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Factors contributing to airborne particle dispersal in the operating room

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Background Surgical-site infections due to intraoperative contamination are chiefly ascribable to airborne particles carrying microorganisms. The purpose of this study is to identify the actions that increase the number of airborne particles in the operating room. Methods Two surgeons and two surgical nurses performed three patterns of physical movements to mimic intraoperative actions, such as preparing the instrument table, gowning and donning/doffing gloves, and preparing for total knee arthroplasty. The generation and behavior of airborne particles were filmed using a fine particle visualization system, and the number of airborne particles in 2.83 m³ of air was counted using a laser particle counter. Each action was repeated five times, and the particle measurements were evaluated through one-way analysis of variance multiple comparison tests followed by Tukey–Kramer and Bonferroni–Dunn multiple comparison tests for post hoc analysis. Statistical significance was defined as a P value ≤ .01. Results A large number of airborne particles were observed while unfolding the surgical gown, removing gloves, and putting the arms through the sleeves of the gown. Although numerous airborne particles were observed while applying the stockinet and putting on large drapes for preparation of total knee arthroplasty, fewer particles (0.3–2.0 μm in size) were detected at the level of the operating table under laminar airflow compared to actions performed in a non-ventilated preoperative room (P < .01). Conclusions The results of this study suggest that surgical staff should avoid unnecessary actions that produce a large number of airborne particles near a sterile area and that laminar airflow has the potential to reduce the incidence of bacterial contamination.
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R E S E A R C H A R T I C L E Open Access
Factors contributing to airborne particle
dispersal in the operating room
Chieko Noguchi
1
, Hironobu Koseki
2*
, Hidehiko Horiuchi
1
, Akihiko Yonekura
1
, Masato Tomita
1
, Takashi Higuchi
2
,
Shinya Sunagawa
2
and Makoto Osaki
1
Abstract
Background: Surgical-site infections due to intraoperative contamination are chiefly ascribable to airborne particles
carrying microorganisms. The purpose of this study is to identify the actions that increase the number of airborne
particles in the operating room.
Methods: Two surgeons and two surgical nurses performed three patterns of physical movements to mimic
intraoperative actions, such as preparing the instrument table, gowning and donning/doffing gloves, and preparing
for total knee arthroplasty. The generation and behavior of airborne particles were filmed using a fine particle
visualization system, and the number of airborne particles in 2.83 m
3
of air was counted using a laser particle
counter. Each action was repeated five times, and the particle measurements were evaluated through one-way
analysis of variance multiple comparison tests followed by TukeyKramer and BonferroniDunn multiple
comparison tests for post hoc analysis. Statistical significance was defined as a Pvalue .01.
Results: A large number of airborne particles were observed while unfolding the surgical gown, removing gloves,
and putting the arms through the sleeves of the gown. Although numerous airborne particles were observed while
applying the stockinet and putting on large drapes for preparation of total knee arthroplasty, fewer particles (0.32.
0μm in size) were detected at the level of the operating table under laminar airflow compared to actions
performed in a non-ventilated preoperative room (P< .01).
Conclusions: The results of this study suggest that surgical staff should avoid unnecessary actions that produce a
large number of airborne particles near a sterile area and that laminar airflow has the potential to reduce the
incidence of bacterial contamination.
Keywords: Surgery, Airborne particle, Surgical-site infection, Intraoperative action
Background
The Centers for Disease Control and Preventions Na-
tional Nosocomial Infection Surveillance (NNIS) system
reported 15,523 surgical-site infections (SSIs) following
593,344 operations between 1986 and 1996, and 77% of
the deaths following complications from surgery were
reported to be related to SSI [1]. Especially in the field
of orthopedics, SSI after prosthetic arthroplasty is a
devastating complication because treating the infection
requires several procedures at considerable expense. The
incidence of SSI in the United States after primary total
hip arthroplasty (THA) is 0.88% and on the rise, whereas
the infection rate for revision THA is more than double
that for primary procedures [2]. Though SSIs are multi-
factorial in origin and include both patient- and
procedure-specific factors, airborne infection is thought
to be one of the major sources of exogenous contamin-
ating bacteria [35]. During surgical procedures,
bacteria-laden airborne particles, including textile fibers,
dust particles, skin fragments, and respiratory aerosols,
may settle on surgical instruments or directly enter the
surgical site, resulting in SSI [69]. Hansen et al. noted
that bacterial counts were lower in environments with
fewer airborne particles, and that the number of parti-
cles larger than 5 μm was closely correlated with bacter-
ial concentration [10]. Campbell et al. reported that a
* Correspondence: koseki@nagasaki-u.ac.jp
2
Department of Locomotive Rehabilitation Science, Unit of Rehabilitation
sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1
Sakamoto, Nagasaki 852-8520, Japan
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Noguchi et al. BMC Surgery (2017) 17:78
DOI 10.1186/s12893-017-0275-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
decreased turnover of operating staff resulted in lower
rates of SSI [11]. Other studies have demonstrated that
80%90% of pathogenic bacteria detected from surgical
wounds were related to airborne particles in the operat-
ing room [12] and that airborne skin scales can act as
vectors for pathogenic microorganisms to infect the
surgical wound [13]. The Healthcare Infection Control
Practices Advisory Committee guidelines for the preven-
tion of SSI published in 1999 recommended to consider
performing orthopedic implant operations in operating
rooms supplied with ultraclean airand classified this
recommendation as category II (suggested for imple-
mentation and supported by suggestive clinical or epi-
demiological studies or theoretical rationale) [1]. Thus,
surgical-site contamination by airborne microorganisms
plays a central role in the exogenous pathogenesis of
SSIs, and controlling and minimizing airborne particles
in the operating room deserves close attention to protect
patients against exogenous infection caused by airborne
bacteria.
