1.1.2. General recommendations
- Medical and nursing staff should wear short, clean, nail polish-free nails. Do not use artificial nails.(2,4,6,20)
NE: Category IIA
- Do not use cosmetic soaps in the hospital area.(10,11,16) NE: Category IIA
- Drying hands performs two main functions: removing excess water and dead or inhibited microorganisms. The cloth towel acts as an inanimate object that carries microorganisms, which is why when it is reused, some of them adhere to the skin of those next to dry, losing the microbicidal action of the soap.(10)
NE: Category IIA
- Before washing your hands, all jewelry should be removed from your hands. Jewelry should not be worn during the work day.(2,4,6,20)
NE: Category IIB
- The first wash of the day should include washing your nails. NE: Category IIB
- Do not use brushes while washing hands.(2,8,20) NE: Category IIIB
- Completely empty soap dispensers when adding new soap.
- People with wounds, burns or open lesions on their hands or arms cannot rub, because this increases the bacterial count, therefore they should refrain from participating in surgical procedures.(2,8,10)
1.1.3. Hand washing technique
Hand washing with ordinary soap is effective for the mechanical removal of transient microorganisms, when it is carried out with antimicrobial agents it destroys or inhibits microbial growth (chemical removal). It is known that the main factor that influences the effectiveness of surgical scrub other than the antiseptic agent is the scrub technique.(2,11,14,21)
1.1.3.1 Hand washing (4,15,17,19)
• Wet your hands, add the indicated solution. NE: Category IA
• Perform vigorous rubbing of the surfaces and sides of the hands for at least 10 seconds straight. NE: Category IA
• Rinse under a source of water.(2-8,10,13-15,19,20) NE: Category IA
• Dry hands with paper towels. NE: Category IIA
1.1.3.2. Surgical hand washing
• Wash your hands for five minutes at the beginning of the day.(6,15,20) NE: Category IIA
• Wash your hands for two minutes between each surgery.(2,16,20) NE: Category IIA
• Do not touch non-sterile objects once you have washed your hands; if this happens, the entire procedure must be repeated.
• Avoid getting the surgical gown wet.
Initial wash: (15,20) NE: Category IIA
• Open the water tap adjusting the quantity and temperature
• Wet hands, arms and elbows; Soap them well with antiseptic solution (Annex 1) and rinse them.
NE: Category IIA
• Then wash the nails, keeping the tips of the fingers (including the thumb) together and uniform. Rinse.
• Continue washing starting with the thumb, 10 times with each of the fingers on all four sides.
• Additionally, rub the skin folds of the knuckles and elbows to allow the soap to penetrate them.
• Add small amounts of water during washing.
• Rub the forearm 10 times in a circular manner taking into account the four planes (anterior, posterior and lateral) starting from the distal part towards the proximal part. The wash should ideally extend about six centimeters above the elbow.
• Keep the arms removed from the body and up, allowing the water to drain towards the elbows.(20,15,17,19)
NE: Category IIA
• Hands and arms after surgical scrubbing should be dried with a sterile compress before putting on the surgical gown and gloves. You should take the compress by one of its corners and dry it in the following order: hand, forearm and elbow, then with your dry hand take the compress by the lower dry end and repeat the procedure on the other hand. NE: Category IIA
1.1.3.3. Hygienic hand friction
Procedure that is performed between patient and patient in order to remove temporary flora from the hands using antiseptic solutions with isopropyl alcohol with concentrations between 70 and 90%.(17-19, 22-25) NE: Category IIA.
The solution with emollients (glycerin for example) is used by rubbing the palms and interdigital areas for 10 to 15 seconds.
This procedure should not be performed if:
• Hand washing has not been carried out at the beginning of the shift
• You have come into direct contact with body fluids. In this case, clinical hand washing must be performed before performing any other procedure.(17-19) NE: Category IIA
1.2. Surgical clothing
Appropriate surgical clothing is one that represents an effective barrier between the skin, hair, oropharynx, feet and the surgical environment.
To reduce the possibility of contamination of surgical clothing, it is important to dress in the following order:
-Cap:
It should be placed before the surgical gown, the hair must be completely covered to prevent particles from falling into the surgical gown. It should be changed if it accidentally gets dirty.(2,6)
-Surgical dress or “May dress”:
It must have the following characteristics: (20) thin, narrow, fresh, clean tissue and represent an effective barrier.
Policies for the management of surgical gowns vary between hospitals, as well as their use outside the wards. The surgical gown must be used solely and exclusively within the institution.
It should not be used to go out to commercial areas, to the house or to the street.(6,13,20,23) To circulate within the institution with the surgical gown, use a white coat over it, except in cases in which the intervention practiced is considered infected or it has been stained.(13,16,26-27)
To re-enter the surgery rooms, the same surgical gown can be used, except in the following situations:
• Having cared for infected patients or having performed cures
• The surgical gown is dirty or stained.
