Ensemble Theatre Group

SURVEILLANCE AND STERILISATION OF OPERATIon THEATRES

In the Developing World

Dr.T.V.Rao MD – Dr.Chithra.VN MD

In spite of brief stay of patients in the operation theatre (in majority of circumstances), the environment of operation theatre plays a great role in the onset and spread of infection because of a multifactor causation of infection. It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances as in most developing countries, work in isolation and few facilities to make any epidemiological surveys Many believe that routine Microbiological monitoring is most essential but in reality it is not practicable. But every hospital should pay good attention in proper maintenance of air conditioning plants, ventilator systems, and to have greater control on mechanisms and personnel involved in disinfection and sterilization of materials used in the theatres in operative procedures.

Operation theatres should be built with implementation of good civil Engineering standards.

OPERATION THEATRE – DISCIPLINE

1. Only people absolutely needed for an assigned work should be present.

2. People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres, which will greatly reduce bacterial count.

3. Air borne contamination is usually affected by type of surgery, quality of air which in fact depends on rate of air exchange.

All the persons including the least cadre of employers are partners in infection control and should be aware to comply with infection control regulations

4 Prompt disposal of Theatre waste out of the theatre is of top priority. Any spillage of Body fluids including Blood on the floors is highly hazardous and prompts the rapid multiplication of Nosocomial pathogens in particular Pseudomonas spp

SURVEILLANCE OF OPERATION THEATRE

Role of Microbiological Surveillance

The environments in the operation theatre are dynamic and subject to continuous change. Good infrastructures do not mean a safe environment as human make a greater difference in making the environment unsafe.

Microbiologists should be aware of organisms, sites and populations as surveillance cultures should be chosen carefully to allow meaningful interpretation of results.

Microbiologists should be familiar with the clinical techniques as those normally used for culturing clinical specimens may not yield correct result when applied to environmental specimens.

Sites and cultured reports should not be chosen as etiological sources in the present infections. Culturing unnecessary surface areas causes confusion and meaningful interpretation is lost.

AIR IS THE IMPORTANT SOURCE OF INFECTION

Bacterial counts in operation theatres are influenced by the number of individuals present, ventilation and air flow, the results should be interpreted taking the above facts into consideration.

Surveillance for Air borne Pathogens:

In resource poor Hospitals settle plates with blood agar are used and can detect pathogens, commensals and saprophytic bacteria. Multiple plates are kept and results are based on overall assessment rather than on a single plate study in the room. Microbiologists will clarify the acceptable counts at the different physical locations in multispeciality hospitals.

There is a sea change in analysis of bacterial counts in recent past with advances in medical technologies like Joint replacement surgeries dealing with critical patients. Slit sampler and Air centrifuge equipment for bacterial counts are replacing settle plates, the safe level of colony counts can be calculated as per the standards created with peer reviewed studies by the manufacturers.

How frequently we can do the Surveillance for Air borne Microbes.

Yet there is no definite answer to this question

Doing too frequent surveys are expensive and will not correlate the existing infection rate in the Hospital.

But can indicate the circumstance we operate which can have bearing effect if the safety standards fall

Surveillance for Clostridia spores

The age old tradition of detection of anaerobic spores of C.tetani, and Gas gangrene producing organisms are losing ground with onset of more awareness on theatre sterilization. Routine testing for the Anaerobes is not essential except when there were suspected cases of Tetanus or Gas gangrene attributed to operating in a particular Operation theatre.

But it is ideal to survey the Operation theatres for anaerobes when newly constructed or any remodeling or structural alterations are done. In such situations which will have trust worthy safety of the theatre.

STERILISATION AND DISINFECTION OF OPERATION THEATRES AND CRITICAL CARE AREAS

GENERAL INSTRUCTIONS

1. Keep the floor dry when in use.

2. Use only vacuum cleaners (booming to be forbidden as it will dispense the infected material all around and on the equipments.

3. Chemical disinfection of an operation room floor is probably unnecessary. The bacteria carrying particles already on the floor are unlikely to reach an open wound in sufficient numbers to cause an infection

(Ayliffe et al 1967. Hombroeus et al 1978)

Cleaning alone followed by drying will considerably reduce bacterial population.

4. Wall and Ceilings- Wall and ceiling are rarely contaminated. The numbers of bacteria do not appear to increase even if walls are not cleaned. Frequent cleaning is not necessary and has little influence on bacterial counts. Routine disinfection is therefore unnecessary, but only cleaned when dirty.