Non-woven fabric, widely used for surgical drapes,
gowns, and hoods, is thought to be one of the major
origins of airborne particles in the operating room.
There is a high level of activity involving fabrics during
preoperative preparation of a patient, resulting in the
dispersal of a large number of airborne particles [14].
Textile fibers from non-woven fabric may migrate to or
come in contact with unsterile areas, such as the walls,
floor, and human skin. Therefore, a greater number of
particles produced from non-woven fabric increases the
chances of airborne particles being contaminated with
bacteria. Although any action in the operating room can
produce particles, the degree to which these actions
generate particles remains unclear, and the dispersal
conditions of airborne particles during preoperative pro-
cedures has not yet been visualized. To prevent SSIs,
operating staff including surgeons must understand the
situations that are at high risk for producing airborne
particles in the operating room.
The aim of this study is to investigate and quantify the
dispersion and distribution of airborne particles due to
actions in the operating room.
Methods
Experimental design
All surgical drapes and garments used in this study were
made from generally used spunlaced non-woven fabric
that consisted of 45% wood pulp and 55% polyester pulp.
Spunlacing is a technique used to give a web of fibers
sufficient cohesion by mechanical bonding, while the
paper-making technique allows the production of a web
where the fibers are consolidated by hydroentanglement.
The water jet pressure was up to 100 bar. After removal
of water by suction, the non-woven fabric was air dried
(180 °C). The surface density of the non-woven fabric
was 80 g/m
2
. The authors performed the following three
patterns of physical movements in the present study to
mimic some of the intraoperative actions that take place
during major orthopedic surgery.
Preparing instrument table
Step 1: an assistant holds and opens a sterilized package.
Step 2: the operating room nurse removes the folded
surgical drape (DEF-58-T®, hopes Co. Ltd., Hokkaido,
Japan) from the package and unfolds it in front of his or
her chest. Step 3: the nurse slowly spreads the drape on
an instrument Table (1 m high, 80 cm wide, and 50 cm
deep).
Gowning and donning/doffing gloves
Step 1: an assistant holds and opens a sterilized package.
Step 2: the surgeon removes the folded surgical gown
(JG-100®, hopes Co. Ltd.) made from spunlaced non-
woven fabric from the package and unfolds it in front of
his or her chest. Step 3: a circulating nurse helps the
surgeon put on the surgical gown according to the trad-
itional closed gowning technique. Step 4: the surgeon
puts on and takes off latex powdered surgical gloves
(Tradition®, Medline International Japan, Tokyo, Japan).
Procedures 1 and 2 were performed in a non-ventilated
preoperative room.
Preparation for total knee arthroplasty (TKA)
Step 1: one of the co-authors acting as a patient is laid
on the operating table and positioned correctly under
laminar airflow (LAF) in a bio-clean room (ISO class 7
criterion; Fed. Standard class 10,000) with a high-
efficacy particulate air (HEPA) filter. The settings for
LAF were: wind velocity, 0.44 m/s; room temperature,
21.9 °C; and humidity, 32.4%. Step 2: after all surgeons
were gowned with Sterishield Togas and T4 helmets
(Stryker Instruments, Kalamazoo, MI, USA), one sur-
geon lifted the patients left leg. Another surgeon applied
a stockinet and wrapped the leg with an elastic bandage.
Step 3: one surgeon fit three hydrophobic drapes (RH-
33®, hopes Co. Ltd.) around the patients thigh, and then
the surgeons passed the patients leg through a large,
holed drape (RH-710EFC90®, hopes Co. Ltd.). Step 4: a
surgeon cut and removed the piece of stockinet from
around the surgical site and covered the patients leg
with an iodine-impregnated plastic film.
The generation and behavior of airborne particles were
filmed using a fine particle visualization system (Shin-
Nihon Air Technologies Co. Ltd., Tokyo, Japan) with a
green laser apparatus. After making a uniform laser
sheet, light reflected from airborne particles was filmed
using a highly sensitive camera with an interference
filter. The number of airborne particles in 2.83 m
3
of air
Noguchi et al. BMC Surgery (2017) 17:78 Page 2 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
was counted using a laser particle counter (KC-52®, RION,
Tokyo, Japan), and the mean value was taken as the mea-
sured value. Sampling was performed at 1.1 m above floor
level, simulating the height of the operating table. The
sampling tube (6 mm internal diameter) was attached to
the air intake port of the particle counter, and the meas-
urement interval was set to 1 min (2.83 m
3
). Particles were
separated into four categories based on their size (0.3
0.5 μm, 0.51.0 μm, 1.02.0 μm, and 2.05.0 μm).
Statistical analysis
Each established intraoperative action was repeated five
times, and the particle measurements were compiled for
statistical analysis, which included one-way analysis of vari-
ance multiple comparison tests followed by TukeyKramer
and BonferroniDunn multiple comparison tests for post
hoc analysis, using SPSS version 22.0 (SPSS, Chicago, IL,
USA). Values are expressed as means ± standard deviations.
Statistical significance was defined as a Pvalue .01.
