.
umbilicus, as diathermy can cause sparks which may ignite. Povidoneeiodine solutions (such as Betadine) are sticky and can cause skin irritation and allergic reaction. More recently incise drapes such as OpSite (Smith and Nephew, UK) Ioban (3M Company, USA), and Steridrape (3M, UK) have been used with the aim of immobilizing bacteria on the skin to prevent migration into a surgical wound. The Cochrane Wounds group updated a review in January 2013 looking at use of plastic adhesive drapes in the prevention of SSI. They found no benefit in reduction of SSI and perhaps some evidence that infection may be increased.11 When preparing the skin prior to surgery, the scrub nurse will usually have the solution and swabs/forceps ready to begin preparing the skin. The solution should be applied to the skin in a methodical manner, to cover the whole surgical field and an area outwith the likely border of the drapes. This will ensure that unprepared skin is not exposed during surgery in the event that a surgical drape is disturbed. Consideration should also be given to possible complications of surgery requiring extension of wounds or conversion from laparoscopic to open if necessary and preparing the skin in advance may be useful. The solution is applied to skin at least twice, using a fresh sterile swab each time. A dry swab is used to prevent pooling of liquid, particularly when using alcohol based solutions, and to dry the area for drapes to stick.
Wound protection Wound protection devices are inserted into an open abdominal wound to provide a barrier between the skin edge and the open operative field. Designs vary but are based on a semi-rigid plastic ring placed into the abdomen through the laparotomy wound to which an impervious drape is circumferentially attached. The aim is to prevent damage to this skin edge during the procedure and to minimize contamination of the wound, particularly in surgery involving bowel where faecal contamination is likely. However, the ROSSINI trial published in the BMJ found that these devices do not in fact reduce the rate of SSI in patients undergoing laparotomy.12
Surgical drapes (Figure 3) Surgical drapes should surround the surgical field without exposing unprepared and hence unsterile skin. After the antiseptic solution has been applied and the skin appropriately dried, the drapes are applied usually by the scrub nurse and either operating surgeon or their assistant. Drapes can be made of cloth requiring towel clips to secure them in place, or disposable paper with adhesive to adhere to skin. The drapes of choice are passed over the patient to allow two practitioners to spread the drape to
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Conclusions The operating theatre environment is unlike any other. It is important to become proficient in non-operative surgical skills in addition to the practical skills required to perform an operative
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procedure. This concept should now be firmly embedded in surgical training and assessment. The guidelines for sterile preparation preoperatively suggests a surgical scrub with alcohol based chlorhexidine in preference to povidoneeiodine solutions for a duration of 2e3 minutes.5 Alcohol rub agents should be used for 3 minutes.5 There is no real evidence to support the use of facemasks in prevention of SSI.8 Double gloving is beneficial to prevent tears of the inner glove when compared with single latex gloves only.8 For preparation of the skin at the surgical site, alcohol-based chlorhexidine is also advocated although povidone eiodine is still used.10 Incise drapes developed to immobilize resident bacteria to prevent migration to wounds are unlikely to reduce SSI and may in fact contribute to infection.11 Wound protectors are also used to cover the edge of laparotomy wounds, but evidence suggests that these do not reduce the rate of SSI.12 By continuing to review current evidence with regard to SSI, sterile technique and surgical site preparation, the surgical trainee can adapt and develop practice. The integration of nontechnical skills into training programmes will also ensure that the surgeons of the future have appropriate behaviours required of the modern theatre environment. A
4
5
6
7
8
9
10 REFERENCES 1 WHO. WHO surgical safety checklist and implementation manual [Internet]. WHO. [cited 2016 July 29]. Available from: http://www. who.int/patientsafety/safesurgery/ss_checklist/en/. 2 NPSA. Patient safety resources [Internet]. [cited 2016 July 29]. Available from: http://www.nrls.npsa.nhs.uk/resources/? EntryId45¼92901. 3 The Royal College of Surgeons of Edinburgh and the School of Psychology Aberdeen University. Non-technical skills for
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12
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surgeons (NOTSS) [Internet]. Available from: http://www.rcsed.ac. uk/education/patient-safety-and-notss/notss.aspx. Crossley J, Marriott J, Purdie H, Beard JD. Prospective observational study to evaluate NOTSS (Non-Technical Skills for Surgeons) for assessing trainees’ non-technical performance in the operating theatre. Br J Surg 2011; 98: 1010e20. WHO. WHO guidelines on hand hygiene in health care [Internet]. WHO. [cited 2016 July 31]. Available from: http://www.who.int/ gpsc/5may/tools/9789241597906/en/. Health Protection Scotland. SICP literature review: hand hygiene: surgical hand antisepsis in the clinical setting. Version 2.1, November 2015. Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev 2016. Issue 1. Art. No.:CD004288. Tanner J, Parkinson H. Double gloving to reduce surgical crossinfection. Cochrane Database Syst Rev 2006. Issue 3. Art. No.: CD003087. Vincent M, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev 2016. Issue 4. Art. No.:CD002929. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Lui Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2015. Issue 4. Art. No.:CD003949. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 2013. Issue 5. Art. No.:CD006353. Pinkney TD, Calvert M, Bartlett DC, et al. Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). Br Med J 2013; 347.: f4305.
