Infection control in operating theatres.
Abstract: The operating theatre complex is the heart of any major surgical hospital. Good operating theatre design meets the functional needs of theatre care professionals. Operating theatre design must pay careful consideration to traffic patterns, the number and configuration of nearby operating rooms, the space required for staff, administration and storage, provisions for sterile processing and systems to control airborne contaminants (Wan et al 2011). There have been infection control issues with private finance initiative built operating theatres (Unison 2003, Ontario Health Coalition 2005). The aim of this article is to address these issues as they relate to infection control and prevention.

KEYWORDS Air conditioning / Cross infection / Heating / Infection control / Operating rooms / Environment controlled / Equipment contamination / Hospital design and construction / Maintenance and engineering / Temperature / Ventilation
Article Type: Report
Subject: Environmental engineering (Health aspects)
Control systems (Health aspects)
Infection (Health aspects)
Infection control (Health aspects)
Architectural design (Health aspects)
Author: Al-Benna, Sammy
Pub Date: 10/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Oct, 2012 Source Volume: 22 Source Issue: 10
Product: Product Code: 8911020 Environmental Engineering NAICS Code: 54133 Engineering Services
Accession Number: 309315288
Full Text: Traffic patterns

Most postoperative surgical infections originate from the patient's own endogenous flora (Hirsch et al 2010). Therefore, the integrity of the patient's immune system and other host factors are more important in determining infections than the numbers of pathogens in the operating room environment (Al-Benna 2011). Nevertheless, airborne contaminants can cause or worsen infections. Therefore, it is best to create traffic patterns that limit the movement of healthcare professionals, equipment and materials from outside the operating theatre department (Quick 2011). This restricts the movement of airborne contaminants, such as pathogens carried and shed by people and objects.

There is no optimum traffic plan, but guidelines are of use for limiting traffic from outside into the operating theatre department. First, no more people than necessary should be present in the operating theatre during operations. Second, movement should be limited within the operating theatre. Third, operating theatre doors should be closed during operations. Theatre care professionals shed squame from skin and hair (Steinstraesser et al 2009) and this generates most of the particles found in operating theatre air (Clark & de Calcina-Goff 2009, Humphreys et al 2012). No direct relationship has been established between the number of personnel in theatre and the rate of postoperative infection, but one study suggested that, as the number of people in the operating theatre increases, so does the incidence of surgical site infection (Young & O'Regan 2010). It is not clear whether this is due to the number of personnel in theatre per se, or to the increase in traffic into and about the operating theatre. It has been demonstrated that opening operating theatre doors decreases the effectiveness of the ventilation system in clearing contaminants from the operating theatre outward. A rational traffic pattern should mirror the realistic traffic and exchange of patients, personnel and supplies, with careful attention to 'clean' and 'semi-clean' work areas (Young & O'Regan 2010, Lynch et al 2009).

Operating theatres

The overriding principle is that the actual operating theatres itself within the department should be the cleanest area, the requirement for cleanliness decreasing towards the perimeter of the department. Thus, any space for handling sterile supplies should be in the central area, and any space for transporting patients, movement of healthcare professionals and removal of used material should be on the perimeter.

The operating theatre must be large enough to accommodate the equipment and personnel necessary to perform the operation (Al-Benna 2011). As increasingly complex technology has come into use, the recommended size of operating theatres has increased. The fundamental model for general operating theatre design is a quadrangular room with minimum dimensions of 7x7 m, exclusive of fixed or wall mounted cabinets and built-in shelves. The room should have access from the one anaesthetic room, a scrub-up room and a supply room (NHS Estates 2004, The American Institute of Architects 2010). Separate exit doors should be provided (The American Institute of Architects 2010). Specialised operating theatres for cardiovascular, neurosurgical, minimally invasive, orthopaedic and other special multi-team procedures should have a minimum clear floor area of 10x10 m, exclusive of fixed or wall mounted cabinets and built-in shelves (NHS Estates 2004, AIA 2010). These standards are also recommended for renovations. Windows are optional, but should an operating theatre have windows, these windows should have coved or angled edges. Designers should make sure that no ledges can collect dust or debris. Windows should be well sealed and have the prime function of a source of natural light. They should not be opened as they may allow entry of contaminated air, cause airflow pattern distortion and condensation formation which will increase infection rates. It has been demonstrated that natural light enhances staff morale. However, for certain operations, the need to darken the room, glare control, and other considerations may outweigh any advantages.