Results
Preparing instrument table
The fine particle visualization system showed that many
particles were dispersed in the antero-inferior direction
while the operating room nurse unfolded a surgical
drape. The mean number of airborne particles for every
action is shown in Table 1. Most of the particles
detected were 0.30.5 μm in size.
Gowning and donning/doffing gloves
Similar to when unfolding the drape, many particles
were dispersed in the antero-inferior direction while the
surgeon unfolded a surgical gown (Fig. 1). Notably,
particles burst from the cuffs or collar of the gown the
moment the arms were put through the sleeves and the
tail of the gown was stretched (Fig. 2). Moreover, a lot of
small airborne particles, which were thought to be
powder, sweat, and skin fragments, were observed when
the surgeon removed the surgical gloves (Fig. 3). The
mean number of airborne particles during gowning and
donning/doffing surgical gloves was similar to that
during preparation of the instrument table.
Preparation for TKA
Before any actions, airborne particles in the bio-clean
room drifted downward slowly under LAF. The actions
of applying a rolled stockinet (Fig. 4), and cutting the
elastic bandage generated a lot of airborne particles.
Additionally, when placing the large drape with a hole in
the center over the leg, many particles were generated
under the drape as it rubbed the stockinet. However,
most of the particles drifted downward slowly due to the
LAF. As a result, the counts in the bio-clean room for
particles (0.31.0 μm in size) were significantly lower
compared to those when preparing the instrument table
or when gowning and donning/doffing gloves (P< .01).
The counts for particles (1.12.0 μm in size) were also sig-
nificantly lower than those when gowning and donning/
doffing gloves (P<.01).
Discussion
The microorganism most often responsible for SSIs is
Staphylococcus aureus, which can adhere to particles.
Airborne transmission has been implicated in nosoco-
mial outbreaks of methicillin-resistant Staphylococcus
aureus (MRSA) [15]. Because MRSA range from 0.8 to
1.0 μm in diameter, it is anticipated that not only larger
sized airborne particles but also aggregates of smaller
sized airborne particles held together by static electricity
can be laden with pathogenic bacteria. Surgical drapes
and garments are thought to be two of the major origins
of airborne textile fiber particles. This is one reason why
the material of surgical drapes and garments has been
switched from cotton to non-woven fabric [16]. Cotton
can generate many textile fiber particles, and woven
cotton has interlacing gaps ranging from 7 to 50 μmin
diameter that can easily pass bacteria-laden airborne
particles or skin fragments from medical staff. Even non-
woven fabrics, however, may generate many textile fiber
particles depending on the action of the wearer in the
operating room. Therefore, prediction and reduction of
particle dispersion and distribution from non-woven
fabrics are key to lowering the risk of contamination by
airborne microorganisms.
In our study, a high number of dispersed airborne
particles were observed when unfolding the drape and
surgical gown. Since the drape and surgical gown were
initially sterile, the particles from them are considered to
be free of bacteria. However, airborne particles can act
as vectors for transmission of bacteria after coming in
contact with unsterile areas (e.g. skin, walls, or floor) [4].
Particles settled on an unsterile floor can be easily
Table 1 Mean number and standard deviation of airborne particles (particles/2.83 m
3
)
Particle size category (μm) 0.30.5 0.61.0 1.12.0 2.15.0
Preparing instrument table 16,826 (509.1) 1423 (33.9) 187 (7.8) 128 (14.8)
Gowning and donning/doffing gloves 18,075 (4202.7) 1589 (344.7) 232 (49.6) 173 (31.4)
Preparation for TKA 1207 (125.9)
§*
202 (15.6)
§*
66 (2.8)
*
109 (0.7)
§
:P< .01 compared to the actions of preparing the instrument table
*
:P< .01 compared to the actions of gowning and donning/doffing gloves
Noguchi et al. BMC Surgery (2017) 17:78 Page 3 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
dispersed by air eddies generated from opening doors
and foot traffic. A recent study noted a trend towards
lower SSI rates in hospitals with decreased operating
room staff turnover [11]. Thus, it is preferable that the
actions such as unfolding a drape and surgical gown
should be carried out away from the operating and
instrument Tables.
A greater number of scattered particles were also seen
when removing gloves, putting the arms through the
sleeves of the surgical gown, and stretching the tail of
the gown. Individuals in the operating room generate
many bacteria-laden skin fragments [17, 18], which may
migrate from sites of uncovered skin (e.g. neck and face)
or through gaps in the material used to make surgical
garments [19]. Dharan and Pittet reported that more
than half of all infections following clean surgery were
caused by the normal skin flora of patients and health-
care workers [20]. Dispersed airborne particles visualized
during removal of surgical gloves and during donning a
surgical gown in this study are thought to contain many
skin fragments and bacteria-laden textile fibers or pow-
ders that may cause SSIs. Regarding SSIs and surgical
gloves, most of the recommendations focus on the risk
of permeability and perforation, and there is no evidence
associated with particle dispersion [2123]. Our findings
support a clear practical recommendationremoving
gloves and donning a surgical gown should be strictly
avoided near the surgical site or sterile instruments.
Moreover, surgeons should pay close attention to minim-
izing the production of airborne particles while applying or
Fig. 3 Removing surgical gloves. Particles including powder, sweat,
and skin fragments dispersed and floated in the air
Fig. 4 Applying stockinet. One surgeon lifted the left leg of an
author acting as a patient and another surgeon applied a stockinet.