Ó 2017 Published by Elsevier Ltd.
Operating theatre etiquette, sterile technique and surgical site preparation
performed. The use of surgical checklists is particularly useful and all theatre users should be familiar with the local protocols used. We will go on to describe the guidelines and latest evidence relating to sterile technique used in scrubbing, preparing the operation site and draping.
Theatre etiquette Preparing for a surgical list Every theatre session is a training opportunity, regardless of the seniority of the trainee. Trainees usually gain maximum benefit from a theatre session if they have looked at the cases on the list before attending. Meeting each patient, becoming involved in the consent process and looking up scans and test results prior to the list will all give a better understanding of the patient’s condition and the need for surgical management. It is also helpful to read about surgical techniques and procedures on a more practical level and to have an understanding of the anatomy that will be involved to further compound learning during each case.
Amanda Roebuck Ewen M Harrison
Abstract The operating theatre is an unusual environment and understanding the systems in place there is an important part of surgical training. ‘Non-technical skills’ is a term used to describe everything a surgeon does in the operating theatre, other than the technical aspects of the procedure itself. This includes communication, decision-making and leadership. Non-technical skills have become a vital aspect of the development of a surgeon and should form part of training programmes. A fundamental responsibility of the surgeon is the maintenance of sterility. The techniques of the surgical scrub and preparing and draping a patient only become second nature after good teaching and reflection by the surgeon. The purpose of this article is firstly to describe how a surgical trainee can get most out of an operating session. We will describe what non-technical surgical skills are and why they are important. We will focus on safety in the operating theatre and discuss worldwide strategies such as the ‘surgical safety checklist’ which aims to improve this. Finally we will present data on measures to reduce surgical site infection, such as which surgical scrub solution to use and whether drapes or wound protectors work.
Introducing the team Good communication in theatre is crucial. It is important that all members of the theatre team are introduced to each other prior to surgery commencing. When working in a new theatre department for the first time, always ensures that you are wearing correct surgical attire in line with hospital policy. Surgical ‘scrubs’, a theatre hat, and appropriate clean footwear that has not been worn outside are the essential minimum. Always wear an identification badge and on entering the department introduce yourself to the members of the team present that day. In particular, present yourself to the theatre sister, anaesthetist, and the operating surgeon if not a member of your usual team. Always ensure the theatre sister and scrub nurse know who you are e as well as being polite and respectful as a relatively new member in their environment, these colleagues can make life a lot easier when you start a new post, particularly for more junior trainees. They are likely to have worked with the consultant for a long time and will have a good knowledge of different surgeons’ preferences, suture and instrument choice.
Keywords Double gloving; facemask; handwash; non-operative skills; NOTSS; surgical brief; surgical safety checklist; surgical scrub; theatre etiquette; wound protector
Introduction The operating theatre can be an intimidating environment for the uninitiated. The purpose of this article is to describe the most appropriate behaviour for the operating theatre, particularly for those at the beginning of surgical training. As well as the technical aspects of surgery, modern training emphasizes so-called ‘non-technical skills’. These describe all aspects of operating theatre behaviour other than the technical aspects of the procedure itself. To maximize the educational value of time spent in the operating theatre, trainees should prepare themselves adequately. This will involve familiarization with the patients on the list, the staff in the theatre, and the procedures being
Surgical safety checklist As part of the World Health Organization (WHO) Safe Surgery Saves Lives initiative, in January 2007 the World Alliance for Patient Safety developed the WHO Safe Surgery Checklist.1 Most surgical departments have now implemented these checklists, and their aim is to identify and prevent the most common risks to patients having surgery. There are three main phases in which a checklist is used: before the induction of anaesthesia (‘sign in’), before the incision of the skin (‘time out’, also known as the ‘surgical pause’) and before the patient leaves the operating room (‘sign out’).1 Use of a checklist creates a culture which firmly focuses on safety. Checklist contents (Figure 1) can be adapted to local needs and WHO provides an implementation manual to guide users in the individual setting. The National Patient Safety Agency (NPSA) published a document in December 2010 entitled “Five steps to safer surgery”. This gives guidance on the implementation of the WHO
Amanda Roebuck MB ChB is a Clinical Research Fellow in Surgery at the Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of interest: none declared. Ewen M Harrison MB ChB PhD FRCS (Gen Surg) is a Senior Lecturer in General Surgery at the Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of interest: none declared.