ENVIRONMENTAL CLEANING OF OPERATION THEATRES

At the Beginning of the Day

1. Only remove the dust with cloth wetted with clean water. ( Mop theatre furniture lamps, sitting tables, trolley tops, operation tables, procedure tables, Boyle’s apparatus)

Note: Need not use chemicals/disinfectants unless contaminated with blood or body fluids

Between the procedures

Clean operation tables or contaminated surfaces with disinfectant solutions.

1. In case of spillages of blood/ body fluids decontaminate with bleaching solution/ chlorine solution (10% available chlorine)

2. All discard waste in plastic bags (do not accumulate around surgical sites)

3. Do not discard soiled linen and gowns in the operation theatre floor.

At the end of the day

1. Clean all the table tops, sinks, door handles with detergent followed by low level disinfectant.

2. Clean the floors with detergents mixed with warm water.

3. Finally mop with disinfectant like phenol in the concentration of 1 in 10 (low concentrations of phenol will not serve the purpose).

4. Keep the operation theatre dry for the next day’s work

Fumigation

1. Seal the room with adhesive tapes round the edges of the doors/windows and ventilators and apertures.

2 For Each 1000 cu.ft of space place 500ml formaldehyde (40% solution) and 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door.

3. Seal the room for 24 hrs

4. Then open the door and neutralize any residual formaldehyde with ammonia by exposing 250ml of S.G 880 ammonia/ 1Lt of formaldehyde used. (Ref – Mackie and McCartney Practical Medical Microbiology 13th Edition)

5. Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. Too frequent use and inhalation is hazardous

6 Several new safe chemicals are emerging but constrains of economy limit the use and several hours of closure of operation theatres can be curtailed with Fumigation.

THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED THE RATES OF INFECTION

1. Every Hospital must constitute Infection control committee to monitor the events in the Hospital, on all matters related to control of Infections.

2. The entry of unnecessary personnel to be restricted into operation theatres as every one contributes to Infection.

3. A thorough washing with warm water and good detergent and carbolisation can bring overall improvement than mere fumigation.

4. Frequent monitoring and training of medical and paramedical staff must carry high priority than mere mechanical and chemical methods.

5. Thorough washing and carbolisation if done everyday after the surgeries will greatly enhance the safety standards and economize the repeated expenditure on fumigation.

TRAINING OF PARAMEDICAL STAFF/ RESIDENTS

1. The short solution to control infection lies with trained staff.

2. The principal and control of infection to all new comers and junior staff should be a goal of any good Institution.

3. Formulate guidelines update as per the changing situation in control the infection.

4. Institute should formulate ideas on infection control to the need of circumstances, as there are no fixed guidelines or formulae to control to suit all occasional.

5. Simple repeated hygienic hand wash is most cost effective method to reduce several infections in Hospitals, in particular operation theatres

Note

The knowledge on Maintenance, Sterilization and control of Infections in Operation theatres a rapidly evolving Science

Wish to know more about Operation theatre Maintenance for control of Infection Read through

Principles, And Practice of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe.

All Institutes wish to develop to improve hygiene and sterilization standards, and start critical surgeries doing Cardiothoracic, Organ replacement and prosthetic surgeries should subscribe to the internationally accredited Journal

“The Operating Theatre journal” published from U K.

*****************************

I’d like to begin by differentiating postmodern theatre from its preceding periodizing categorization, the ‘classical’ and the ‘modern’ drama. Classical drama is characterized by the value placed in the plot and its adherence to Aristotle’s laws of dramatic unities. In the nineteenth century we also observed how Hegelian philosophy filtered into modern drama with the movement of ‘man’/character at the forefront of dramaturgy in the character dramas of Ibsen, Strindberg and Chekov. We also see how Aristotle’s mimesis is taken to the heights in the period of naturalism as influenced by the Darwinian science in the stagings of modern theatre. Raymond Williams observes the perfection of tragedy in modern drama where the alienated predicament of the human being in a highly industrialized world is highlighted. He sees Beckett’s tragicomedies representing the reduction and degradation of the human beings in a new absurdist dramatic structure.

