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Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery

Published:January 30, 2012DOI:https://doi.org/10.1016/j.ajic.2011.09.015

      Background

      Understanding the protective potential of operating room (OR) ventilation under different conditions is crucial to optimizing the surgical environment. This study investigated the air quality, expressed as colony-forming units (CFU)/m3, during orthopedic trauma surgery in a displacement-ventilated OR; explored how traffic flow and the number of persons present in the OR affects the air contamination rate in the vicinity of surgical wounds; and identified reasons for door openings in the OR.

      Methods

      Data collection, consisting of active air sampling and observations, was performed during 30 orthopedic procedures.

      Results

      In 52 of the 91 air samples collected (57%), the CFU/m3 values exceeded the recommended level of <10 CFU/m3. In addition, the data showed a strongly positive correlation between the total CFU/m3 per operation and total traffic flow per operation (r = 0.74; P = .001; n = 24), after controlling for duration of surgery. A weaker, yet still positive correlation between CFU/m3 and the number of persons present in the OR (r = 0.22; P = .04; n = 82) was also found. Traffic flow, number of persons present, and duration of surgery explained 68% of the variance in total CFU/m3 (P = .001).

      Conclusions

      Traffic flow has a strong negative impact on the OR environment. The results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.

      Key Words

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      References

        • Bozic K.J.
        • Ries M.D.
        The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization.
        J Bone Joint Surg Am. 2005; 87: 1746-1751
        • Coello R.
        • Charlett A.
        • Wilson J.
        • Ward V.
        • Pearson A.
        • Borriello P.
        Adverse impact of surgical site infections in English hospitals.
        J Hosp Infect. 2005; 60: 93-103
        • de Lissovoy G.
        • Fraeman K.
        • Hutchins V.
        • Murphy D.
        • Song D.
        • Vaughn B.B.
        Surgical site infection: incidence and impact on hospital utilization and treatment costs.
        Am J Infect Control. 2009; 37: 387-397
        • Monge Jodra V.
        • Sainz de Los Terreros Soler L.
        • Diaz-Agero Perez C.
        • Saa Requejo C.M.
        • Plana Farras N.
        Excess length of stay attributable to surgical site infection following hip replacement: a nested case-control study.
        Infect Control Hosp Epidemiol. 2006; 27: 1299-1303
        • Andersson A.E.
        • Bergh I.
        • Karlsson J.
        • Nilsson K.
        Patients’ experiences of acquiring a deep surgical site infection: an interview study.
        Am J Infect Control. 2010; 38: 711-717
        • Neumayer L.
        • Hosokawa P.
        • Itani K.
        • El-Tamer M.
        • Henderson W.G.
        • Khuri S.F.
        Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the Patient Safety in Surgery study.
        J Am Coll Surg. 2007; 204: 1178-1187
        • Zhan C.
        • Kaczmarek R.
        • Loyo-Berrios N.
        • Sangl J.
        • Bright R.A.
        Incidence and short-term outcomes of primary and revision hip replacement in the United States.
        J Bone Joint Surg Am. 2007; 89: 526-533
        • Lindstrom D.
        • Sadr Azodi O.
        • Wladis A.
        • Tonnesen H.
        • Linder S.
        • Nasell H.
        • et al.
        Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial.
        Ann Surg. 2008; 248: 739-745
        • Thomsen T.
        • Tonnesen H.
        • Moller A.M.
        Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation.
        Br J Surg. 2009; 96: 451-461
        • Pull ter Gunne A.F.
        • Cohen D.B.
        Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery.