Many particles were produced around the patients leg and then
migrated downward slowly under laminar airflow
Fig. 2 Putting arms through the sleeves. A large number of particles
burst from the cuffs of the gown
Fig. 1 Unfolding the surgical gown. The dispersal of reflective
airborne particles (bright dots) could be observed with a fine particle
visualization system
Noguchi et al. BMC Surgery (2017) 17:78 Page 4 of 6
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cutting an elastic bandage or stockinet and covering a limb
with a holed drape, especially for immunocompromised
patients. Our results demonstrated that both an elastic
bandage and stockinet made of cotton produce many
textile fiber particles when cut, stretched, or even rubbed
close to the surgical site. Interestingly, although many parti-
cles were observed during preparation for TKA, only a
small number of airborne particles were detected at the
level of the operating table. The LAF system, which is com-
monly used in bio-clean rooms [24], creates a homogenous,
low-turbulence airflow directly over the operating area
through a combination of high airflow rates and HEPA
filtration [10]. Laminar airflow with HEPA filters can
remove approximately 99.97% of airborne particles
larger than 0.3 μm, resulting in minimal air bacterial
counts [6, 20]. The fine particle visualization system
used in the present study revealed that airborne particles
in the operating room drifted downward slowly under
LAF. This is why there were fewer particles at the level of
the operating table compared to the number of particles
detected in the non-ventilated preoperative room. Re-
cently, some publications have questioned whether LAF
ventilation confers any benefit and even suggest that post-
operative SSI rates may be higher after surgery under LAF
conditions compared to conventional operating rooms
with turbulent ventilation [25, 26]. The most recent global
guidelines from the World Health Organization on the
prevention of SSI also suggested that LAF ventilation
systems should not be used for patients undergoing total
arthroplasty [27]. However, the strength of the recommen-
dation is conditional level, and the quality of the evi-
dence is low to very low. Moreover, the onset of SSIs is
influenced by multiple factors, including the virulence of
the bacteria, quality of the patients immune defenses, and
prophylactic antibiotic therapy. Therefore, although the
relationship between LAF systems and SSI rates remains
unclear, it can be speculated from our results that LAF
can decrease the chances of bacterial air contamination.
Each action investigated in the present study was in
preparation for TKA, and not representative of the entire
operation. Although surgical-site bacterial counts correl-
ate with airborne bacteria and particle counts [35], they
have not been demonstrated to correlate directly with the
rate of SSIs [4]. The actual relationship among the amount
of particles, the incidence of bacterial contamination, and
the rate of SSIs was not addressed in this study. The
present results, obtained using well-defined environmental
conditions, cannot necessarily be translated directly to
different settings, i.e. different sized operating rooms or a
different number of personnel within the operating room.
However, our study simulating some of the intraoperative
actions gives surgical staff a clearer picture of the disper-
sion and distribution of particles that could contaminate
the surgical site. Surgical staff should consider carefully
measures to minimize the production of airborne particles
and decrease particle counts during intraoperative proce-
dures to lower the risk of contamination by airborne
microorganisms.
Conclusions
Fine particle visualization and automatic particle counting
revealed that a large number of airborne particles were
produced during unfolding the surgical gown, removal of
gloves and placing arms through the sleeves of the gowns.
Medical staff in the operating room should avoid those
actions near sterile areas. Fewer particles were detected at
the level of the operating table under laminar airflow,
which suggests that laminar airflow has the potential to
reduce the incidence of bacterial contamination.
Abbreviations
HEPA: High-efficacy particulate air; LAF: Laminar airflow; MRSA: Methicillin-
resistant Staphylococcus aureus; NNIS: National Nosocomial Infection
Surveillance; SSIs: Surgical-site infections; THA: Total hip arthroplasty;
TKA: Total knee arthroplasty
Acknowledgements
The authors gratefully acknowledge Central Uni Co. Ltd. (Tokyo, Japan) for
kindly permitting use of the bio-clean operating room. The authors did not
receive and will not receive any benefits or funding from any commercial
party related directly or indirectly to the subject of this article.
Funding
This work was partially supported by JSPS KAKENHI Grant Number
232024000.
Availability of data and materials
The authors do not wish to share their data for the following reason:
-The dataset is part of ongoing study protocols.
Authorscontributions
All authors made substantial contributions to this article. CN and HK
conceived and designed the study. CN, HK, HH, TH, and SS participated in
the experiments and gathered the data. CN, HK, AY, MT, and MO analyzed
and interpreted the data. CN wrote the initial drafts of the manuscript, and
HK and MO performed the statistical analysis and ensured the accuracy of
the data. All authors have read and approved the final version of the
manuscript and affirm that the work has not been submitted or published
elsewhere in whole or in part.
Ethics approval and consent to participate
All study participants were informed both verbally and in writing of the
objectives of the study and were asked to sign a consent form when
they agreed to participate in the study. The study was granted an
exemption from requiring ethics approval by the ethics committee of
Nagasaki University Graduate School of Biomedical Sciences because this
study did not involve human subjects, human materials, nor did it use
data from actual patients.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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Author details
1
Department of Orthopedic Surgery, Nagasaki University Graduate School of
Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
2
Department of Locomotive Rehabilitation Science, Unit of Rehabilitation
sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1
Sakamoto, Nagasaki 852-8520, Japan.
Received: 15 May 2017 Accepted: 28 June 2017
References
1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for
prevention of surgical site infection. Am J Infect Control. 1999;27:97134.
2. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Par vizi J. Infection burden
for hip and knee arthroplasty in the United States. J Arthroplast. 2008;
23:98491.
3. Beggs CB. The airborne transmission of infection in hospital buildings: fact
or fiction? Indoor Built Environ. 2003;12:918.
4. Chauveaux D. Preventing surgical-site infections: measures other than
antibiotics. Orthop Traumatol Surg Res. 2015;101:S7783.
5. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Airborne
contamination of wounds in joint replacement operations: the relationship
to sepsis rates. J Hosp Infect. 1983;4:11131.
6. McHugh S, Hill A, Humphreys H. Laminar airflow and the prevention of
surgical site infection. More harm than good? Surgeon. 2015;13:528.
7. Sadrizadeh S, Tammelin A, Ekolind P, Holmberg S. Influence of staff number
and internal constellation on surgical site infection in an operating room.
Particuology. 2014;13:4251.
8. Pasquarella C, Pitzurra O, Herren T, Poletti L, Savino A. Lack of influence of
body exhaust gowns on aerobic bacterial surface counts in a mixed-
ventilation operating theatre. A study of 62 hip arthroplasties. J Hospital
Infect. 2003;54:29.
9. Diab-Elschahawi M, Berger J, Blacky A, Kimberger O, Oguz R, Kuelpmann R,
et al. Impact of different-sized laminar air flow versus no laminar air flow on
bacterial counts in the operating room during orthopedic surgery. Am
J Infect Control. 2011;39:e259.
10. Hansen D, Krabs C, Benner D, Brauksiepe A, Popp W. Laminar air flow
provides high air quality in the operating field even during real operating
conditions, but personal protection seems to be necessary in operations
with tissue combustion. Int J Hyg Environ Health. 2005;208:45560.
11. Campbell DA Jr, Henderson WG, Englesbe MJ, Hall BL, O'Reilly M, Bratzler D,
et al. Surgical site infection prevention: the importance of operative
duration and blood transfusion results of the first American College of
SurgeonsNational Surgical Quality Improvement Program Best Practices
Initiative. J Am Coll Surg. 2008;207:81020.
12. Howorth FH. Prevention of airborne infection during surgery. Lancet.
1985;1:3868.
13. Brown J, Doloresco Iii F, Mylotte JM. "never ev ents": not every
hospital-acquired infection is preventable. Clin Infect Dis. 2009;49:7436.
14. Knobben BAS, van Horn JR, van der Mei HC, Busscher HJ. Evaluation of
measures to decrease intra-operative bacterial contamination in
orthopaedic implant surgery. J Hosp Infect. 2006;62:17480.
15. Mortimer EA, Wolinsky E, Gonzaga AJ, Rammelkamp CH. Role of airborne
transmission in staphylococcal infections. Br Med J. 1966;1:31922.
16. Blomgren G, Hoborn J, Nyström B. Reduction of contamination at total
hip replacement by special working clothes. J Bone Joint Surg Br. 1990;
72:9857.
17. Dineen P, Drusin L. Epidemics of postoperative wound infections associated
with hair carriers. Lancet. 1973;302:11579.
18. Moylan JA, Fitzpatrick KT, Davenport KE. Reducing wound infections:
improved gown and drape barrier performance. Arch Surg. 1987;122:1527.
19. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the
operating room: an explorative and descriptive study on air quality during
orthopedic trauma implant surgery. Am J Infect Control. 2012;40:7505.
20. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp
Infect. 2002;51:7984.
21. Alijanipour P, Karam J, Llinas A, Vince KG, Zalavras C, Austin M, et al.
Operative environment. J Arthroplast. 2014;29:4964.
22. Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP, Bannister GC.
Clothing in laminar-flow operating theatres. J Hosp Infect. 1996;32:17.
23. Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N, Dujardin F. Surgical
glove bacterial contamination and perforation during total hip arthroplasty
implantation: when gloves should be changed. Orthop Traumatol Surg Res.
2012;98:43240.
24. Iudicello S, Fadda A. A road map to a comprehensive regulation on
ventilation technology for operating rooms. Infect Control Hosp Epidemiol.
2013;34:85860.
25. Brandt C, Hott U, Sohr D, Daschner F, Gastmeier P, Rüden H. Operating
room ventilation with laminar airflow shows no protective effect on the
surgical site infection rate in orthopedic and abdominal surgery. Ann Surg.
2008;248:695700.
26. Salassa TE, Swiontkowski MF. Surgical attire and the operating room: role in
infection prevention. J Bone Joint Surg Am. 2014;96:148592.
27. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al.
New WHO recommendations on intraoperative and postoperative measures
for surgical site infection prevention: an evidence-based global perspective.
Lancet Infect Dis. 2016;16:e288303.
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... In order to prevent airborne transmission, special air handling and ventilation are needed. This is because microorganisms carried in this way can be widely dispersed by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors [27]. Legionella, Mycobacterium tuberculosis, the rubeola and varicella viruses, as well as other microorganisms can be spread through the air [28]. ...