To Elinor Fuchs, it is in the postmodern theatre that we witness the “death of the character” and the eradication of the plot. In this statement we are reminded of Barthes’ announcement of the “death of the author”, Foucault stating the “death of man” and Lyotard hailing the dissolution of metanarratives. As rigid categorization and structures of modernism collapse, eclecticism now characterizes postmodernism. But unlike Jameson’s notion of pastiche and extreme consumerism of multi-national capitalism, critical postmodern theatre derives its theory from the post-structuralists’ insight on semiotics. De Saussure laid bare the very construction of the human language exposing its structure of signs and codes. Taking off from this, Derrida’s analysis of the subjectivity of man’s meaning-making has furthered the invalidation of metanarratives. Now as the validity of the sign-signified and code-meaning constructs of languages are put into question, postmodernists are forced to investigate the language construction itself. Ultimately, we come to realize that meaning and signification is subjective and should be contextualized. With this, categorizing boundaries set by modernism collapse as well.

How do all these reflect in postmodern theatre?

Raymond Williams notion of the theatre convention explains this. Conventions in theatre according to Raymond Williams are methods such as figurative speech, stage blocking, songs or dance through which specific dramatic objectives are achieved. He pointed out how conventions in the theatre whether, performative techniques or literary devices, are characterized by its acceptability by the audience and its relations to the specific given standards. With this, he stressed the fact how dramatic conventions are maintained as “terms upon which author, performers and audience agree to meet, so that the performance may be carried on.” Nicole Boireau expounded on the concept of dramatic conventions through the Hamletesque metaphor of the ‘Mousetrap’. From this, he claims that the truth can be accessed through the world of illusion; that it is only through theatricality that truth can be revealed. Theatre expresses reality through the use of artificial conventions. He explained that only through the reflective nature of drama and the dramatic conventions that truths presented in drama are validated . It is then through the same dramatic and theatrical conventions set as the medium in expressing truths, that the expressed truths can be validated. It is through the limitations and self-confined means of definition can the expressed truths substantiate.

Williams and Boireau’s explanation is a profound manifestation of structuralist and post-structuralist concept of laying bare language and systems of signs and codes. Although rooted in the Classical and Modern Theatre tradition, this is a postmodern realization of what Linda Hutcheon calls the self-reflexive nature of postmodern theatre.

With the dissolution of a ‘universal’ language, postmodern theatre is but provoked to look into historical and cultural contexts for a language to articulate itself. The same characteristic is seen in other art forms. Postmodern choreographers made dances about dance, inquiring on the very core of movement vocabularies that gave birth to choreographical works on walking, skipping, etc. This is also true in the experimentations on the various dance styles seen in Twyla Tharp’s combinations of jazz, ballet and ballroom. In the Philippines, this is seen in Agnes Locsin’s and Alice Reyes’ fusion of jazz and ballet and Philippine folk and ethnic movements. Postmodern architects see the history of architectural design as a diverse source of signs to be combined and recombined, thus Greek columns, Art Deco ornamentation and Modern Industrial materials are eclectically put together in a single building.

Postmodern theatre sees the various cultural and historical traditions as a vast source of signs. Kaye describes how postmodernism sees history as a store of signs available for postmodern theatre practice. In a recent production of Hamlet in Singapore, Hamlet was shown as a Noh actor Ophelia as a Balinese dancer. Or in the recent staging of Dulaang Habi’s musical Sa Kaharian ng Araw, audiences are taken into an seemingly incoherent worlds of a cabaret/rock concert, a Peking opera stage, and an extremely expressionistic theatrical world. The music is a mixture of Broadway influenced pop and rock songs, and fusion of classical and traditional Filipino ethnic and folk music. In the postmodern theatre, representations in acting style, costumes, production design, music and other elements are taken from different contexts.

With the collapse of the modernist boundaries, postmodern theatre takes on pluralism and multiplicity in style, approach and over-all process. This has been reflected in various approaches to production. Another important postmodern theatre practice is the use of inter-text, or what Jameson calls a culture of quotations, where various texts could be used to comment on each other. Such is in a production of Romeo and Juliet, where the play ends with the closing monologue by Puck from A Midsummer Night’s Dream. In Nick Pichay’s musical version of the Oyayi ng Ulan, the character Dugong complained about the accumulating garbage in the ocean. He remarked that the worst kind of garbage is the postmodern poetry of new poets- which of course includes Pichay himself.