Floors should be slip resistant under wet and dry conditions and should be robust enough to withstand frequent washings and harsh cleaning with scrubbing machines. They should also be smooth and able to tolerate rolling loads. Carpets must not be used in operating theatres due to the spilling of blood and bodily fluids and the need for efficient, frequent and thorough cleansing (Frabetti et al 2009).

Walls should be water-impermeable, resistant to cracks and scrubbable. They should also be protected from impact by gurneys and other equipment coming to and from the operating theatre department. There is no evidence that antimicrobial additives in wall surfacing material or paint have any role to play in infection control.

Monolithic ceilings are recommended for operating theatres where operations are actually performed. Ceiling surfaces should be smooth and washable. Ceilings are usually made of plaster, however, moisture-resistant gypsum wall-board systems with special epoxy-based coatings can be an inexpensive alternative material. All ceiling-mounted lights or fixtures must be sealed so that dust and contaminants cannot enter through these openings and so that there is no compromise to the ventilation system. Lay-in ceilings may be used in semi-restricted and unrestricted areas, including recovery and holding areas, but are not permitted in operating theatres. Where lay-in ceilings are used, clips must be applied to ensure that dust and other contaminants do not enter the room.

Storage considerations

The task of providing adequate storage is a challenging problem in operating room design. During initial design of an operating theatre, careful planning must go into determining what equipment, if any, should be stored in the room. In rooms with one purpose, such as a room where only laparascopic operations are performed, it may be appropriate to provide space to store monitors, insufflators, light sources, and other regularly needed equipment in the room.

However, as a general rule, unless a piece of equipment is almost always and exclusively used in a given operating theatre, it should be stored elsewhere. Most equipment should be kept in an equipment storage area in the semi-restricted area of the operating theatre. British guidelines recommend specifying not less than 15[m.sup.2] or 5[m.sup.2] per operating theatre, whichever is greater (AIA 2010). For specialty theatres, an adjacent space in the restricted area, preferably adjoining the room, should be designated. These would include, but are not limited to a pump room for cardiac surgery, and large equipment storage for the neurological and orthopaedic theatres.

There is a strong tendency to opt for more operating room space rather than storage space when putting together a wish list in the design phase of an operating theatre suite. However, failure to provide adequate storage space results in cluttered corridors and operating theatres, which can easily become safety hazards. In addition to providing space for storing equipment, designers must also provide space for storing sterile supplies. This is logically placed in the sub-sterile areas between operating theatres. Other storage spaces should be designated for clean supplies and packaged reusable items and should be in a separate area from the soiled workrooms. Carts and gurneys should not be stored where they obstruct corridors.

Sterile processing

All sterile supplies should be transported into operating rooms in closed sterile containers. Inadequate sterilisation of surgical instruments has been implicated in outbreaks of surgical site infections (Al-Benna 2010a, Correa et al 2010, Kim & Mascolo 2010). Therefore, indicators documenting adequate sterilisation should be included in all sterile instrument sets (DH 1999). Case carts, when used, should be transported in covered, enclosed units and should not follow a route from the point of assembly to the operating theatre that traverses thoroughfares.

Air handling

According to legislation (European Directive 2002/91/EC, EN ISO 13790:2008, EN 13779:2008 VDI 6022, DIN 1946-4, Italian president's decree of 14 January 1997), the ventilation and air-conditioning systems in operating theatres must ensure the ideal temperature-humidity conditions for the activity of the surgeons, while also assuring the needs of the patients. Accurate humidity control is therefore not only an additional feature, but is rather a legal requirement.

Proper air handling is the single most important environmental factor in the prevention of surgical site infection (Lindsay et al 2011, Wan et al 2011). Well-conducted research has linked all of the following to air quality and infection rates: type of air filter, direction of airflow and air pressure, air changes per hour in room, humidity, and ventilation system cleaning and maintenance (Evans 2011, Wan et al 2011).

Operating suites should be maintained at positive pressure so that air flows from the cleanest areas to the least clean areas (Evans 2011). This means that air should flow from the operating rooms towards the corridors and adjacent areas. Positive pressure ventilation should be maintained with respect to corridors and adjacent areas. At least 15 air changes per minute should be maintained, of which at least three air changes per minute should be made up of fresh air (Evans 2011, Wan et al 2011). All recirculated air and fresh air should be filtered so as to provide at least 90% efficiency by drop-spot testing. Most operating theatres are designed to introduce air at the ceiling with the exhaust near the floor (plenum system) (Evans 2011, Wan et al 2011). This kind of system * requires that the opening of doors and other movement be limited to the greatest possible extent, as such movements can decrease the efficiency of the system.