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Figure 1
checklist and also describes a briefing and debriefing stage as a time to discuss important information regarding the safety of the patient.2 In 2009 there were 155,000 reports of patient safety incidents from surgical specialties in England and Wales.2 Over 1000 of these incidents caused severe harm or death. In 2009 the NPSA issued a safety alert to NHS organizations and in 2010 a requirement was introduced in England and Wales for all NHS trusts to implement an adapted WHO Safety checklist and to record and monitor the use of this tool. The NPSA guideline describes a 5-minute briefing ‘before the start of the list that will enable the core team to meet to discuss the requirements of that list, including safety concerns, equipment and staffing’.2 This may also include special instructions for patient positioning and antibiotic prophylaxis. It also describes a debriefing stage during which any concerns or incidents can be discussed with team members to promote improvement.
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Non-technical skills for surgeons (NOTSS) The NOTSS project was developed by a team of surgeons, psychologists and anaesthetists and acts as a framework for training and assessment of ‘non-technical skills’ in the operating theatre. It is necessary for surgeons to develop these non-technical or non-operative skills in conjunction with their clinical and surgical skills. Four areas are included in the assessment framework: situation awareness, decision-making, communication and teamwork, and leadership (Table 1). It incorporates ideas from similar systems used in professional training elsewhere in industry and has been developed to enable surgical trainers to implement it in the operating theatre with minimal difficulty. The skills taxonomy shown in Table 1 can be used to assess key competencies including professionalism, interpersonal and communication skills, and systems-based practice.3 In a prospective observational study published in 2011, the NOTSS system was used to assess surgical trainees’ non-technical
178
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The surgical scrub is performed to remove as many resident hand flora as possible.5 The agents used in this scrub are broad spectrum and cover a range of bacteria and fungi. Studies comparing the efficacy of different scrubbing techniques and antiseptic solutions are limited e most practice is based on evidence from in vitro studies or in vivo trials outwith the operating environment. The common surgical scrub agents contain chlorhexidine or povidoneeiodine and although other agents available, these have fallen out of favour due to toxicity and lower efficacy.5 Chlorhexidine and iodine are comparable when considering initial reduction in bacterial count, however rapid regrowth of bacteria occurs after povidoneeiodine use but not with chlorhexidine.5 The povidoneeiodine solutions induce more allergic reactions and despite a lower efficacy, the solution is still widely used in practice today. When performing an aqueous handwash, the warm water is an essential catalyst facilitating the action of the scrub soaps and solutions. However, very hot water removes protective fatty acids from the skin and should be avoided.5 Health Protection Scotland (HPS) suggest a steady flow of warm or tepid water be used.6 The length of the surgical scrub has been the subject of much scrutiny over the years and in the past a 10-minute scrub was recommended. Initial studies showed no difference between 5and 10-minute scrubs, with subsequent work showing that 2 or 3 minutes were adequate.5 Alcohol hand rub techniques are also effective and require 3 minutes.5 Figure 2 outlines the recommended technique for application of an alcohol hand rub.5 HPS suggests that manufacturer guidance be adhered to in this decision to ensure efficacy.6 A number of studies have failed to show the benefit of scrubbing brushes as part of the surgical handwash.5 It has been suggested that vigorous scrubbing with a brush can damage and shed skin cells and so the WHO guideline recommends cleaning nails with a file. If a nailbrush is to be used, it should be sterile and single use. Box 1 shows the WHO recommended steps to prepare for and the procedure for performing an aqueous surgical scrub. A Cochrane review initially published in 2008 was reviewed in 2015. It compared methods of surgical hand antisepsis on the rate of surgical site infections (SSIs) and the numbers of bacteria present after hand antisepsis.7 There were 14 studies included with four looking at SSI and ten reporting on colony-forming units (CFU) but not SSI. It concluded that: most studies used as an evidence-base to guide surgical antisepsis are regarded as poor in quality due to small numbers or poor data reporting and analyses there was no clear evidence that any one method of surgical antisepsis is superior alcohol rubs with additives were potentially more effective than aqueous scrubs to reduce CFUs there was some evidence for chlorhexidine to reduce colony-forming unit (CFU) number more effectively than povidoneeiodine There was limited evidence to suggest that the surgical scrub time of 3 minutes reduced CFU numbers more than a 2-minute scrub
