Standard Operating Procedure: Infection Control Audit for Operating Theatres

This Standard Operating Procedure (SOP) outlines the mandatory protocols for conducting a comprehensive infection control audit within the Operating Theatre (OT) suite. The objective of this audit is to minimize the risk of Surgical Site Infections (SSIs), ensure compliance with national healthcare accreditation standards (e.g., NABH/JCI), and maintain a sterile environment through rigorous monitoring of environmental controls, personnel practices, and sterilization workflows. This audit must be conducted at least monthly by the designated Infection Control Officer or Head Nurse to ensure continuous quality improvement.

1. Environmental Controls and Infrastructure

• Air Quality Monitoring: Verify the status of the HEPA filtration system; ensure the differential pressure gauges read within the mandated range (typically 10–15 Pascals positive pressure).
• Temperature and Humidity: Check the logging system for daily recordings; ensure temperature is maintained between 18°C–22°C and humidity between 40%–60%.
• Surface Integrity: Inspect walls, ceilings, and floors for cracks, peeling paint, or gaps where microbes can colonize.
• Cleaning Documentation: Audit the "Terminal Cleaning" logbooks to verify that floor-to-ceiling disinfection occurred after the last case of the day.

2. Personnel Practices and Personal Protective Equipment (PPE)

• Scrub Attire: Observe adherence to the dress code: clean, designated theatre scrubs, hair covers, and beard covers.
• Hand Hygiene: Evaluate compliance with the "5 Moments of Hand Hygiene" and the use of the correct surgical scrub technique (contact time with alcohol-based rub or chlorhexidine).
• Aseptic Technique: Monitor the surgical team for breaches in sterile fields, such as improper gowning/gloving or unauthorized movement near sterile trays.
• PPE Availability: Verify the availability of N95 masks, fluid-resistant gowns, and eye protection in the immediate vicinity.

3. Sterilization and Sterile Supply Management

• Sterile Storage: Check the "Clean Sterile Store" for proper temperature/humidity and ensure supplies are stored at least 6 inches off the floor and 18 inches from the ceiling.
• Inventory Audit: Inspect peel-packs and blue wraps for tears, moisture, or signs of tampering; verify that all packs have undergone chemical indicator color changes.
• Expired Items: Conduct a spot check for expired sterilized items; ensure the "First-In, First-Out" (FIFO) principle is applied.
• Instrument Tracking: Confirm that steam sterilization logs (biologic and chemical indicators) are correctly dated, signed, and filed.

4. Waste Management and Hazardous Materials

• Segregation: Ensure all waste is segregated at the point of generation (e.g., yellow for infectious/anatomical, red for plastics, blue for metals/glass, black for general).
• Sharps Safety: Inspect sharps containers for overfilling; ensure they are located within arm’s reach of the point of use.
• Spill Kits: Verify the presence and accessibility of blood/body fluid spill kits, ensuring they are not expired.

Pro Tips & Pitfalls

• The "Invisible" Audit: Conduct "spot checks" during active surgery rather than scheduled walkthroughs to observe real-world behavior and culture.
• Pitfall - The "Check-the-Box" Mentality: Do not simply verify if a log exists; verify if the data within the log is accurate and reflects actual facility conditions.
• Pro Tip: Use UV-fluorescent marking sprays on high-touch surfaces (handles, monitors, switches) prior to cleaning shifts to objectively audit the effectiveness of the housekeeping staff.
• Pitfall - Neglecting Traffic: Excessive movement in and out of the OT is a primary cause of air contamination. Always audit the "door-opening count" during complex procedures.

Frequently Asked Questions (FAQ)

Q: How often should biological indicator testing be performed for the autoclaves? A: Biological indicators (e.g., Geobacillus stearothermophilus) should be tested at least once a week, and ideally with every load containing an implantable device.

Q: What is the recommended frequency for surface microbiological swabbing? A: Routine surface swabbing of OT walls and equipment is generally recommended quarterly. However, this frequency should increase if a cluster of SSIs is detected.

Q: Who is primarily responsible for the final sign-off of the infection control audit? A: While the audit may be performed by an OT Nurse or Technician, the final review and signature must be provided by the OT In-charge or the Hospital Infection Control Officer (HICO) to ensure accountability.

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