Good hygiene practice in hospitals and in operating theatres is mandatory to minimise nosocomial postoperative infections. Health care-associated infection is a major cause of morbidity and mortality. The personal and financial consequences of avoidable infections are enormous in personaland global terms. Patients expect to be treated and cared for in clean conditions, and not be exposed to the risks of acquiring an infection by poor practice on the part of healthcare workers. Infection control and prevention in perioperative settings assumes an even greater significance because of the vulnerability of patients who are already ill or injured, and because surgery, anaesthesia and immediate postoperative recovery may expose them to invasive procedures, allowing more portals of entry for infection. This literature review will discuss cleaning within the perioperative setting; the importance of hand hygiene, surgical site infections and training for healthcare professionals to minimise infection risk.

A systematic search for literature was carried out using online databases such as, Pubmed, Medline, Cinahl, OVID and Cochrane Library . A search of online sources such as the Department of Health (DOH), Association of Peri-operative Registered Nurses and Science Direct sites has also been implemented. In addition the World Wide Web was searched using search engine Google/Google Scholar for relevant articles and web sites. The search terms for this literature review included a combination of infection control measures, infection control prevention in theatres, infection control risks, surgical site infections and peri-operative infection control. Publication dates used are between 2005-Present.

Cleaning regimes are paramount in controlling the spread of infection in the hospital environment. They play a significant role in reducing the instances of healthcare associated infections that can be transferred; from the healthcare practitioner to the patient; from the environment to the patient and from patient to patient. Theatre walls, ceiling and floor finishes should be impermeable to bacteria and able to endure frequent wet chemical cleaning. Curved joints between walls, ceilings and floor aid effective cleaning and drying (Davey and Ince 2004).Kim et al 2006 highlights the importance of high standards of ward cleaning to stop the spread of methicillin-resistant Staphylococcus aureus. British infection control doctors argue that instead of attempting to apply limited MRSA control measures, which are impossible to achieve, infection control has a duty to press for investment in cleaning (Barrett et al 2003). Hospital cleaning services play a key part in minimising the risk of hospital acquired infections, which have serious consequences for patients and lead to significant costs. A meta analysis of three randomised controlled trials showed that cleaning is essential to containing MRSA, gastrointestinal, and other types of infection outbreaks (Dancer 2005) (Anderson and Rasch 2005) (Griffith et al 2007). This view is reinforced by Noone and Griffiths2004 who conducted one large randomised study on hospitalised patients showing the only intervention used to combat a glycopeptide-resistant enterococci (GRE) infection outbreak at a UK hospital was a very thorough and systematic cleaning of the wards, after which reduction in both the level of environmental contamination and the numbers of infected patients were noted.

The use of flash sterilisation is commonplace in non-central sterilising facilities such as operating theatres, eliminating the need to transport instruments to a central location and permitting sterilisation of frequently used items for immediate use (AS, 2008; Bennett, 2005). Because the limitations of this process mean a wide margin of safety cannot be ensured, the Standard recommends that flash sterilisation should be reserved for emergencies only, and in certain instances should never be used, for example, for sterilising blind-ended cannulated instruments. The use of flash sterilisation also demands adequate decontamination/cleaning of instruments, and daily performance monitoring of cycles to ensure efficacy of the sterilisation process (AS, 2008). While steam sterilisation is always the sterilisation process of choice, it is not suitable for heat sensitive equipment such as flexible endoscopes, and glutaraldehyde is currently used in many hospitals to ‘sterilise’ such equipment between patients. Because this use of glutaraldehyde also lacks important quality controls to ensure a sterile instrument, the Standard recommends its use only for disinfection (AS, 2008). Options proposed to deal with this recommendation have included increases in endoscope inventory, use of disposable endoscopes, and use of alternative low temperature sterilisation techniques such as ethylene oxide (EtO). These options are likely to be impractical for busy endoscopy facilities because of their high costs and lengthy cycle times for EtO sterilisation (AS, 2008).

Sterilization is a process intended to kill all microorganisms and is the highest level of microbial kill that is possible. Sterilizers may be heat only, steam, or liquid chemical. Effectiveness of the sterilizer (e.g., a steam autoclave) is determined in three ways. First, mechanical indicators and gauges on the machine itself indicate proper operation of the machine. Second heat sensitive indicators or tape on the sterilizing bags change colour which indicate proper levels of heat or steam. And, third (most importantly) is biological testing in which a highly heat and chemical resistant microorganism (often the bacterial endospore) is selected as the standard challenge. If the process kills this microorganism, the sterilizer is considered to be effective. It should be noted that in order to be effective, instruments must be cleaned; otherwise the debris may form a protective barrier, shielding the microbes from the lethal process. Similarly care must be taken after sterilization to ensure sterile instruments do not become contaminated prior to use (Davey and Ince 2004). Disinfection refers to the use of liquid chemicals on surfaces and at room temperature to kill disease causing microorganisms. Disinfection is a less effective process than sterilization because it does not kill bacterial endospores.