Non-technical skills for surgeons (NOTSS) framework3 Category
Element
Situation awareness
C C C
Decision-making
C C
C
Leadership
C C C
Communication and teamwork
C C
C
Gathering information Understanding information Projecting and anticipating future state Considering options Selecting and communicating option Implementing and reviewing decisions Setting and maintaining standards Supporting others Coping with pressure Exchanging information Establishing a shared understanding Coordinating team
Table 1
skills.4 This study found that minimally trained assessors were sufficiently discriminating and consistent in their judgements of trainee surgeons’ non-technical skills to provide reliable scores based on an achievable number of observations.4 These assessors included scrub nurses, anaesthetists, and surgical care practitioners. Positioning the patient An important part of the surgical brief is the positioning of the patient and the responsible surgeon will clarify their preferences at this time. It is useful to assist the theatre staff in positioning the patient and to become familiar with the components of the surgical table and how they are assembled. When operating outwith working hours (evenings, overnight and weekends) operating theatre staff may be less experienced in certain procedures. It is often at these times that it is the responsibility of the surgical trainee to ensure proper patient positioning. Observing how this is done during the day will prove invaluable to avoid the difficulties that can be encountered operating on a patient not appropriately positioned.
Sterile technique The surgical scrub Before performing a surgical scrub ensure a gown and gloves are laid out. It is also polite to put out these items for other members of the surgical team. It is advisable to wear appropriate eye protection and a facemask to reduce the risk of exposure to contaminated fluids. The WHO document ‘Guidelines on Hand Hygiene in Healthcare’ provides extensive guidelines for hand hygiene to prevent healthcare associated infection. It describes the different antiseptic solutions used, the risk of allergies and skin reactions, and the surgical hand scrub procedure. It includes a discussion on religious and cultural considerations and provides solutions to practical barriers to implementation.
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Figure 2 Surgical hand preparation technique using an alcohol-based hand rub.5
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Figure 2 (Continued).
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and in high-risk procedures where double gloving is advocated it would be uncomfortable and potentially affect performance if accustomed to only one pair of gloves.
Key steps before starting surgical hand preparation and the recommended procedure for an aqueous surgical scrub with medicated soap5
Facemasks A Cochrane review first published in 2002 and reviewed in 2011 then 2016, looked at only three trials including a total of 2106 participants to assess the efficacy of surgical facemasks in prevention of surgical wound infections. With these limited data, there was no ‘statistically significant difference in infection rates between the masked and unmasked group in any of the trials’,9 but it was noted that this result was limited by low numbers included in the review. From a practical point of view, the facemask provides a physical barrier between the surgeon and the patient’s bodily fluids. As such many surgeons wear a facemask to prevent ingestion of such fluids in case of splash injury.
Key steps C Keep nails short and pay attention to them when washing your hands e most microbes on hands come from beneath the fingernails C Do not wear artificial nails or nail polish C Remove all jewellery (rings, watches, bracelets) before entering the operating theatre C Wash hands and arms with a non-medicated soap before entering the operating theatre area or if hands are visibly soiled C Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of cells. If used, nailbrushes must be sterile, once only (single use) Reusable autoclavable nail brushes are on the market
Approaching the table After gloving and gowning it is important not to contaminate the sterile field created. Gloved hands should be held in front of the body above waist height and not underneath arms or behind the back. Care should be taken to move around the theatre environment with your back to non-sterile surfaces and people, especially if in close proximity or limited spaces. Ask for help if a piece of equipment could be moved to make your route to the operating table easier to avoid contaminating yourself. When you approach the table, it is obviously safe to touch sterile drapes and the sterile operating field. Take care to ensure that light handles and cables are sterile if uncertain before touching them, and never be afraid to ask for new gloves or to completely re-scrub if you feel you have been contaminated. It would be much more embarrassing to be linked to a surgical wound infection. When passing cables and equipment to un-scrubbed theatre staff take care and time to keep essential parts sterile. This may require communication with team members when unfamiliar equipment is being used, or inexperienced staff are handling equipment.
