- International Journal of Gynecology & Obstetrics
Contents
1. International Journal of GYNECOLOGY amp OBSTETRICS International Journal of Gynecology amp Obstetrics 75 2001 287 294 www elsevier com locate ijgo Averting maternal death and disability Recommendations for renovating an operating theater at an emergency obstetric care facility E Abreu D Potter Averting Maternal Death and Disability Program Heilbrunn Center for Population and Family Health Mailman School of Public Health Columbia University New York NY USA Architectural Projects Office of Nepal Kathmandu Nepal Accepted 24 August 2001 Abstract The importance of emergency obstetric care EmOC in reducing maternal mortality has focused attention on both the skills of the clinicians to provide high quality care and on the health facilities in which the care is provided Essential elements of EmOC include the capacity to perform cesarean sections for which an operating theater is needed This article focuses on renovation of existing operating theaters to meet the necessary standards While building adding to or renovating operating theaters can be expensive this article emphasizes appropriate materials that are likely to be locally available and relatively inexpensive The importance of proper maintenance is discussed 2001 International Federation of Gynecology and Obstetrics All rights reserved Keywords Emergency obstetric care Operating theater Building materials for operating theaters Or2. 2001 287 294 293 3 3 6 Housekeeping The WHO stresses that cleanliness is very im portant Cleaners should be given careful training so they understand the importance of their role duties in the maintenance of a clean facility environment one that could affect the outcome of a patient 3 Cleaners should be provided with the proper tools disinfectant detergents mops with han dles mop buckets rubber floor scrapers steel wool or abrasive powder as well as gloves and boots 4 There should be a housekeeping closet exclusively for the obstetric suite and directly accessible from the suite with a service sink plus storage space for housekeeping tools supplies 1 3 3 6 1 Floors It is recommended that hard surface floors be wet mopped with a disinfectant solution between cases in the OT and every several hours during the day in the corridors 2 A good disinfectant is a 0 5 chlorine solution 5 3 3 6 2 All surfaces Walls windows doors etc should routinely be scrubbed to remove dirt These surfaces should be wiped starting from the top and working downward with a disinfectant solution each day 5 3 3 6 3 Toilets Toilets should be maintained and kept clean with the use of a chlorine solution on a daily basis 3 3 7 Biomedical waste disposal All handling and disposing of instrument wash ing solutions suction bottle contents human tis sue as well as contaminated disposable items such as syri
3. sterile supplies and instruments and dirty carts for soiled linen instruments biomedical wastes ete 1 2 2 Clean and dirty utility areas servicing the OT It is very important that all items that come into contact with the patient are sterile and that after use all of them are cleaned and re steri lized or disposed of safely Ideally the clean and dirty utility areas for processing items used in the OT should be separate rooms Both the clean utility room and the dirty utility room should have a sink with drain and table space for organizing and drying items And these rooms should be used exclusively by the obstetric suite to reduce the risk of infection from patients being treated in other areas of the facility 1 The dirty utility room should have enough work space to clean medical surgical instruments and equipment and conduct an initial decontamina tion by sterilization and disinfection 1 It is important to have a deep sink in the dirty utility room so that all surfaces of items being cleaned can be easily washed with minimal splashing of contaminants In addition the sink should have a drain to carry off the contaminated flush waters to an appropriate enclosed disposal site The dirty utility room should also have a direct route to the waste collection or disposal site so that biomedi cal wastes and used disposable materials are not taken through clean areas The clean utility room should have equi
4. toward a drain outlet in one wall 4 In this way the floor can be easily kept clean 3 1 2 2 Vinyl A very hard vinyl floor covering on a concrete base is acceptable for the OT provid ing that the seams are heat sealed and the vinyl adheres to the concrete by a non water soluble material 2 However this material should not be used where there is the slightest suspicion of dampness within the underlying floor 4 3 1 3 Ceilings In the OT as well as in the clean utility room the ceilings should have a finish that reduces the possibility of contamination by falling particles 1 An oil based paint is recommended 4 See Section 3 1 1 on walls above 3 1 4 Doors The doors of the OT are often of the swing type The lifespan of the doors can be greatly increased by protecting the bottoms from con stant wetting An inexpensive and effective way is to bend a single thin aluminum sheet around the lower 150 mm inches of the faces bottom edge and side edges 4 3 2 Equipment The advantage of using standardized equip ment is that issues of training maintenance spare parts supply and repair are minimized WHO suggests 3 that equipment whether obtained through direct purchase or as a gift should be installed only if e there is a genuine need for the technology e there is a suitable site e all necessary services electricity water etc are available e there is a warranty e the user s manual is i
