Air contamination during total hip arthroplasty in an ultraclean air enclosure using different types of staff clothing

doi:10.1016/S0883-5403(06)80231-7

The Journal of Arthroplasty

Volume 5, Issue 2, June 1990, Pages 127-130

https://doi.org/10.1016/S0883-5403(06)80231-7 Get rights and content

Abstract

Air contamination was measured in a down-flow, clean air enclosure during 50 total hip arthroplasties to compare the effect of different scrub suits and operating gowns. In one series, with cotton clothes, the operating gowns used were either disposable nonwoven operating gowns or total body exhaust gowns. With the exhaust gowns the median air contamination, measured as colony-forming units (cfu)/m³, was reduced by about 5 times, to 0.3. In another series, nonwoven operating gowns were used together with scrub suits made of either cotton or one of two types of synthetic materials. The latter two scrub suits were equipped with elastic sealings at the openings. With both of these types the median air contamination, compared to cotton scrub suits, was reduced by about one half, to 0.4 cfu/m³. The authors conclude that both specially designed scrub suits and exhaust gowns can further reduce an already low level of bacterial air contamination in a down-flow, clean air enclosure.

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A high volume of staff movement and activities could play a role in higher risk of surgical site infections (SSIs) [6]. Generally, staff movement can increase the colony forming unit (cfu) level by three means: (1) clothes rub against the skin, leading to increased shedding [7]; (2) a pumping effect inside clothes that creates air streams that can transport skin scales into the OR air through pores in the fabric structure or from openings (such as the wrists, neck, ankles and the waist) [8]; and (3) movement may cause settled particles on the floor and other surfaces to be re-suspended into the air [7]. A number of studies have explored influencing factors using various experimental methods.
Operating rooms (ORs) have strict requirements regarding cleanliness. While existing standards concerning the ventilation and staff guidelines are theoretically sufficient to subvert the threats posed by micro-organisms within the room, there exist potential sources of contamination due to human activity around the area. Studies exploring this influence of human activity on distribution of micro-organism contamination in ORs have relied on manual observations, or indirect methods such as number of door openings.
Aim: To utilize depth registration sensing technology to identify the activities of surgical staff and investigate their effect on the distribution of airborne micro-organism contamination in ORs.
A mock surgical experiment was performed using a depth registration technique for the dynamic capturing of human presence and activity levels. Field measurements were carried out in one real OR to analyse its influence on the bacterial distribution in ORs with mixing ventilation system. Findings: Bacterial contamination levels tended to correlate with higher activity levels, albeit with some inconsistencies. The highest activity levels were around the surgical bed when the patient was placed, and around the instrument table during the surgical procedure. Locations with obstructions had the highest cfu densities, indicating that airflow patterns are important in such spaces.
Our activity monitoring methods demonstrate a novel means of studying the influences of human activities in hospital rooms.
Ventilation design conditions associated with airborne bacteria levels within the wound area during surgical procedures: a systematic review
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Without confirmation of the ventilation design conditions (typology and airflow rate), the common practice of identifying unidirectional airflow (UDAF) systems as equivalent to ultra-clean air ventilation systems may be misleading, but also any claims about the ineffectiveness of UDAF systems should be doubted. The aim of this review was to assess and compare ventilation system design conditions for which ultra-clean air (mean <10 cfu/m³) within 50 cm from the wound has been reported. Six medical databases were systematically searched to identify and select studies reporting intraoperative airborne levels expressed as cfu/m³ close to the wound site, and ventilation system design conditions. Available data on confounding factors such as the number of persons present in the operating room, number of door openings, and clothing material were also included. Predictors for achieving mean airborne bacteria levels within <10 cfu/m³ were identified using a penalized multivariate logistic regression model. Twelve studies met the eligibility criteria and were included for analysis. UDAF systems considered had significantly higher air volume flows compared with turbulent ventilation (TV) systems considered. Ultra-clean environments were reported in all UDAF-ventilated (N = 7) rooms compared with four of 11 operating rooms equipped with TV. On multivariate analysis, the total number of air exchange rates (P=0.019; odds ratio (OR) 95% confidence interval (CI): 0.66–0.96) and type of clothing material (P=0.031; OR 95% CI: 0.01–0.71) were significantly associated with achieving mean levels of airborne bacteria <10 cfu/m³. High-volume UDAF systems complying with DIN 1946-4:2008 standards for the airflow rate and ceiling diffuser size unconditionally achieve ultra-clean air close to the wound site. In conclusion, the studied articles demonstrate that high-volume UDAF systems perform as ultra-clean air systems and are superior to TV systems in reducing airborne bacteria levels close to the wound site.
General Assembly, Prevention, Operating Room - Surgical Attire: Proceedings of International Consensus on Orthopedic Infections
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Hip and Knee Section, Prevention, Operating Room Environment: Proceedings of International Consensus on Orthopedic Infections
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Do 'Surgical Helmet Systems' or 'Body Exhaust Suits' Affect Contamination and Deep Infection Rates in Arthroplasty? A Systematic Review
2016, Journal of Arthroplasty
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Operating room staff are thought to be the source of air and wound contamination in up to 98% of cases [2,3]; an individual can shed between 5000 and 55000 particles per minute and physical activity of the staff is known to affect the circulation of the shed particles [29]. A fundamental design principle of BES is high flow extraction to remove these particles, and extraction rates of up to 400 L/min have been recommended [30]. Whilst some early SHS designs included portable exhaust outlets [31,32], SHS primarily use air intake fans to provide adequate airflow for surgeon comfort.
This systematic review examined whether negative-pressure Charnley-type body exhaust suits (BES) or modern positive-pressure surgical helmet systems (SHS) reduce deep infection rates and/or contamination in arthroplasty. For deep infection, four studies (3990 patients) gave adjusted relative risk for deep infection of 0.11 (P = 0.09) against SHS. Five of 7 (71%) studies found less air contamination and 2 of 4 studies (50%) less wound contamination with BES. One of 4 (25%) found less air contamination with SHS and 0 of 1 (0%) less wound contamination. In contrast to BES, modern SHS designs were not shown to reduce contamination or deep infection during arthroplasty.
Preventing surgical-site infections: Measures other than antibiotics
2015, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
The only benefit from the suit was improved protection of the staff from splashes of blood or other body fluids. Similarly, filtered exhaust suits incorporating a self-contained ventilation system were not more effective than conventional surgical masks [22,26]. Furthermore, Shaw et al. suggested that the increased temperature around the face might promote bacterial growth and that the increased pressure within the suit might increase the dissemination of bacteria if the seal between the helmet and gown was not fully effective [27].
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.

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^*: Supported by the Alfred Österlunds Foundation and the Greta and Johan Kocks Foundation.

^*: From the Department of Orthopaedics Malmö General Hospital, University of Lund, Malmö, Sweden

^†: the Department of Clinical Microbiology, Malmö General Hospital, University of Lund, Malmö, Sweden

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Air contamination during total hip arthroplasty in an ultraclean air enclosure using different types of staff clothing*

Abstract

J Hosp Inf

J Hosp Inf

Reoperated total hip arthroplasties in Sweden, 1979–1983

Thesis, University of Göteborg, Sweden

Ultraviolet radiation and air contamination during total hip replacement

J Hosp Inf

Cowan and Steel's manual for the identification of medical bacteria