Article
Full-text available
An infection that can be acquired in the hospital or other clinical settings is known as a health care associated infection. It is a major cause of morbidity and mortality among hospitalized patients. It is also one of the factors that contribute to the rising cost of hospital care. According to the CDC, around 1.7 million health care associated infections occur globally each year, which contributes to around 99,000 deaths. Some of these infections are surgical site infections, bloodstream infections, and urinary tract infections. Healthcare related infection can include uncomfortable urination, fever, vomiting, breathing difficulties, skin redness, and discharge from surgical sites. These diseases are transmitted by a variety of means, including damaged skin, mucous membranes, and respiratory pathways. Microbial agents like viruses, bacteria, parasites, and fungi, environmental factors like crowded conditions, patient factors like age, immune status, underlying disease, and diagnostic procedures like endoscopy, catheterization, mechanical ventilation, as well as other surgical procedures, are among the risk factors that predispose one to health care associated infection. Utilizing the relevant specimens, these infections can be identified in the laboratory utilizing microscopy, culture, and serological based tests. Personal hygiene, frequent hand washing, sterilization, disinfection, and proper waste disposal can all help avoid illnesses that are related to healthcare. It is thought that hospital-acquired infections can be controlled and mostly eliminated if they are dealt with methodically and properly, making hospitals safer and more efficient.
... The generation and behaviors of airborne particles were filmed using a fine particle visualization system (ViEST TM ; Shin-Nihon Air Technologies Co., Tokyo, Japan) with a green laser (22,23). After generating a uniform laser light sheet, light reflected from airborne particles was filmed using a highly sensitive camera with an interference filter. ...
Article
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Background: The operating theater is recognized to involve a high frequency of occupational blood and body fluid contacts. Objectives: This study aimed to visualize the production of blood and body fluid airborne particles by surgical procedures and to investigate risks of microbial contamination of the conjunctival membranes of surgical staff during orthopedic operations. Methods: Two physicians simulated total knee arthroplasty (TKA) and total hip arthroplasty (THA) in a bio-clean theater using model bones. The generation and behaviors of airborne particles were filmed using a fine particle visualization system, and numbers of airborne particles per 2.83 L of air were counted at the height of the operating and instrument tables. Each action was repeated five times, and particle counts were evaluated statistically. Results: Numerous airborne particles were dispersed to higher and wider areas while “cutting bones in TKA” and “striking and driving the cup component on the pelvic bone in THA” compared to other surgical procedures. The highest particle counts were detected while “cutting bones in TKA” under unidirectional laminar air flow. Discussion: These results provide a clearer image of the dispersion and distribution of airborne particles and identified higher-risk surgical procedures for microbial contamination of the conjunctival membranes. Surgical staff including surgeons, nurses, anesthesiologists, and visitors, should pay attention to and take measures against occupational infection particularly in high-risk surgical situations.
... Recent studies demonstrated that virtually all common surfaces in healthcare settings contain dry biofilms covering microbial, mostly multi-resistant pathogens [23], and found that the profile of microorganisms in the air resembles that on the hospital surfaces [24]. Manipulations performed by the healthcare personnel contribute to the transfer of surface microorganisms into the hospital air [25,26]. The indicated risk, however, can be controlled through enhanced environmental cleaning and disinfection procedures [27]. ...
Article
Full-text available
Most healthcare-associated infections (HCAIs) develop due to the colonisation of patients and healthcare workers by multidrug-resistant organisms (MDRO). Here, we investigated whether the particulate matter from the ventilation systems (Vent-PM) of health facilities can harbour MDRO and other microbes, thereby acting as a potential reservoir of HCAIs. Dust samples collected in the ventilation grilles and adjacent air ducts underwent a detailed analysis of physicochemical properties and biodiversity. All Vent-PM samples included ultrafine PM capable of reaching the alveoli. Strikingly, >70% of Vent-PM samples were contaminated, mostly by viruses (>15%) or multidrug-resistant and biofilm-producing bacterial strains (60% and 48% of all bacteria-contaminated specimens, respectively). Total viable count at 1 m from the ventilation grilles was significantly increased after opening doors and windows, indicating an association between air flow and bacterial contamination. Both chemical and microbial compositions of Vent-PM considerably differed across surgical vs. non-surgical and intensive vs. elective care units and between health facilities located in coal and chemical districts. Reduced diversity among MDRO and increased prevalence ratio in multidrug-resistant to the total Enterococcus spp. in Vent-PM testified to the evolving antibiotic resistance. In conclusion, we suggest Vent-PM as a previously underestimated reservoir of HCAI-causing pathogens in the hospital environment.
... Two out of the five participants in the spray test expressed concerns that non-visible aerosolised particles could fall through the gap at the top of the headbands or stay trapped behind the visor. A subsequent review of the literature found that while some studies exist on the effects of aerosolised particles in an operating theatre environment, 12 little is known about how a face shield impacts this exposure. 13 This feedback suggests the need for further evaluation to assess efficacy against aerosolised particles, particularly in light of recommendations that face shields, without associated face masks, could help reduce community transmission. ...