With the similar collapse of the modernist notion of Aristotle’s linearity and the Hegelian logic of cause and effect, postmodern theatre is characterized by multi-dimensionality and simultaneity. A simplified example of this is Maria Irene Fornes’s Fefu and Her Friends where the audiences are divided into groups to see different scenes of the play happening in various places. Or in the seashore scene of the 2002 staging of Sa Kaharian ng Araw, past and present converge with the appearance of Paolo’s deceased parents in the same stage where Paolo lovingly recalls them. On the same space in the stage an actor fishes on one side, while another plays with a rain stick, while other actors waiting for their cue sit attentively on chairs onstage. Here, multi-dimensionality and simultaneity is not just seen in how the plot is (dis)arranged. Even the actors playing the characters go through different dimensions of performance and representation in the same time and space. The actor although dressed up for the character he is to portray sits on a chair on the side waiting for his cue, substantiate both as the actor and as the character. The person exist as both the actor and character simultaneously but in different dimensions – where at one point, while he waits for his cue he essentially is not part of the play but simultaneously, physically and intentionally, he is physically there.

As Fuchs sees the diminution of character and plot in postmodern theatre, she sees the other theatrical elements taking on equal importance with these elements. She sees that “each signifying element – lights, visual design, music, etc., as well as plot and character elements – stand to some degree as independent actor.” She pointed out that the Aristotelian elements survived but their classical and modern structural hierarchies ceased to operate. This attitude in theatre production takes its roots from the Brechtian Epic Theatre. Brecht earlier on said: “Today we see the theatre being given absolute priority over actual plays. The theatre apparatus’s priority is a priority of means of production… The Theatre can stage anything; it theatres it all” (Raymond Williams, p.280).

And as postmodern theatre see the “death of the author” (the playwright), the director now takes the central role as the theorist responsible for creating the language of a production.

Postmodern theatre is also differentiated from the modern theatre with its mode-of-production. The Industrial Revolution and the idea of mass-production and the division-of-labor affected music and theatre production. The symphony orchestra and the opera are megalomaniac inventions of modernism. The eighteenth century symphony captured the massive sound of modernism. Here music is produced by a big group of musicians who are divided into sections. The opera is an even bigger modernist creation. Such massive theatre production requires a complex web of ‘workers’/artists who work as a big company that include an orchestra, singers, dancers, clothes-makers, carpenters, etc. Even the art-products are now produced for mass consumption. While music used to be performed in courts and chambers, the symphony and the opera are staged in large opera houses that sit thousands.

This new paradigm in theatre production calls for a different attitude from the audience as well. In postmodern theatre, Aristotle’s notion of catharsis comes to extreme obscurity in postmodern theatre. Aesthetic experience becomes completely dependent upon the meaning making process. The aesthetic experience that transpires in the postmodern process is closer to Kant’s sublime. Unlike Aristotle’s cathartic drama that succumbs its audience to empathizing attitude towards the mimetic illusion of classical and modern drama, Kant states that distance is necessary in achieving aesthetic pleasure. Brecht in turn, proposes ‘complex seeing’ in theatre: “Complex seeing must be practiced… . Thinking above the flow of the play is more important than thinking from within the flow of the play” (Ibid., p281).

In as much as postmodern theatre is required to go through a dialogic process of taking theory into practice and back to theory for it to be able to express itself, postmodern audience then is also called to go through this process of meaning-making. Here, postmodern theatre forces its audience to always take on a critical stance in watching. Language-creation and meaning-making in postmodern theatre is never a simple one-on-one correspondence mode of cognition. With a wary stance towards subjectivity of language, postmodern productions then are manifested with recurring disruptions in its audience’s cognitive process. John Orr sees this as intentional dis-recognition/mis-recognition and he notes that these are often used as dramatic-shock effects. The audience is provoked to figure out what is ‘menacing’ and ’strange” in familiar objects onstage and they are prodded to “translate back the strangeness, as a performed disguise of the metonymic, into something they truly recognize, knowing there is no complete translation” (John Orr, p.32) .

In the elusive nature of postmodernism as a theory, DiGaetani sees the importance of having a terminology that can serve as a handle. He noted that “it is wonderful to have a term like postmodernism to describe the art” (John DiGaetani, p. xv). To Fuchs, the theatre has indeed what we can call now postmodern and she asserts that the sooner we grasp its methods we are “immediately at a better vantage point from which to view what used to be called ‘avant-garde’ theatre” (Elinor Fuchs, p.171).

Works Cited:

Boireau, Nicole. Drama in Drama. Macmillan Press: London, c.1997. John DiGaetani. The Search for Postmodernism: Interviews with Contemporary Playwrights. Greenwood Press: New York, 1991. Elinor Fuchs . Death of the Character. Bloomington: Indiana University Press, c.1996 John Orr. Tragicomedy and Contemporary Culture. Hong Kong: Macmillan Academic and Professional, Ltd., 1991 Raymond Williams. Drama from Ibsen to Brecht. Oxford University Press: New York, 1969 c. 1968.