5. an 4 In addition there are concerns about durability and resis tance to wear Ceramic tiles however are suit able for other areas such as the dirty utility room 3 1 1 3 Paint Not all kinds of paint are equally satisfactory Laminated walls with three coats of polyethylene withstand wear and with an additio nal coat of epoxy paint the problems of chipping flaking or blistering are reduced 2 Gloss or enamel oil based paint can be used for areas of the wall from 135 cm 4 5 feet above floor level to the ceiling in the OT and in other areas of the obstetric suite that are wiped periodically but not washed frequently 4 Although frequently used because it is inexpensive limewash is not suitable for any wall surfaces in the obstetric suite and in particular this type of paint should not to be used in the OT 4 Limewash is water soluble and therefore will dissolve when washed 4 Cement paint also is not appropriate for any surface in the OT because its rough finish easily harbors dirt and therefore makes cleaning difficult 4 3 1 2 Floors The floors of the OT should be hard seamless easy to clean and able to withstand germicidal cleaning solutions 2 Wooden and cement floors are not suitable in the OT because contaminants can easily collect in the pitted cracked surface 3 1 2 1 Mosaic This is an excellent floor finish for the OT See Section 3 1 1 on walls above It is recommended that the mosaic floor slopes
6. ect ing the waste water from the sinks should be of sufficient diameter to handle large sudden volumes of water flushes during the cleaning process for instruments linens etc For areas around plumbing fixtures the walls should be smooth and waterproof Limewash ce ment paint or gloss enamel paint should not be used around sink areas because the constant dampness would cause flaking in turn exposing plaster and harboring dirt particles 4 A splash board of mosaic smooth finish cement plaster or waterproof paint is recommended around a sink or tap stand 4 Wood is not a suitable material due to its progressive decay 3 3 2 Electricity Electrical wiring should be designed and in stalled in accordance with relevant codes of prac tice It is best to have the electrical wiring within the walls where it is safe and does not collect dirt or interfere with cleaning A less satisfactory al ternative but often the only choice in an existing building is to hide wires inside a plastic surface mounted electrical ducting pipe 4 Sockets and switches should be housed in a standard grounded metal box which is recessed into the wall and not on a wooden block 3 3 3 Back up systems It is important that there is absolutely no inter ruption with respect to lighting in the OT A good back up system is therefore needed during power fluctuations outages A generator located within the OT provides a reasonable back up power s
7. entative measures e providing continuous support services water electricity laundry housekeeping and biomed ical waste disposal Some basic concepts for the successful func tioning of an OT are reviewed and specific sug gestions for its renovation are presented An im portant underlying recommendation is that plan ners should use the best available local resources Improvements of the OT in an EmOC facility will improve staff morale and result in higher quality of service to the community Acknowledgements The authors express their gratitude to Drs De borah Maine and Zafarullah Gill for their sugges 294 E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 tions and are thankful to the manuscript review ers for their very helpful comments This work was supported by the AMDD Program at the Heilbrunn Center for Population and Family Health Joseph L Mailman School of Public Health Columbia University with funding from The Bill and Melinda Gates Foundation References 1 American Institute of Architects Guidelines for design and construction of hospital and health care facilities 2 3 4 5 Washington DC American Institute of Architects Press 1996 Schultz J Traffic and commerce in the surgical suite In Laufman H editor Hospital Special Care Facilities New York Academic Press 1981 233 238 World Health Organization The hospital in rural and
8. erating Theatre soiled linen control point or barrier point or barrier to limit access to the OT Ss Staff staftchanging clean SS errr ae sterile instruments sterile supplies dirty equipment dirty instruments biomedical waste used disposable materia semi clean items Waste Out gloves sponges syringes tubing used sharps blades needles Fig 1 Correct traffic flow in and out of the operating theatre E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 289 instruments equipment supplies etc being moved into the OT And the other traffic pattern from the OT should be for the removal of all used dirty items en route to being cleaned used disposables sponges syringes gloves etc and biomedical wastes It is important that the OT area for EmOC should be separate from the areas where patients seek other forms of treatment at the facility 1 A control point or barrier created for example by a counter with a small pass through window or a half door helps establish a traffic pattern which will reduce the spread of infection into the OT area 2 In this way visitors would not gain entry and patients would remain within the clean area Carts equipment etc designated for EmOC should also remain within the EmOC area de creasing the chance of contamination Carts should be further identified as clean carts for
9. ganization of operating theaters Corresponding author Tel 1 212 304 5910 fax 1 212 544 1933 E mail addresses ea2 columbia edu E Abreu davidpotter apon wlink com np D Potter 0020 7292 01 20 00 2001 International Federation of Gynecology and Obstetrics All rights reserved PH 0020 7292 01 00527 6 288 E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 1 Introduction The operating theater OT is crucial to emer gency obstetric care EmOC Many EmOC facili ties while improving their services simultane ously direct efforts towards physical renovations of the OT Planners are usually faced with limita tions financial resources pre existing space layout structural quality of the building etc as they propose needed changes We will briefly explore the basic principles that support the successful functioning of the OT The primary focus will be on some of the problems encountered in the renovation of the OT as well as the approaches that planners can take in the renovation efforts Although the discussions are specific to the OT many basic concepts can be applied to other areas of the obstetric suite such as the labor and delivery rooms Since what may be plentiful and easily attain able at one location may be too costly in another part of the world there is no one solution In light of this planners are encouraged to use the best available local re