Article
Background An often-overlooked item that could cause contamination in the operating suite are the towels used for hand drying following surgical scrub. The purpose of this current study was to determine if there was a difference in the particulate count from different hand drying methods following surgical hand preparation. Methods Three simulated hand drying groups were established: disposable sterilized surgical towels, reusable sterilized surgical towels, and a waterless alcohol-based dry rub. Particle size measurements of 0.3 µm, 5.0 µm, and 10.0 µm were collected at time zero and repeated every minute for 5 minutes for a total of 10 trials each. Results Both the reusable and disposable towels produced significantly more particle matter in all size groups compared to the alcohol scrub control group. A comparison analysis and ANOVA testing demonstrated that alcohol dry scrub produced significantly fewer particles compared to both the disposable blue towels (P<0.01) and the reusable green towels (P<0.01). Disposable towels produced significantly more particles in the 0.3 µm count compared to reusable towels (P<0.05). Conclusions An alcohol-based dry rub without using a towel yielded the lowest amount of particulate formation in this experimental model, while reusable surgical towels produced the highest number of particles. Level of Evidence Level II Experimental Study
Chapter
The chapter discusses a range of potential intra‐operative problems that may be encountered in equine fracture repair. The emphasis, dovetailing with Chapters 9 and 14, is on strategies of avoidance and minimization of risk. Early identification signs are given together with advice on correction and/or damage limitation. Technical problems are organized on an instrument and technique basis allowing comprehensive application to clinical scenarios. For similar reasons, a holistic approach is given to asepsis.
Article
Air quality in the microenvironment of operating rooms (ORs) has attracted much attention as surgical smoke may pose health risks. We investigated air pollution in the operating room with a laminar flow system by examining the number and size distribution of airborne particles, the chemical composition and morphology of single particles, and polycyclic aromatic hydrocarbons (PAHs). In addition, environmentally persistent free radicals (EPFRs) in ORs are reported for the first time. The results showed that there were high levels of fine particles, EPFRs, and PAHs in laminar flow operating rooms during surgical procedures. PM2.5 is the dominant particle in ORs (accounting for >90%), consisting mainly of calcareous and metal-related particles based on the morphology and chemical analysis of single particles. In addition, anesthetic gas-related particles were found in the fine particles, and their toxicology requires more attention. EPFRs in the ORs were mainly carbon-centered radicals that may be reactive to cells. The concentrations of EPFRs and PAHs in ORs were higher than in the outside environment and present a potential health risk to surgeons and anesthetists. Hence, effective filtration and evacuation of surgical smoke are necessary.
Article
Background Meticulous prepping and draping of the surgical field is paramount to reduce the risk of infection. A consistent technique for draping for hip arthroplasty is not well established. One technique for preparing the operative field utilises a sterile stockinette over an unprepped foot. This study aims to assess surgical site contamination when draping for hip arthroplasty without disinfecting the foot. Methods Ultraviolet (UV) fluorescent powder was used as a surrogate for microbial presence on the foot. Powder was applied to a volunteer's foot to a level where antibacterial prep would stop. The leg was then draped according to three methods; directly with stockinette only, wrapping the foot without using an adhesive seal followed by stockinette, and wrapping the foot with the adhesive seal followed by stockinette. Proximal spread of powder after draping was assessed with UV light. Results Contamination of the sterile field was found with all draping methods. Spread was particularly noted in the groin, posterior to the thigh and distal to mid-thigh. Wrapping the foot in a small drape without the adhesive seal prior to stockinette application was associated with significantly greater contamination when compared with use of the seal (p = 0.004). Conclusion Routine formal prepping of the foot during hip arthroplasty is recommended to reduce the risk of surgical site contamination. Surgeons who select not to prep the foot should make use of a small drape with occlusive, adhesive seal prior to stockinette application and consider applying a further U drape to the hip.
Article
In operating rooms (OR), the transport of Colony-Forming Units (CFU) can generate surgical site infections in patients and, as a consequence, CFU must be properly evacuated from the surgical site. Moreover, fine particles (FP) and ultrafine particles (UFP) can be generated during surgeries by cutting and cauterizing surgical tools, with consequent effects on the health of patients and medical staff. Therefore, indoor air quality, comfort and safety conditions in OR must take into account CFU, FP and UFP concentrations. Due to the importance of the topic, the authors have carried out a review of experimental, numerical and experimental-numerical combined works available in the literature, that analyse generation, diffusion and deposition of CFU, FP and UFP in ORs. Numerical studies have been majorly focused on the simulation of CFU using computational fluid dynamics, in order to model the motion inside ORs and the evaluation of factors that influence it. Experimental studies mainly deal with the analysis of particles and CFU motion and deposition. Based on the present analysis, it appears that more research effort is needed to analyse FP and UFP in ORs. Technical standards and national laws have been reviewed in order to analyse the constraints commonly used in the design and operation of ORs and ventilation systems, and to find the technical aspects that are not yet properly considered.
Article
Full-text available
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
Article
• A 21-month study involving 2181 clean and clean-contaminated general surgical procedures was performed to evaluate the effectiveness of a commercially available disposable gown and drape system vs a cotton system in reducing wound infection. The series in which the disposable spun-laced fiber system was used had a significantly lower overall infection rate (2.83% vs 6.5%) as well as better rates in clean (1.8% vs 3.8%) and clean-contaminated (4.8% vs 11.4%) procedures. This effect was independent of all other factors. The odds of developing a wound infection was 2½ times higher with a cotton system than with a disposable system. Actual cost analysis from three types of hospitals showed lower costs with utilization of disposable gown and drape systems. Hospital charges were significantly higher for those patients developing wound infections. The results of this study demonstrated not only significant reduction in wound infection rates but also major cost savings when a disposable gown and drape system was used in the operating room. (Arch Surg 1987;122:152-157)
Article
Surgical-site infections (SSIs) due to intra-operative contamination are chiefly ascribable to airborne particles carrying microorganisms, mainly Staphylococcus aureus, which settle on the surgeon's hands and instruments. SSI prevention therefore rests on minimisation of airborne contaminated particle counts, although these have not been demonstrated to correlate significantly with SSI rates. Maintaining clear air in the operating room classically involves the use of ultra clean ventilation systems combining laminar airflow and high-efficiency particulate air filters to create a physical barrier around the surgical table; in addition to a stringent patient preparation protocol, appropriate equipment, and strict operating room discipline on the part of the surgeon and other staff members. SSI rates in clean surgery, although influenced by the type of procedure and by patient-related factors, are consistently very low, of about 1% to 2%. These low rates, together with the effectiveness of prophylactic antibiotic therapy and the multiplicity of parameters influencing the SSI risk, are major obstacles to the demonstration that a specific measure is effective in decreasing SSIs. As a result, controversy surrounds the usefulness of many measures, including laminar airflow, body exhaust suits, patient preparation techniques, and specific surgical instruments. Impeccable surgical technique and operating room behaviour, in contrast, are clearly essential.