Rooms may be engineered for horizontal laminar flow whereby particle-free air is moved over the operative field at a uniform velocity picking up particles in its path and passing them through a high efficiency particulate air filter. However, it is not clear that this is necessary in any but the highest-risk operations, such as joint replacements where surgical site infections can be devastating (Evans 2011, Stocks et al 2011, Howard & Hanssen 2007). Multiple studies have described improved periprosthetic joint infection rates with laminar flow systems replacement (Evans 2011, Howard & Hanssen 2007, Lidwell et al 1987). Historical high-level data demonstrate that laminar flow systems without systemic antibiotics reduce the prevalence of infection from 3.4% to 1.2% (Lidwell et al 1987). The directed air flow system was effective in reducing airborne particulate and colony-forming units in the surgical field during total hip arthroplasty (Stocks et al 2011). The only studies supporting laminar flow rooms were done on patients undergoing orthopaedic operations (Evans 2011, Stocks et al 2011).

Traffic in the operating theatre should be limited to essential equipment and personnel, and every effort should be made to minimise door openings (Choi & Edwards 2012, Panahi et al 2012). Operating theatre floor markings have been shown to facilitate and stimulate safety awareness and result in significantly increased compliance with the positioning of surgical devices in the clean air flow (de Korne et al 2011). Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills (Woodward 2011).

Maintenance

Regularly scheduled surveillance and maintenance of the air handling system is essential. This includes checking for moisture on walls, ceilings and other potentially porous materials, assuring integrity of the air ducts and checking fan settings and filters. Temperature and humidity also influence the likelihood of surgical site infection. Most building codes require stringent humidity control in operating rooms, because water borne bacteria such as Legionella sp. do not survive at relative humidity below 35%, and many non-bacterial pathogens, such as fungi and viruses, thrive in high humidity.

Low air humidity affects both comfort and the well-being/health of people. In the winter in closed and heated spaces the relative humidity of the air drops, which can increase respiratory problems and disturbances affecting the eyes, skin, nose and mouth. Low humidity levels facilitate the spread of bacteria and viruses in the atmosphere. High humidity levels increase the risk of proliferation of viruses and bacteria. To prevent biological contaminants from spreading and proliferating, humidity in the operating theatre should ideally be kept between 50 and 60%. Humidity greater than 60% may cause condensation on cool surfaces. Humidity less than 50% may not suppress static electricity. Static electricity can adversely affect the function of modern computers and smart medical devices.

Conventional cooling systems dehumidify by cooling air to temperatures below its dew point, causing moisture to condense and drip off the coil into a drain pan. The air that leaves the coil is therefore extremely moist, usually close to saturation. When temperatures are kept above 21[degrees]C this poses no problem. However, when the room is cooled significantly below this temperature (for example, to 18[degrees]C), the humidity goes up to an unacceptable level, requiring the lowering of the chillers in the heating, ventilating and air conditioning (HVAC) system to a low-chilled water temperature, or the use of dessicant dehumidifiers in the cooling system.

Desiccant dehumidifiers are particularly helpful in places where the climate is very warm and humid. The systems work by removing the moisture from the outside air before it reaches the chilled water coil, allowing the chilled water temperature to be raised in the cooling system with less moisture condensing into the drain pans and ductwork. Most modern systems can maintain adequate temperature, humidity, and pressure relationships, however, any disruption of the ductwork can change internal pressure relationships and can cause airborne particle to migrate into the system

Room turnover

Theatre cleaning

Despite the absence of data supporting routine disinfecting of operating theatres and equipment between operations in the absence of visible soiling or contamination, standard practice is to routinely clean rooms after each operation to provide a clean environment for the next one with a wet mop, washing with hot water and a general purpose detergent (NHS Estates 2003). NHS guidelines specify that hospitals use a one-stop process and a general purpose detergent for general housekeeping purposes. A chlorine releasing solution 1000ppm av cl. (e.g. Presept, Haztabs, Sanichlor or household bleach at 1 part bleach to 10 parts water) should be used for surfaces contaminated with body fluid; and for blood spillage Sodium dichloroisocyanurate (NADCC) granules or solution (e.g. Presept, Haztabs) at 10,000ppm av cl. (NPSA 2009).

