Operation Theatre quality is the biggest concern for health care industry because most infection results from low standard.  Surgical Site Infections account for 14 to 17 % of all hospital acquired infections and about 38% of nosocomial infection in surgical patients.  Elderly patients with chronic and immune compromising conditions and emergence of antibiotic –resistant microbes are the major cause for morbidity and death. There are two factors which influence the risk of surgical site infections namely Patient related (endogenous risk factors) and Procedure related (external risk factors) factors. Operating theatre quality is to be governed properly because rate of surgical wound infection are very high due to poor operation theatre quality.  A safe operative theatre is the only way to prevent the surgical site infections and can be done by careful planning, maintenance and periodic check, proper training for staff.

Surgical Site Infections (SSI):


SSI are defined as infections occurring up to 30 days after surgery ( or up to one year after  surgery in patients receiving implants) and affecting either the incision or deep tissue at the operation site.

SSI can be superficial infections involving skin and other surgical site infections are involving tissues under the skin, organs or implanted material.

There are three types of surgical site infections are

 1. Superficial infections, 

2. Deep Incisional infections,

3. Infection involving organs or body spaces.

Severe SSI is mostly deep incision or body spaces. Surgical site contamination at the time of surgery is the important reasons for more chance for SSI.

According to the presence and degree of contamination, wounds can be classified as

1. Clean wounds.
2. Clean-contaminated wounds.
3. Contaminated wounds.
4. Dirty or infected wounds.

Infection rates for respective wounds are 1-2% for clean wounds, 6-9% for clean-contaminated wounds, 13-20% for contaminated wounds and 40% for dirty wounds.

Antibiotic prophylaxis can able to reduce the risk of SSI mainly for surgery procedures mainly gastrointestinal tract.  Methicillin Resistant Staphylococcus aureus (MRSA) is the major cause for surgical site infection.

Classification of Surgical Site Infection:

We can classify the surgical site infection by three ways – Superficial Incisional infection, deep incisional SSI and organ/space SSI.

1. Superficial Incisional SSI

This infection occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision.

This infection can be detected by looking few things

1. Purulent drainage from the superficial incision,
2. Organisms isolated from fluid or tissue from superficial incision
3. Pain or tenderness, localized swelling, redness, heat, superficial incision opened by surgeon.

2. Deep Incisional SSI

This infection occurs within 30 days after the operation and these infection appears to be related to the operation and infection involves deep soft tissue of the incision. E.g. fascial and muscle layer.

Infection can be detected by look up

1. Purulent drainage from deep incision but not from organ/space.

3. Organ/Space SSI

This infection occurs within 30 days after the operation. Infection appears to be related to the operation and infection involves any part of anatomy. E.g. organs or spaces.

Ways to look up organ/space SSI

1. Purulent drainage from a drain.
2. Organisms isolated in the organ/space.
3. Abscess.

About Microorganisms:

                      Microorganisms are either come endogenous and exogenous sources.

Clean surgical procedures involving gastrointestinal, gynecologic and respiratory tract can cause infection by Staphylococcus aureus from patient skin flora. When mucous membrane or skin is incised, exposed tissue is at risk of contamination by endogenous flora namely normal flora. About 20 -30% of SSI are caused by S.aureus  (Normal flora).

 In exogenous source, pathogen comes from operating theatre environment, surgical personnel, tools, instruments and materials brought to sterile field during operation.

 Organisms involved in surgical site infections are Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus spp. And E.coli.


Risk factors for Surgical Site Infections:

1. Patient-related (endogenous) and Procedure-related (external) factors.
2. Potential patient-related factors – malnutrition, older age, coexistent infection, diabetes.  (serum albumin concentration and advanced age)
3. External factors – type and duration of operation of operation, surgeon’s skill, quality of preoperative skin preparation, timing of antimicrobial prophylaxis, insertion of foreign material or implants, inadequate sterilization of surgical instruments.

Prevention of Operating Theatre Quality:

Operating Theatre Quality

1. Safe operating theatre and prevent pollution and any micro-environmental alternation are kept under control.
2. Careful planning, maintenance, periodic checks and ongoing training for staff.

Structural Features

1. Specific rooms should be designated for performing surgical procedures and for processing instruments and other items.
2. Control traffic and activities in this area start reception to operation theatre.
3. Operating unit should be arranged in order.
Surface of floors should be easily cleaned and should be stain resistant.
Color of operation theatre should be bright, so that any items fell into the ground can be easily identified.
Water management – Drinking water and tap water.


AUTHOR: Arun Kumar Rajamani

Operation Theatre Quality - Surgical Site Infection and its Prevention –  A Simple Guide for Nurses.