10. ing theater OT In general with renovations and additions to any existing space planners should strive to make use of the best local resources and technology available to them Also cost effective measures in the utilization and maintenance of the space should be explored 3 There may be many obstacles in running a successfully functioning OT at an EmOC facility 2 4 Some common occurring problems are listed below e equipment acquired without adequate techni cal support training e dampness and deterioration of buildings caused by water leaks from improperly de signed or maintained roofs and plumbing e dangerous electrical wiring e unsafe disposal of biomedical wastes e window configurations which do not allow patient privacy e space wasted by unnecessarily large lobbies or corridors and the storage of nonfunctioning equipment in usable rooms e wall and floor finishes which cannot be cleaned properly e insufficient toilet facilities and e inadequate water supplies Renovations addressing these and other prob lems as they relate to a successfully functioning obstetric OT will be discussed 3 1 Appropriate surface finishes and fittings for the OT It is important to note that the performance of a surface finish is only as good as the soundness of the construction to which it is applied The best possible materials on a failing structure would not be cost effective Furthermore materials used in the re
11. n a language that can be understood by the users e spare parts and maintenance supplies are eas ily obtainable e consumable supplies are readily available and affordable e technicians are available to maintain the equipment and e staff will be trained how to use the equipment Before any electrical equipment is plugged in the socket and the wiring to it should be checked to confirm that a there are no faults b the electrical load of the equipment can be safely handled and c the earth ground line is func 292 E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 tioning properly 4 Voltage regulators should be considered for refrigerators and high power equipment When equipment is stored in a service area such as a corridor it will collect contaminants Such equipment should be wiped with a germici dal solution prior to moving into the delivery room or OT 2 Electrical equipment should be unplugged when not in use to reduce potential damage by voltage surges 4 3 3 Facility services supporting the OT It is very important that there are adequate safe and uninterrupted supplies of water and electricity to the operating suite 3 3 1 Water Leaky plumbing pipes fixtures as well as blocked sinks drains and toilets should be promptly repaired There should be an adequate number of both handwashing sinks and deep util ity sinks with drains The plumbing pipes dir
12. nges needles etc should be done carefully and with the protection of gloves WHO stresses that special care must be exercised in the disposal of wastes whether by burning burial or other means 3 3 3 7 1 Burning This is best done in an incinera tor However wastes can be burned in an oil drum 5 The site for burning wastes should be carefully chosen so that the fire can be safely confined and the smoke is downwind and does not enter the building The resulting ash can then be buried or thrown into a pit 5 3 3 7 2 Burying One possible solution is to con struct an underground masonry chamber with a chute and capped lid to prevent the entrance of animals and vermin 4 Unlike a fenced open pit which requires covering with a layer of soil the advantage of an underground masonry chamber is that the only actions required are the pouring of the waste down a chute and the replacing of the cap With careful sorting this is an easy and relatively inexpensive way to solve the biomedical waste disposal problem for several years 4 Summary The OT is essential to EmOC Often as a medical facility upgrades its EmOC services the existing OT undergoes renovations Many prob lems are encountered in the process This paper discusses the importance of e using appropriate materials in construction or renovation surface finishes for the walls floors and ceilings e establishing good maintenance practices re pair and prev
13. novation of the OT should be of good quality to endure daily washing with strong clean ing agents 3 1 1 Walls In the OT the walls should be hard non por ous free of joints and crevices which harbor dirt easy to wash and withstand repeated contact with strong cleaning agents 2 Dampness of walls or ceilings is often the result of a leaky roof or faulty plumbing The source of the problem must be determined appropriately corrected or repaired and sufficient time allowed for complete drying before the application of a surface finish 4 For instance a mosaic surface with a cement mortar on a wall constructed with mud mortar would almost certainly fail because a constantly wet mud base would collapse with the additional weight of the finishing surface 4 3 1 1 1 Mosaic A very good wall finish for the OT and other clean wet areas is mosaic also known as terrazzo or granolithic 4 Mosaic is composed of stone chips set in a cement mortar matrix and ground to a smooth surface It is recommended for walls and from the floor to 135 cm 4 5 feet This surface finish and its height E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 291 provide additional protection to the walls of a typically small OT and allow for easy mainte nance and cleaning 3 1 1 2 Ceramic tiles Walls with ceramic tiles are not recommended in the OT because the many joints are difficult to keep cle