        Spine (Phila Pa 1976). 2009; 34: 1422-1428
        • Bierbaum B.E.
        • Callaghan J.J.
        • Galante J.O.
        • Rubash H.E.
        • Tooms R.E.
        • Welch R.B.
        An analysis of blood management in patients having a total hip or knee arthroplasty.
        J Bone Joint Surg Am. 1999; 81: 2-10
        • Culver D.H.
        • Horan T.C.
        • Gaynes R.P.
        • Martone W.J.
        • Jarvis W.R.
        • Emori T.G.
        • et al.
        Surgical wound infection rates by wound class, operative procedure, and patient risk index: National Nosocomial Infections Surveillance System.
        Am J Med. 1991; 91: 152S-157S
        • Stocks G.W.
        • Self S.D.
        • Thompson B.
        • Adame X.A.
        • O’Connor D.P.
        Predicting bacterial populations based on airborne particulates: a study performed in nonlaminar flow operating rooms during joint arthroplasty surgery.
        Am J Infect Control. 2010; 38: 199-204
        • Innerhofer P.
        • Klingler A.
        • Klimmer C.
        • Fries D.
        • Nussbaumer W.
        Risk for postoperative infection after transfusion of white blood cell–filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty.
        Transfusion. 2005; 45: 103-110
        • Willis-Owen C.A.
        • Konyves A.
        • Martin D.K.
        Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases.
        J Bone Joint Surg Br. 2010; 92: 1128-1133
        • Gruenberg M.F.
        • Campaner G.L.
        • Sola C.A.
        • Ortolan E.G.
        Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system.
        Spine (Phila Pa 1976). 2004; 29: 2330-2334
        • 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 Hygiene Environ Health. 2005; 208: 455-460
        • Lidwell O.M.
        • Lowbury E.J.L.
        • Whyte W.
        Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study.
        BMJ. 1982; 285: 10-14
        • McCann M.T.
        • Gilmore B.F.
        • Gorman S.P.
        Staphylococcus epidermidis device-related infections: pathogenesis and clinical management.
        J Pharm Pharmacol. 2008; 60: 1551-1571
        • Lidwell O.M.
        • Lowbury E.J.L.
        • Whyte W.
        Airborne contamination of wounds in joint replacement operations: the relationship to sepsis rates.
        J Hosp Infect. 1983; 4: 111-131
        • Chow T.T.
        • Yang X.Y.
        Ventilation performance in operating theatres against airborne infection: review of research activities and practical guidance.
        J Hosp Infect. 2004; 56: 85-92
        • Whyte W.
        • Hodgson R.
        • Tinkler J.
        The importance of airborne bacterial contamination of wounds.
        J Hosp Infect. 1982; 3: 123-135
        • Tammelin A.
        • Domicel P.
        • Hambraeus A.
        • Ståhle E.
        Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing.
        J Hosp Infect. 2000; 44: 119-126
        • Edmiston J.C.E.
        • Seabrook G.R.
        • Cambria R.A.
        • Brown K.R.
        • Lewis B.D.
        • Sommers J.R.
        • et al.
        Molecular epidemiology of microbial contamination in the operating room environment: is there a risk for infection?.
        Surgery. 2005; 138: 573-582
        • Tammelin A.
        • Hambreaus A.
        • Ståhle E.
        Source and route of methicillin-resistant Staphylococcus epidermidis transmitted to the surgical wound during cardio-thoracic surgery: possibility of preventing wound contamination by use of special scrub suits.
        J Hosp Infect. 2001; 47: 266-276
        • Whyte W.
        The role of clothing and drapes in the operating room.
        J Hosp Infect. 1988; 11: 2-17
        • Ljungqvist B.
        • Reinmüller B.
        Aseptic production, gowning systems, and airborne contaminants.
        Pharm Technol. 2005; 29: S30-S34
        • Letts R.M.
        • Doermer E.
        Conversation in the operating theater as a cause of airborne bacterial contamination.
        J Bone Joint Surg Am. 1983; 65: 357-362