Similarly, the National Patient Safety Agency requires that any equipment or surface contaminated with blood or potentially infectious agents be cleaned and decontaminated (NPSA 2009). If single-use, disposable mops and cloths are not used, mopheads and cloths should be cleaned after each use and allowed to dry before reuse. After the last surgical operation of the day or night, operating theatre floors should be wet-vacuumed or wet-mopped with a single-use mop and disinfectant. Tacky surfaces and mats at the entrance of operating theatres for infection control purpose are not necessary and should not be used, nor should ultraviolet lights (Ritter et al 2007, NICE 2008, NPSA 2009, Evans 2011). Despite the common practice of closing operating theatres or having special procedures to clean theatres after the surfaces or equipment are visibly soiled or contaminated with blood or other body fluids, no data support such practices and it can affect theatre utilisation (Al-Benna 2012).

Repairs and renovations

Nosocomial infections, ranging from Aspergillus and mould in ceilings (Cristina et al 2009) to Legionella in wet areas (Mouchtouri 2010), have prompted support of mandatory proactive infection risk assessments (Syndor & Perl 2011). Major renovations, particularly those involving air-handling systems or ventilation, require an infection risk assessment before beginning any remodelling or new reconstruction (NDSC 2002, Public Health Agency of Canada 2001). A multidisciplinary team should conduct infection risk assessments and this team should include infection control personnel, risk managers, contractors, facility designers, HVAC specialists, structural engineers, safety officers, and hospital epidemiologists. Infection risk assessments should be initiated in the earliest stages of the design or development phase of a project to identify potential infection risks to the patient population, any risks associated with the mechanical systems of the building, and the areas that will be affected by the project. Its goals include defining necessary contaminant measures (such as traffic diversion, waste removal, and work disruption) during construction and anticipating any safety hazards that can result from the construction.

Conclusion

Research has consistently confirmed that the operating theatre environment is a secondary reservoir for organisms with the potential for infecting patients undergoing surgery. If healthcare-association infection is to be reduced, it is imperative that infection control is 'designed-in' at the planning and design stages of an operating theatres new build or renovation project and that input continues up to the final build stage. It is imperative that architects, designers and infection control teams are partners when planning new operating theatres or renovating older buildings.

A major function of operating theatre design, ventilation, maintenance, room turnover and renovations is to prevent microbial contaminants from entering surgical wounds (Al-Benna et al 2007). The purpose of many perioperative care processes is to minimise surgical wound contamination (Al-Benna 2011, Byrne et al 2011, Pirie 2010a). Under normal circumstances, sources of airborne microbial contaminants include microscopic skin fragments given off by staff in theatre (Pirie 2010b,c), improperly-filtered outdoor air, contaminated fabrics worn by theatre staff (Al-Benna 2010a, Sivanandan et al 2011) and backtracking of contaminated air from outside the theatre (Lindsay et al 2011, Evans 2011, Wan et al 2011). Exogenous source control includes surgical team personal protective equipment requirements (Al-Benna et al 2008, Al-Benna 2010b), surgical instrument reprocessing guidelines and air handling controls (Evans 2011, Wan et al 2011). It is incumbent that effective and evidence-based wound infection control strategies be developed (Al-Benna 2010c, Al-Benna et al 2010, Smith 2011) and used consistently and appropriately in order to reduce perioperative infections to a minimum.

It is important that the infection control team is involved at all stages from pre-theatre design through to opening and that adequate time for commissioning is built in to the schedule, including an allowance of time for microbiological assessments to match standards and optimise patient care (Sayers 2010, Smith 2010). The same is applicable for repairs and renovations of operating theatres. This may need particular consideration for theatre facilities built under private finance initiatives in that there may be a need for contractual conditions regarding rectification of faults, maintenance, repairs and renovations.

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Correspondence address: Sammy Al-Benna, Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany. Email: sammy.al-benna@ruhr-uni-bochum.de

About the author

Sammy Al-Benna

MB ChB, PhD, PGCNano, FAPAC

Plastic Surgeon, Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany

No competing interests declared

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Provenance and Peer review: Unsolicited contributed; Peer reviewed; Accepted for publication May 2012.
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