What is the recommended protocol for arranging open surgical instruments in the operating theatre?

Protocol for Open Surgical Instruments Arrangements in Operating Theatre

The recommended protocol for arranging open surgical instruments in the operating theatre prioritizes minimizing equipment to only what is strictly necessary for each specific procedure, with instruments organized on dedicated pre-prepared trolleys rather than standard anesthetic carts, while maintaining strict decontamination protocols between cases. 1

Pre-Operative Instrument Setup

Equipment Minimization Strategy

• Position only strictly necessary equipment for each procedure in the operating room, replacing standard anesthetic trolleys with dedicated pre-prepared ones containing minimal but adequate stock 1, 2
• Prepare all required surgical materials before the procedure begins to minimize staff movement during the operation 3, 2
• Remove packaging only at the point of use to maintain infection control, ensure proper identification, enable traceability for manufacturer recalls, and enhance safety 4

Environmental Considerations

• Ensure all operating theatre doors remain closed at all times to maintain ventilation system efficiency and reduce airborne contamination 1
• Verify adequate air exchange systems are functioning properly, with high air exchange rates (≥25 cycles/hour when available) to reduce viral and bacterial load 1

Instrument Classification and Handling

Risk-Based Instrument Categories

The choice of equipment and level of decontamination required follows a three-tier risk assessment 4:

• High Risk devices (penetrate skin/mucous membranes, enter vascular system or sterile spaces): require sterilization 4
• Intermediate Risk devices (contact intact mucous membranes or may become contaminated with readily transmissible organisms): require high-level disinfection or sterilization 4
• Low Risk devices (contact intact skin or no direct patient contact): require low-level disinfection or cleaning 4

Single-Use vs. Reusable Equipment

• Prioritize single-use disposable equipment where appropriate to eliminate difficulties of re-use and decontamination procedures 4
• Balance between single-use items and re-usable equipment requires local determination based on patient safety assessment, available facilities, and cost 4
• Items like oral airways, nasal airways, and tracheal tubes must be single-use type since they readily become contaminated with transmissible organisms and blood 4

Sharps Management Protocol

Safe Handling Procedures

• Sharps must not be transferred between personnel and handling should be kept to a minimum 1
• Never recap, bend, or break needles prior to disposal 1
• Discard used sharps into an approved sharps container at the point of use 1
• Use dedicated containers for sharp disposable instruments placed immediately outside the OR 3
• Seal and dispose of sharps containers by incineration when two-thirds full or after four weeks of use, whichever comes first 1

Between-Case Decontamination Protocol

Cleaning and Disinfection Requirements

• Clean operating theatres appropriately between all patients, focusing on airborne transmission routes and surfaces that contacted the patient 1
• When visible contamination with blood or body materials exists, disinfect the area with sodium hypochlorite (according to local protocols) and then clean with detergent and water 1
• Clean and disinfect all surfaces and electromedical devices after each procedure 1, 3
• Disinfect floors of the operating room at the end of each session 1

Decontamination Process Steps

The effective decontamination of re-usable devices follows this sequence 4:

1. Cleaning: Remove all foreign material through washing with detergent, followed by rinsing and drying—all organic debris (blood, tissue, body fluids) must be removed before disinfection or sterilization 4
2. Disinfection/Sterilization: Apply appropriate level based on risk category 4

Critical Equipment Considerations

• Anaesthetic face masks, though normally contacting intact skin, are frequently contaminated by patient secretions and have been implicated in causing cross-infection; these should be single-use items or sterilized between patients by an audited Sterile Supplies Department 4

Case Scheduling Considerations

Contamination Risk Management

• Identify and schedule "dirty cases" (patients likely to disperse high-risk microbes) last on the operating list to minimize cross-contamination risk 1
• Allow a minimum of 15 minutes in plenum-ventilated theatres before proceeding to the next case when dirty cases cannot be scheduled last 1
• Develop accurate printed theatre lists available prior to the scheduled date with a written hospital policy 1

Critical Pitfalls to Avoid

Common Errors That Compromise Safety

• Failing to keep operating theatre doors closed disrupts ventilation efficiency and increases contamination risk 1
• Scheduling high-risk cases early in the day without adequate time for environmental decontamination increases transmission risk 1
• Allowing excessive staff movement during procedures increases airborne contamination 1
• Local disinfection of face masks is not normally effective—these require proper sterilization or single-use alternatives 4

Evidence-Based Transmission Prevention

The evidence strongly supports that transmission between successive patients occurs primarily through airborne routes and contaminated surfaces/items that contacted the patient, making thorough between-case cleaning with appropriate disinfectants essential 1

Regulatory Oversight

Equipment Inventory Management

• The regulatory committee must know the facility's capacity regarding stocks of PPE, drugs, blood products, and equipment needed to carry out interventions 4
• Ensure availability of needed equipment, consumables, and medical devices (including single-use or disposable surgical instruments) 4
• Conduct inventory by specialty and ward to assist in prioritization and scheduling 4