Procedural steps C Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes C Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands C Wash each side of the arm from wrist to the elbow for 1 minute C Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated C Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water C Proceed to the operating theatre holding hands above elbows C At all times during the scrub procedure, care should be taken not to splash water onto surgical attire C Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and gloves Box 1
Surgical site preparation
Double gloving Wearing a protective outer glove in theory reduces the risk of tears to the inner glove and thus protects the patient from surgical site contamination and the wearer from exposure to body fluids. In specialties where sharp structures are encountered, such as in orthopaedics and dentistry, this practice is already widely adopted. A Cochrane review updated in 2009 showed that an outer glove had a protective effect, reducing the number of tears to the inner glove in comparison to a single glove.8 It also looked at the use of coloured indicator gloves, which made perforations in the outer glove more apparent, use of a cloth outer glove which reduced perforations to the inner glove. There was no evidence that an additional glove protected the patient from SSI. From a more practical point of view, as a trainee, it is good practice to become accustomed to the practice of double gloving. The tactile feedback when wearing two pairs of gloves is reduced
Preparing the skin Before applying drapes to surround the surgical field, the skin must be prepared with a sterile solution to minimize risk of contamination of the surgical field with the patient’s skin commensal organisms. As with the surgical scrub, the main agents used to sterilize the skin are chlorhexidine and povidone eiodine containing solutions. A Cochrane review of preoperative skin antiseptics updated in 2015 found that use of chlorhexidine in alcohol led to a reduced rate of SSI in comparison to a povidoneeiodine in alcohol solution,10 However, this study did not report important details such as strength of iodine solution and as such bias may have influenced the result. There are a few practical considerations depending on which solution is chosen and this usually depends on the responsible consultant or departmental preference. Chlorhexidine is usually prepared with alcohol and is therefore highly inflammable. Care should be taken not to allow pools of the liquid to form. Skin should be dried with sterile swab, paying particular attention to
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Examples of surgical drape techniques Incise panels of clear plastic along inner legs
Abdomen Leg drapes
1. Draping of abdomen – drapes applied to make a ‘square’ to allow variety of approaches for abdominal access incisions
Panel over middle chest
Perianal area
2. Lithotomy position for perianal procedures – use of leg drapes
3. Cardiothoracic surgery – incise panels on chest and inner legs to allow sternotomy and harvesting of long saphenous veins during coronary artery bypass grafting
Figure 3
cover the patient and secured carefully without contaminating the sterile drape surface or the sterile field. There are different types of drapes and set-ups depending on the type of procedure. For example, abdominal and breast surgery use square-draping technique, where four drapes are applied overlapping in a square to expose the surgical field centrally. In perianal surgery, the patient will likely be placed in the lithotomy position where the legs are held elevated in stirrups. This requires draping of the legs to prevent contamination of the operator sitting between the legs. In coronary artery bypass grafting, access is often needed to the legs to obtain long saphenous vein. Pre-formed drapes are available with incise panels over the chest and legs which cover the whole patient. The trainee should ensure they are able to prepare the patient depending on the responsible surgeon’s preference or department policy. The theatre nursing staff are a very useful resource when learning these techniques.
umbilicus, as diathermy can cause sparks which may ignite. Povidoneeiodine solutions (such as Betadine) are sticky and can cause skin irritation and allergic reaction. More recently incise drapes such as OpSite (Smith and Nephew, UK) Ioban (3M Company, USA), and Steridrape (3M, UK) have been used with the aim of immobilizing bacteria on the skin to prevent migration into a surgical wound. The Cochrane Wounds group updated a review in January 2013 looking at use of plastic adhesive drapes in the prevention of SSI. They found no benefit in reduction of SSI and perhaps some evidence that infection may be increased.11 When preparing the skin prior to surgery, the scrub nurse will usually have the solution and swabs/forceps ready to begin preparing the skin. The solution should be applied to the skin in a methodical manner, to cover the whole surgical field and an area outwith the likely border of the drapes. This will ensure that unprepared skin is not exposed during surgery in the event that a surgical drape is disturbed. Consideration should also be given to possible complications of surgery requiring extension of wounds or conversion from laparoscopic to open if necessary and preparing the skin in advance may be useful. The solution is applied to skin at least twice, using a fresh sterile swab each time. A dry swab is used to prevent pooling of liquid, particularly when using alcohol based solutions, and to dry the area for drapes to stick.