14. pment for the final sterilization of medical surgical equipment and supplies 1 WHO stresses that the boiling or soaking of instruments in disinfec tant solutions are not reliable means of steriliza tion Steam under pressure i e an autoclave is the most common and desired form of steriliza tion 3 2 3 Storage areas for supplies specific to the OT Clean supplies sheets towels bedpans etc and sterile supplies gloves sponges syringes etc should not be stored in the same cabinet 2 The need to gain access to clean items is more fre quent than for sterilized items By providing sepa rate storage areas the possibility of damaging sterilized packets and therefore exposing the contents to dust and microorganisms is reduced Also clean supplies and sterile supplies should not be in locations which increase the risk of contamination such as next to the scrub sink Storage rooms should be located within the obstetric suite It is important that all drugs are easily accessi ble to the OT and stored appropriately as speci fied by the manufacturer For best results and to ensure maximum effectiveness drugs are stored under specific conditions The proper storage for some drugs is a dry clean place at room tempera ture For other drugs the proper storage is at a constant temperature in a refrigerator or freezer The storage units should function properly and maintain the required temperatures at all times Note tha
15. sources to upgrade the OT The desired end result for all improvements is to provide the best possible environment and sup port to the OT as EmOC is enhanced to serve the community 2 The ideal operating theater OT The OT is the focal point of an EmOC facility In the ideal situation the obstetric OT should have a scrub area at the entrance and a nearby staff changing area Also the OT should be close to the labor room delivery room recovery room dirty utility room clean utility room with auto clave clean storage room and toilets sinks This section will take a closer look at the OT in the ideal setting Considerations in striving to wards an ideal yet attainable OT will be dis cussed In addition some aspects of good mainte nance and repair in the support of the OT will be reviewed 2 1 Striving towards an ideal yet attainable OT It is critical that all staff doctors nurses and support personnel have a good understanding of the basic principles for in and out traffic of the OT Fig 1 In the ideal situation the OT should be such that the clean and the dirty items do not cross paths To best accomplish this two distinct traffic patterns should be established One traffic pattern should be dedicated to the two way traffic flow both in and out of patients doc tors and nurses This route is also for clean items Patient Staff Clean Materials and Equipment Op
16. t a brief power outage resulting in a rise in temperature in the case of a refrigerator or the thawing of contents for a freezer could lead to the breakdown of a drug and loss of its potency It is important that all stored drugs are labeled clearly with an expiration date and are used be fore that expiration date to avoid loss of the drug s effectiveness In addition accurate records should be kept as to amounts received and dis pensed 3 Safety measures should be taken for the storage 290 E Abreu D Potter International Journal of Gynecology amp Obstetrics 75 2001 287 294 of materials in order to avoid explosions fires and toxic fumes 3 For example gas cylinders should be strapped or chained to a wall or firm surface to prevent accidental dropping Glutaraldehyde con taining solutions which are commonly used in the cold chemical sterilization process should be stored in closed containers in a well ventilated space 2 4 Good maintenance and repair in the support of the OT WHO stresses the following 3 e repairs to buildings and equipment should be done in a timely fashion e preventative maintenance eventually justifies the costs and e senior staff should inspect for maintenance up keep Attention should immediately be given to faulty design workmanship For example sloping floors towards the toilet fittings can easily fix toilets that stand in pools of water 4 3 Renovating an existing operat
17. urban districts WHO Technical Report Series 819 1992 Potter D Evaluation reports focusing on South Asia Kathmandu Nepal Architectural Projects Office Nepal 2000 AVSC International Infection prevention a reference booklet for health care providers AVSC International now EngenderHealth 2000
18. ystem as long as it has been housed and maintained properly However a wall or ceiling mounted battery powered light unit may be a better solution for the OT This back up system does not require skilled mainte nance and the batteries need to be replaced after 2 3 years 4 The long term availability and costs of fuel or batteries to run these systems are important considerations when choosing a back up system for the OT 3 3 4 Where there is no back up system During power failures the OT in some facili ties may have no back up system and rely on natural light Under these circumstances it is best to design the windows so that the lower ledge is just above eye level and thus providing privacy to the patient 4 In the OT window treatments such as curtains and screens should not be used because they gather dust and contaminants 3 3 5 Laundry There are three types of laundry and they should be separated at the collection point 3 e linen soiled with use e linen contaminated with infective material and e staff work clothes It is good practice to have all gowns removed and deposited in a special container before per sonnel leave the OT 2 It is recommended that they be laundered in machines if possible rather than by hand Laundering involves a series of water flushes followed by detergent chlorine so lution and additional water rinses E Abreu D Potter International Journal of Gynecology amp Obstetrics 75
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