Sterilization, if performed properly, is an effective way of preventing bacteria from spreading. It should be used for the cleaning of the medical instruments or gloves, and basically any type of medical item that comes into contact with the blood stream and sterile tissues. Other sterilization methods exist, though their efficiency is still controversial. These methods include gas sterilization, UV sterilization, and sterilization with other chemical agents such as peroxyacetic acid, paraformaldehyde and gas plasma sterilization (British Society of Gastroenterology 2008).

Hand hygiene is widely acknowledged to be the single most important activity for reducing the spread of infection, yet evidence suggests that many healthcare professionals do not decontaminate their hands as often as they need or use the correct technique. This means that areas of the hands can be missed. Hand decontamination refers to the process for the physical removal of blood, body fluids and transient microorganisms from the hands, i.e., hand washing, and/or the destruction of microorganisms. Transient Flora are acquired by touch e.g. from the environment, touching patients laundry, equipment etc. They are located superficially on the skin, readily transmitted to the next thing touched, and are responsible for the majority of healthcare associated infections. They are easily removed by hand Decontamination (Department of Health 2006).

Effective hand washing is one of the main contributions to infection control. An effective hand washing technique involves three stages: preparation, washing and rinsing and drying. Preparation requires wetting hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. The hand wash solution must come into contact with all surfaces of the hands. The hands must be rubbed together for a minimum of 10-15 seconds paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with paper towels (Pratt et al 2007).

Patients in hospital, nursing homes and long-term care facilities are at high risk of developing infections that they did not have before admission. Most healthcare-associated infections are spread by direct contact, especially via the hands of healthcare workers. Traditionally, hand hygiene, such as washing hands before and after touching patients, has been considered the single most important way of reducing infections. Increasingly, the use of alcohol-based hand rub is used alongside or in replacement of traditional washing with soap and water. However, compliance with hand hygiene is poor (Vernaz et al 2008).

A prospective study carried out by Pratt et al 2007 concluded there is still not enough evidence to be certain what strategies improve hand hygiene compliance. Introducing alcohol-based hand rub accompanied by education/training is not enough, while using multiple strategies, including involvement of staff in planning activities or applying social marketing strategies, may be helpful. Pratt summarised more research is needed. In addition Bellis 2006 summarised a hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.

The practice of scrubbing hands before surgery has been highly regimented and ritualized. Scientific evidence to support many tradition-based perioperative practices such as surgical hand scrubs is lacking, and more studies are needed to build a body of empirical knowledge that demonstrates their efficacy. Well designed randomized controlled trials are needed to evaluate different scrubbing regimens such as different scrubbing durations, antiseptic products, and whether to use a brush (Luby et al 2006).

A study by Tanner, Blunsden and Fakis 2007 found that nail picks and nail brushes did not provide additional decontamination. Indeed the findings suggested a trend towards chlorhexidine alone being more effective than chlorhexidine used in conjunction with a brush or a nail pick, though a larger sample size would be needed to show statistical significance. The ineffectiveness of the nail bush is not surprising as scrubbing skin with a brush has already been shown to increase bacterial counts (Tanner, Swarbrook, Stuart 2008).

Drying is an essential part of the hand hygiene process. In November 2008, a non-peer-reviewed study was presented to the European Tissue Symposium by the University of Westminster, London, comparing the bacteria levels present after the use of paper towels, warm air hand dryers, and modern jet-air hand dryers. Of those three methods, only paper towels reduced the total number of bacteria on hands, with “through-air dried” towels the most effective.

A surgical site is the incision or cut in the skin made by a surgeon to carry out a surgical procedure. The position and size of the surgical site depends on the intended procedure and the type of surgery. For example, laparoscopic surgery (which uses fine instruments and a video-camera) requires very small incisions whereas more complex surgery may require a very large incision.

A SSI can occur when bacteria from the skin, other parts of the body or the environment enter the incision made by the surgeon and multiply in the tissues. This results in physical symptoms as the body tries to fight the infection. There may be pus, inflammation, swelling, pain and fever.

SSI is relatively rare. High standards of asepsis (procedures that reduce the risk of bacterial contamination e.g. sterile equipment) in operating theatres are