Wound protection Wound protection devices are inserted into an open abdominal wound to provide a barrier between the skin edge and the open operative field. Designs vary but are based on a semi-rigid plastic ring placed into the abdomen through the laparotomy wound to which an impervious drape is circumferentially attached. The aim is to prevent damage to this skin edge during the procedure and to minimize contamination of the wound, particularly in surgery involving bowel where faecal contamination is likely. However, the ROSSINI trial published in the BMJ found that these devices do not in fact reduce the rate of SSI in patients undergoing laparotomy.12
Surgical drapes (Figure 3) Surgical drapes should surround the surgical field without exposing unprepared and hence unsterile skin. After the antiseptic solution has been applied and the skin appropriately dried, the drapes are applied usually by the scrub nurse and either operating surgeon or their assistant. Drapes can be made of cloth requiring towel clips to secure them in place, or disposable paper with adhesive to adhere to skin. The drapes of choice are passed over the patient to allow two practitioners to spread the drape to
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Conclusions The operating theatre environment is unlike any other. It is important to become proficient in non-operative surgical skills in addition to the practical skills required to perform an operative
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procedure. This concept should now be firmly embedded in surgical training and assessment. The guidelines for sterile preparation preoperatively suggests a surgical scrub with alcohol based chlorhexidine in preference to povidoneeiodine solutions for a duration of 2e3 minutes.5 Alcohol rub agents should be used for 3 minutes.5 There is no real evidence to support the use of facemasks in prevention of SSI.8 Double gloving is beneficial to prevent tears of the inner glove when compared with single latex gloves only.8 For preparation of the skin at the surgical site, alcohol-based chlorhexidine is also advocated although povidone eiodine is still used.10 Incise drapes developed to immobilize resident bacteria to prevent migration to wounds are unlikely to reduce SSI and may in fact contribute to infection.11 Wound protectors are also used to cover the edge of laparotomy wounds, but evidence suggests that these do not reduce the rate of SSI.12 By continuing to review current evidence with regard to SSI, sterile technique and surgical site preparation, the surgical trainee can adapt and develop practice. The integration of nontechnical skills into training programmes will also ensure that the surgeons of the future have appropriate behaviours required of the modern theatre environment. A
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10 REFERENCES 1 WHO. WHO surgical safety checklist and implementation manual [Internet]. WHO. [cited 2016 July 29]. Available from: http://www. who.int/patientsafety/safesurgery/ss_checklist/en/. 2 NPSA. Patient safety resources [Internet]. [cited 2016 July 29]. Available from: http://www.nrls.npsa.nhs.uk/resources/? EntryId45¼92901. 3 The Royal College of Surgeons of Edinburgh and the School of Psychology Aberdeen University. Non-technical skills for
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surgeons (NOTSS) [Internet]. Available from: http://www.rcsed.ac. uk/education/patient-safety-and-notss/notss.aspx. Crossley J, Marriott J, Purdie H, Beard JD. Prospective observational study to evaluate NOTSS (Non-Technical Skills for Surgeons) for assessing trainees’ non-technical performance in the operating theatre. Br J Surg 2011; 98: 1010e20. WHO. WHO guidelines on hand hygiene in health care [Internet]. WHO. [cited 2016 July 31]. Available from: http://www.who.int/ gpsc/5may/tools/9789241597906/en/. Health Protection Scotland. SICP literature review: hand hygiene: surgical hand antisepsis in the clinical setting. Version 2.1, November 2015. Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev 2016. Issue 1. Art. No.:CD004288. Tanner J, Parkinson H. Double gloving to reduce surgical crossinfection. Cochrane Database Syst Rev 2006. Issue 3. Art. No.: CD003087. Vincent M, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev 2016. Issue 4. Art. No.:CD002929. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Lui Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2015. Issue 4. Art. No.:CD003949. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 2013. Issue 5. Art. No.:CD006353. Pinkney TD, Calvert M, Bartlett DC, et al. Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). Br Med J 2013; 347.: f4305.
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