Article
Laminar airflow (LAF) systems are thought to minimise contamination of the surgical field with airborne microbes and thus to contribute to reducing surgical site infections (SSI). However recent publications have questioned whether LAF ventilation confers any significant benefit and may indeed be harmful. A detailed literature review was undertaken through www.Pubmed.com and Google scholar (http://scholar.google.com). Search terms used included "laminar flow". "laminar airflow", "surgical site infection prevention", "theatre ventilation" and "operating room ventilation", "orthopaedic theatre" and "ultra-clean ventilation". Peer-reviewed publications in the English language over the last 50 years were included, up to and including March 2014. Laminar airflow systems are predominantly used in clean prosthetic implant surgery. Several studies have demonstrated decreased air bacterial contamination with LAF using bacterial sedimentation plates placed in key areas of the operating room. However, apart from the initial Medical Research Council study, there are few clinical studies demonstrating a convincing correlation between decreased SSI rates and LAF. Moreover, recent analyses suggest increased post-operative SSI rates. It is premature to dispense with LAF as a measure to improve air quality in operating rooms where prosthetic joint surgery is being carried out. However, new multi-centre trials to assess this or the use of national prospective surveillance systems to explore other variables that might explain these findings such as poor operating room discipline are needed, to resolve this important surgical issue. Copyright © 2014. Published by Elsevier Ltd.
Article
Although there is some evidence that scrubs, masks, and head coverings reduce bacterial counts in the operating room, there is no evidence that these measures reduce the prevalence of surgical site infection. ▸ The use of gloves and impervious surgical gowns in the operating room reduces the prevalence of surgical site infection. ▸ Operating-room ventilation plays an unclear role in the prevention of surgical site infection. ▸ Exposure of fluids and surgical instruments to the operating-room environment can lead to contamination. Room traffic increases levels of bacteria in the operating room, although the role of this contamination in surgical site infection is unclear. Copyright
Article
Prediction of bacteria-carrying particle (BCP) dispersion and particle distribution released from staff members in an operating room (OR) is very important for creating and sustaining a safe indoor environment. Postoperative wound infections cause significant morbidity and mortality, and contribute to increased hospitalization time. Increasing the number of personnel within the OR disrupts the ventilation airflow pattern and causes enhanced contamination risk in the area of an open wound. Whether the amount of staff within the OR influences the BCP distribution in the surgical zone has rarely been investigated. This study was conducted to explore the influence of the number of personnel in the OR on the airflow field and the BCP distribution. This was performed by applying a numerical calculation to map the airflow field and Lagrangian particle tracking (LPT) for the BCP phase. The results are reported both for active sampling and passive monitoring approaches. Not surprisingly, a growing trend in the BCP concentration (cfu/m3) was observed as the amount of staff in the OR increased. Passive sampling shows unpredictable results due to the sedimentation rate, especially for small particles (5–10 μm). Risk factors for surgical site infections (SSIs) must be well understood to develop more effective prevention programs.
Article
A 21-month study involving 2181 clean and clean-contaminated general surgical procedures was performed to evaluate the effectiveness of a commercially available disposable gown and drape system vs a cotton system in reducing wound infection. The series in which the disposable spun-laced fiber system was used had a significantly lower overall infection rate (2.83% vs 6.5%) as well as better rates in clean (1.8% vs 3.8%) and clean-contaminated (4.8% vs 11.4%) procedures. This effect was independent of all other factors. The odds of developing a wound infection was 2 1/2 times higher with a cotton system than with a disposable system. Actual cost analysis from three types of hospitals showed lower costs with utilization of disposable gown and drape systems. Hospital charges were significantly higher for those patients developing wound infections. The results of the study demonstrated not only significant reduction in wound infection rates but also major cost savings when a disposable gown and drape system was used in the operating room.
Article
Among strategies to reduce surgical site infection (SSI) risk, we concentrate on the optimization of the air quality through the heating, ventilation, and air conditioning (HVAC) system. Current ventilation standards applied by some European countries have been compared and show uncertainty in the criteria for dimensioning the HVAC system. The development of a comprehensive regulation needs further discussion.
Article
EXECUTIVE SUMMARYThe “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)’s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1 and 2 Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, “Recommendations for Prevention of Surgical Site Infection,” represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge. It has been estimated that approximately 75% of all operations in the United States will be performed in “ambulatory,” “same-day,” or “outpatient” operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not:•Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care.•Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures.•Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6, 7, 8, 9, 10 and 11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy).•Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activities in the latest Food and Drug Administration (FDA) monograph. 12