Identification of OR patient zone (study phase 2) Phase 1 observations ended when repeating themes indicated saturation of data. Participating ORs were drawn at random from a list of surgeries, meeting the inclusion criteria, available on the electronic scheduling system. Observations were conducted during office hours. The minimum quota was one full-length surgery planned to last ⩽ 2 h for each of the specialties. These were Urology, Ear Nose and Throat, Gynaecology, Ophthalmology and Maxillofacial. Using password access to an electronic OR booking system, surgical specialties planned over a four-week period (March 2016) with scheduled case lengths of ⩽ 2 h were identified. Therefore, surgical disciplines were limited by non-probability judgement sampling to those with a planned operative case length of ⩽ 2 h. Evidence ( Munoz-Price et al., 2014 Rowlands et al., 2014) and local experience indicated the peak of hand contact between non-scrubbed intraoperative staff, the patient and equipment occurred at the beginning and end of the operation. Selection of surgical disciplines and ORs (study phase 1)Īll surgical disciplines in the adult and children’s acute hospitals were available for phase 1 observation. Our study aimed to build upon current evidence by quantifying the WHO definition of the patient zone and developing a useful resource to help frontline staff practically identify the OR patient zone from the healthcare zone. While the patient zone is clearly defined in the literature, practical application of it is not. Where confusion exists around which pieces of equipment are included in the patient zone, both HH at ‘moment 5’ and cleaning equipment between patients in the OR may be missed, thus increasing the risk of HAI ( Hopf, 2015). The fifth moment’s reliance on understanding of two geographical areas (the patient and healthcare zones) is a challenge for reducing microbial spread ( Sax and Clack, 2015). Equipment included in the patient zone is cleaned between patients, complementing HH in disruption of microbial transmission ( WHO, 2009). HH at ‘moment 5’ interrupts transmission of microorganisms from equipment included in the patient zone into the healthcare zone ( Sax et al., 2007), which is the rest of the OR. HH and equipment cleaning are embedded into the WHO fifth moment for HH ( Figure 1) ( Sax et al., 2007). Equipment outside the patient zone is in the healthcare zone. Finally, equipment within the same narrow area touched by the patient completes the WHO definition of the patient zone. The second is equipment touched by healthcare staff while caring for the patient. The first of these is equipment in direct contact with the patient. The patient zone is composed of three elements, each within the narrow geographical area around the patient. It is represented in Figure 1 as equipment inside the dashed black line. The literature defines the patient zone as a narrow area around the patient that is dedicated to that patient wherever the patient receives care ( Sax et al., 2007). Source: reproduced with permission from World Health Organization ( WHO, 2009). Concern that reported local confusion about the practical content of the patient zone would lead to erosion of HH compliance and equipment cleaning prompted infection prevention and OR collaboration on this quality improvement project. In our ORs, monthly HH audit based upon the WHO method had not dropped below the required standard of 95% compliance ( Smith et al., 2016). The core of these guidelines is the concept of ‘My five moments for hand hygiene’ ( Figure 1). Responding to the risk of HAI associated with bacterial transmission around equipment ( Loftus, 2016), which occurs in as little as 30 min ( Rowlands et al., 2014), the research team introduced the WHO HH guidelines ( Smith et al., 2016). Multi-drug resistant bacterial transmission around an OR from patient to non-scrubbed staff hands and equipment to the next patient has been associated with healthcare-associated infection (HAI) ( Loftus et al., 2012). The focus of this study is non-sterile equipment, which will be referred to as equipment. Despite high design specification of the OR and equipment, with exception of sterile surgical instruments in the surgical field, the OR is a clean, not a sterile environment ( Loftus, 2016). Prevention of surgical infection is a global priority, to which applying the World Health Organization’s (WHO) hand hygiene (HH) campaign is of critical importance in the operating room (OR) ( Abbas and Pittet, 2016).
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