-Scrubs:
Sterile blouses must have waterproof material in the front region and on the sleeves. The front of the gown, from the waist up to shoulder level and from the sleeves to the elbows, is considered a sterile area.(20) Many gowns have a polyester cuff that is not fluid resistant, so Therefore, it is necessary that it be completely covered by the glove. This gown should be used only and exclusively in the surgical area.
-Leggings:
Wearing gaiters has not been shown to decrease bacteria counts in the operating room. Ideally, they should be made of waterproof material and completely cover the shoes.(16,27) The gaiters should be placed after the surgical gown and immediately before entering the operating rooms. Do not use them outside of the surgery rooms. Its use can be dispensed with by using exclusive shoes for the operating room.(20,26)
Face masks or face masks:
Masks are used as a bacterial filter and become contaminated with wet, bacteria-laden saliva quickly after they are put on. Gauze or cloth masks do not actually offer adequate protection, they should preferably be used disposable and completely cover the nose and mouth.(20,26-28) NE: Category IIA
If blood or body fluids touch the mask, it must be replaced. If a procedure has the possibility of splashing the face or eyes, all team members must wear protectors, whether masks with a visor or surgical glasses.(2,20,27,28)
Gaiters, hats and masks will only be changed in cases where there are splashes of blood and body fluids.
-Gloves:
Sterile gloves must be used when handling sterile items. Hands should only touch the inside of the gloves, if the outside of the glove is touched it is considered contaminated, therefore it should be changed.(2,4,6,8,10,11,20,21,29 ,30) NE: Category IIA.
If the gloves contain powder to lubricate the posture, all traces of it must be removed with a sterile wet compress. (2,4,6,8,10,11,20,21,29,30) NE: Category IA.
In non-sterile procedures, clean examination gloves can be used to protect the healthcare worker, using one pair of gloves per patient. Gloves do not replace hand washing.(2,4,6,8,10,11,20,21,29,30) NE: Category IIB
Once the gloves are removed, hand washing must be carried out again. (2,4,6,8,10,11,20,21,29,30) NE: Category IIA.
2. Hospital Areas
2.1. Transit or circulation
Access or passage of staff, patients and/or visitors from one area to another (critical, semi-critical and non-critical) within the Institution must comply with the following standards for the prevention and control of infection.
• Access of staff, patients and/or visitors to hospital areas will be limited in areas demarcated with red lines or “restricted area” notices.
• Patients should be transferred by the most direct route to the destination area to avoid cross-contamination.(2,6,10,12,14,29-31) NE: Category IIB
• Limit the number of people in critical areas mainly during the performance of procedures (maximum 10 people), because the levels of microbial contamination are proportional to the number of people in the area.(2,6,12, 20,29-31) NE: Category IIB
Specific recommendations for operating rooms (2,6,12,20,29-31)
• Maintain positive pressure ventilation in operating rooms in relation to adjacent areas.
NE: Category IIA
• Maintain at least 15 air changes per hour. NE: Category IIA
• Keep the operating room doors closed once the procedure has started, thus avoiding interfering with the ventilation system of the surgical room or mixing the air from the room with the hallway.(2,6,21,29-31)NE:
Category IIA
• Use laminar flow for orthopedic implant surgeries. NE: Category IIA
• The surgical team must remain inside the room throughout the procedure and verbal communication must be limited to what is strictly necessary. NE: Category IIB.
• Use air filters. They must be serial filters in which the first must have a filtering effectiveness of at least 30% and the second an effectiveness of 90% or HEPA (High Efficiency Particulate Air) filters with an effectiveness of 99.97%.(2) ,6,21,27,29-31)
NE: Category IIA.
• It is necessary to change them according to the manufacturer’s instructions.
2.2. Cleaning and disinfection
The cleaning practiced in health care institutions excludes the use of a broom to sweep, because many microorganisms deposited on the floor can become viable if they are lifted by the action of air currents that can form.
According to the classification of areas and disinfection: low level disinfection (DBN) is recommended for non-critical areas, intermediate level disinfection (DNI) for semi-critical areas and critical areas.(3,10,15) NE : Category IIA.
The most commonly used disinfectants are chlorinated and phenolic compounds, the latter are not available in Colombia.(3,10,14) (Annex 1)
There is no evidence regarding the rotation of disinfectants within hospital institutions; this type of action is only being carried out in the pharmaceutical industry.
The recommended cleaning and disinfection technique includes the use of the following principles:
• From top to bottom: starting with ceilings, then walls and doors; and finally floors
• From inside to outside starting on the opposite side to the entrance
• Start with the cleanest area and end with the most contaminated area, thus avoiding the proliferation of microorganisms.
• The surfaces must be as dry as possible. Humidity favors the multiplication of germs
• When changing jobs, it is necessary to wash the gloves very well and disinfect them or discard them if necessary.
• Remove items and/or hospital waste according to biosafety and waste management regulations.
Below, the three types of cleaning will be specified: terminal, recurring and weekly for each area of the institution.