Behaviour of OR Team

A topic under which many aspects can be subsumed

Why self-protection is so relevant for SSI prevention

“Exogenous sources of SSI pathogens include surgical personnel (especially members of the surgical team).”1

“The invasive nature of surgery introduces a high risk for the transfer of pathogens that may cause bloodborne infections in patients and/or the surgical team, as well as SSI. This risk may be reduced by implementing protective barriers, such as wearing surgical gloves.”2

“Published data about the impact of operating-room behaviour on the risk of infection are limited and heterogeneous.”3

Denise Leistenschneider, Senior Clinical Consultant
"SSI prevention starts with the hygienic behaviour of every person involved in the surgical procedure."
Nails and jewelry
CDC1Keep nails short and do not wear artificial nails. (IB)

Do not wear hand or arm jewelery. (II)

Clean underneath each fingernail prior to performing the first surgical scrub of the day. (II)
WHO²The WHO guidelines on hand hygiene in health care recommend to keeping nails short and to remove all jewellery, artificial nails or nail polish before surgical hand preparation.
NICE4The operating team should remove artificial nails and nail polish before operations.The operating team should remove hand jewellery before operations.
KRINKO5All persons who wish to enter the operating should not wear jewellery or watches on the forearms and hands or any other jewellery that may pose a risk, and no artificial fingernails or nail polish. (II)

Theater wear, surgical mask and cap/hood
Theater wearSurgical mask and cap/hood
CDC1-Wear a surgical mask that fully covers the mouth and nose when entering the operating room… (IB)
Wear a cap or hood to fully cover hair on the head and face when entering the operating room. (IB)
WHO²-The operating team should cover their hair…
NICE4All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken.-
KRINKO5All persons who wish to enter the operating should remove all their outer clothing, including shoes, in the staff locker room and, after hygienic hand disinfection, wear low-germ (prepared in a disinfection washing process) area clothing (e.g. trousers, shirt/coat, OR shoes) in the clean area.Before entering the operating room, a mouth-nose protection and hair protection should be put on, completely covering all beard and head hair as well as mouth and nose. (II)

Hand washing and surgical hand disinfection
Hand washingSurgical hand disinfection
CDC1-Perform a preoperative surgical scrub… (IB)
WHO²If hands are visibly soiled, the guidelines recommend to wash hands and remove debris from underneath fingernails using a nail cleaner (not brushes), preferably under running water (sinks should be designed to reduce the risk of splashes).Surgical hand preparation should be performed by scrubbing with a suitable antimicrobial soap and water or using a suitable ABHR before donning sterile gloves. (Strong recommendation, moderate quality of evidence).
NICE4The operating team should wash their hands prior to the first operation…-
Before subsequent operations, hands should be washed… If hands are soiled then they should be washed again…
KRINKO5The operating area is to be entered with clean hands. (II)Surgical hand disinfection must be performed by the surgical team, including instrumentation staff. (IB)
Hand washing should be performed after visiting the toilet. (IB)

Gowns and gloves
CDC1Wear sterile gloves if a scrubbed surgical team member. Put on gloves after donning a sterile gown. (IB)
Change scrub suits that are visible soiled, contaminated, and/or penetrated by blood or other potentially infectious materials. (IB)
WHO²…and wear sterile gowns and sterile gloves during operation.
NICE4The operating team should wear sterile gowns in the operating theatre during the operation.Consider wearing 2 pairs of sterile gloves when there is a risk of glove perforation and the consequences of contamination may be serious.
KRINKO5The surgical team should put on a sterile surgical gown and then sterile gloves in the operating room after surgical hand disinfection. (IB)
Other OR personnel (e.g., jumpers) should avoid hand contamination with potentially contaminated materials or fluids by wearing protective gloves. (IA)

Movements, doors, talking, ill person and exit


DoorsTalkingIll personExit
CDC1-Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient. (IB)-Educate and encourage surgical personnel with signs and symptoms of transmissible infectious illness… (IB)-
NICE4Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area to a minimum.----
KRINKO5During surgery, the number of people present in the operating room, their turnover, and their talking should be kept to a minimum, and the doors of the operating room should be kept closed whenever possible. (II)-Staff should exit the operations department through the staff locker room and remove all area clothing there.

Instructions for Behaviour of OR Team

At any time

Consider appropriate hygienic hand disinfection according 5 Moments of WHO6

When leaving the operating room

Exit the OR unit through the staff locker room and remove all scrub suits there5

Switching to scrub suits5

Scrub suits are designed to prevent the spread of bacterial populations in both directions (into and out of the operating room). The rationale for changing other workwear for scrub suits is the proven contamination of workwear with facultative pathogens including MRE

Denise Leistenschneider, Senior Clinical Consultant
"Colored area clothing is common practice, but there are no studies that prove an infection-preventing effect. The signal effect "this clothing only belongs in area xy" can certainly be beneficial…"

Role of frequency of door openings during surgery

"In uni- and multivariable analysis, an increasedmean door opening frequency during cardiacsurgery was associated with higher risk forconsecutive SSI (adjusted hazard ratio per 5-unitincrement, 1.49; 95% confidence interval, 1.11–2.00; P = .008).”7

What about noise level and SSI?

“Intraoperative noise volume was associated with SSI. This may be due to a lack of concentration, or a stressful environment, and may therefore represent a surrogate parameter by which to assess the behaviour of a surgical team.”9
Please click to see full list References

1 CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.

2 WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.

3 Birgand G, et al. (2015) Influence of staff behavior on infectious risk in operating rooms: what is the evidence? Infect Control Hosp Epidemiol. 36(1):93–106.

4 NICE (2019) Surgical site infections: prevention and treatment. NICE guidelines. Published 11 April 2019.

5 KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.

6 WHO (2009) WHO Guidelines on Hand Hygiene in Health Care.

7 Roth JA, et al. (2019) Frequent Door Openings During Cardiac Surgery Are Associated With Increased Risk for Surgical Site Infection: A ProspectiveObservational Study. Clin Infect Dis. 69(2): 290–294.

8 Rezapoor M, et al. (2018) Operating Room Traffic Increases Aerosolized Particles and Compromises the Air Quality: A Simulated Study. J Arthroplasty 33(3): 851–855.

9 Kurmann A, et al. (2011) Adverse effect of noise in the operating theatre on surgical-site infection. Br J Surg 98(7): 1021–1025

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