        • Kurmann A.
        • Peter M.
        • Tschan F.
        • Mühlemann K.
        • Candinas D.
        • Beldi G.
        Adverse effect of noise in the operating theatre on surgical-site infection.
        Br J Surg. 2011; 98: 1021-1025
        • Shaw B.H.
        • Whyte W.
        Air movement through doorways: the influence of temperature and its control by forced airflow.
        Build Serv Eng. 1974; 42: 210-218
        • Wilson D.J.
        • Kiel D.E.
        Gravity-driven counterflow through an open door in a sealed room.
        Build Environ. 1990; 25: 379-388
        • Ritter M.A.
        • Eitzen H.
        • French M.L.
        • Hart J.B.
        The operating room environment as affected by people and the surgical face mask.
        Clin Orthop Relat Res. 1975; 111: 147-150
        • Scaltriti S.
        • Cencetti S.
        • Rovesti S.
        • Marchesi I.
        • Bargellini A.
        • Borella P.
        Risk factors for particulate and microbial contamination of air in operating theatres.
        J Hosp Infect. 2007; 66: 320-326
        • Silverman D.
        Interpreting qualitative data: methods for analysing talk, text and interaction.
        Sage, London2001
        • World Medical Association
        Declaration of Helsinki: ethical principles for medical research involving human subjects.
        J Postgrad Med. 2002; 48: 206-208
        • Bachoura A.
        • Guitton T.G.
        • Smith R.M.
        • Vrahas M.S.
        • Zurakowski D.
        • Ring D.
        Infirmity and injury complexity are risk factors for surgical-site infection after operative fracture care.
        Clin Orthop Relat Res. 2011; 469: 2621-2630
        • Parikh S.N.
        • Grice S.S.
        • Schnell B.M.
        • Salisbury S.R.
        Operating room traffic: is there any role of monitoring it?.
        J Pediatr Orthop. 2010; 30: 617-623
        • Lynch R.J.
        • Englesbe M.J.
        • Sturm L.
        • Bitar A.
        • Budhiraj K.
        • Kolla S.
        • et al.
        Measurement of foot traffic in the operating foom: implications for infection control.
        Am J Med Qual. 2009; 24: 45-52
        • Young R.S.
        • O’Regan D.J.
        Cardiac surgical theatre traffic: time for traffic-calming measures?.
        Interact Cardiovasc Thorac Surg. 2010; 10: 526-529
        • Campbell Jr., D.A.
        • Henderson W.G.
        • Englesbe M.J.
        • Hall B.L.
        • 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 Surgeons National Surgical Quality Improvement Program Best Practices Initiative.
        J Am Coll Surg. 2008; 207: 810-820
        • Whyte W.
        • Niven L.
        Airborne bacteria sampling: the effect of dehydration and sampling time.
        J Parenter Sci Technol. 1986; 40: 182-188
        • Godish D.R.
        • Godish T.J.
        Relationship between sampling duration and concentration of culturable airborne mould and bacteria on selected culture media.
        J Appl Microbiol. 2007; 102: 1479-1484
        • Parks S.R.
        An assessment of the Sartorius MD8 microbiological air sampler.
        J Appl Bacteriol. 1996; 80: 529-534
        • Rupp M.E.
        • Archer G.L.
        Coagulase-negative staphylococci: pathogens associated with medical progress.
        Clin Infect Dis. 1994; 19: 231-245
        • Memarzadeh F.
        • Manning A.P.
        Comparison of operating room ventilation systems in the protection of the surgical site.
        ASHRAE Trans. 2002; 108: 3-15
        • Breum N.O.
        Air-exchange efficiency of displacement ventilation in printing plant.
        Ann Occup Hyg. 1988; 32: 481-488
        • Friberg B.F.
        • Burman S.
        • Lundholm L.G.
        • Östersson R.
        Inefficiency of upward-displacement operating theatre ventilation.
        J Hosp Infect. 1996; 33: 263-272
        • Polit D.F.
        • Beck T.C.
        Nursing research: principles and methods.
        7th ed. Lippincott Williams & Wilkins, Philadelphia [PA]2004