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standardized and tailored

No two hospital facilities have the exact same challenges or opportunities, nor are they at the same place in their clinical efficacy or facilities systems performance. This approach recognizes the necessary balance between providing value-driven products and honoring each organization’s unique culture. Each hospital will have comfort in knowing there are predictable programs, policies, procedures, and training delivered by seasoned staff.

Methodology for analyzing environmental quality indicators in a dynamic operating room environment

Methodology for analyzing environmental quality indicators in a dynamic operating room environment

Background: Sufficient quantities of quality air and controlled, unidirectional flow are important elements

in providing a safe building environment for operating rooms.

Methods: To make dynamic assessments of an operating room environment, a validated method of testing

the multiple factors influencing the air quality in health care settings needed to be constructed. These

include the following: temperature, humidity, particle load, number of microbial contaminants, pressurization,

air velocity, and air distribution. The team developed the name environmental quality indicators

(EQIs) to describe the overall air quality based on the actual measurements of these properties taken during

the mock surgical procedures. These indicators were measured at 3 different hospitals during mock surgical

procedures to simulate actual operating room conditions. EQIs included microbial assessments at

the operating table and the back instrument table and real-time analysis of particle counts at 9 different

defined locations in the operating suites. Air velocities were measured at the face of the supply diffusers,

at the sterile field, at the back table, and at a return grille.

Results: The testing protocol provided consistent and comparable measurements of air quality indicators

between institutions. At 20 air changes per hour (ACH), and an average temperature of 66.3°F, the

median of the microbial contaminants for the 3 operating room sites ranged from 3-22 colony forming

units (CFU)/m3 at the sterile field and 5-27 CFU/m3 at the back table. At 20 ACH, the median levels of the

0.5-μm particles at the 3 sites were 85,079, 85,325, and 912,232 in particles per cubic meter, with a predictable

increase in particle load in the non–high-efficiency particulate air-filtered operating room site.

Using a comparison with cleanroom standards, the microbial and particle counts in all 3 operating rooms

were equivalent to International Organization for Standardization classifications 7 and 8 during the mock

surgical procedures.

Conclusions: The EQI protocol was measurable and repeatable and therefore can be safely used to evaluate

air quality within the health care environment to provide guidance for operational practices and

regulatory requirements.


© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier

Inc. All rights reserved.

Cost-benefit analysis of different air change rates in an operating room environment

Cost-benefit analysis of different air change rates in an operating room environment

Background: Hospitals face growing pressure to meet the dual but often competing goals of providing

a safe environment while controlling operating costs. Evidence-based data are needed to provide insight

for facility management practices to support these goals.

Methods: The quality of the air in 3 operating rooms was measured at different ventilation rates. The

energy cost to provide the heating, ventilation, and air conditioning to the rooms was estimated to provide

a cost-benefit comparison of the effectiveness of different ventilation rates currently used in the health

care industry.

Results: Simply increasing air change rates in the operating rooms tested did not necessarily provide an

overall cleaner environment, but did substantially increase energy consumption and costs. Additionally,

and unexpectedly, significant differences in microbial load and air velocity were detected between the

sterile fields and back instrument tables.

Conclusions: Increasing the ventilation rates in operating rooms in an effort to improve clinical outcomes

and potentially reduce surgical site infections does not necessarily provide cleaner air, but does

typically increase operating costs. Efficient distribution or management of the air can improve quality

indicators and potentially reduce the number of air changes required. Measurable environmental quality

indicators could be used in lieu of or in addition to air change rate requirements to optimize cost and

quality for an operating room and other critical environments.

© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier

Inc. All rights reserved.

Hats and Sleeves: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators

Hats: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators

Background: The effectiveness of operating room headgear in preventing airborne contamination has been

called into question. We hypothesized that bouffant style hats would be as effective in preventing

bacterial and particulate contamination in the operating room compared with disposable

or cloth skull caps, and bouffant style hats would have similar permeability, particle

penetration, and porosity compared with skull caps.

Study Design: Disposable bouffant and skull cap hats and newly laundered cloth skull caps were tested. A

mock surgical procedure was used in a dynamic operating room environment. Airborne particulate

and microbial contaminants were sampled. Hat fabric was tested for permeability,

particle transmission, and pore sizes.

Results: No significant differences were observed between disposable bouffant and disposable skull

caps with regard to particle or actively sampled microbial contamination. However, when

compared with disposable skull caps, disposable bouffant hats did have significantly higher

microbial shed at the sterile field, as measured by passive settle plate analysis (p < 0.05).

When compared with cloth skull caps, disposable bouffants yielded higher levels of 0.5

mm and 1.0 mm particles and significantly higher microbial shed detected with passive analysis.

Fabric assessment determined that disposable bouffant hats had larger average and

maximum pore sizes compared with cloth skull caps, and were significantly more permeable

than either disposable or cloth skull caps.

Conclusions: Disposable bouffant hats had greater permeability, penetration, and greater microbial shed, as

assessed by passive microbial analysis compared with disposable skull caps. When compared

with cloth skull caps, disposable bouffants yielded greater permeability, greater particulate

contamination, and greater passive microbial shed. Disposable style bouffant hats should

not be considered superior to skull caps in preventing airborne contamination in the operating



J Am Coll Surg 2017;225:573e581. © 2017 by the American College of Surgeons.

Published by Elsevier Inc. All rights reserved.)


Sleeves: A Study of Different Operating Room Gear Assessed by Environmental Quality Indicators

Background: The use of long sleeves by non-scrubbed personnel in the operating room has been called into

question.We hypothesized that wearing long sleeves and gloves, compared with having bare arms without

gloves, while applying the skin preparation solution would decrease particulate and microbial contamination.

Methods: A mock patient skin prep was performed in 3 different operating rooms. A long-sleeved gown

and gloves, or bare arms, were used to perform the procedure. Particle counters were used to assess airborne

particulate contamination, and active and passive microbial assessment was achieved through air

samplers and settle plate analysis. Data were compared with Student’s t-test or Mann-Whitney U, and

P < .05 was considered to be significant.

Results: Operating room B demonstrated decreased 5.0- μm particle sizes with the use of sleeves, while

operating rooms A and C showed decreased total microbes only with the use of sleeves. Despite there

being no difference in the average number of total microbes for all operating rooms assessed, the use of

sleeves specifically appeared to decrease the shed of Micrococcus.

Conclusion: The use of long sleeves and gloves while applying the skin preparation solution decreased

particulate and microbial shedding in several of the operating rooms tested. Although long sleeves may

not be necessary for all operating room personnel, they may decrease airborne contamination while the

skin prep is applied, which may lead to decreased surgical site infections.


© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier

Inc. All rights reserved.


Back Instrument Table Covers

Background: Covering the instrument table during surgery may decrease contamination. We hypothesized that 1) covering the instrument table in an operating room during static periods of non-use as well as dynamic periods of active use would dramatically decrease the bacterial bioburden on the table, and 2) the use of sterile plastic table covers would be equivalent to sterile impervious paper covers in reducing the bioburden in a dynamic environment.

Study Design: Bacterial contamination of the instrument table was evaluated by settle plates in static and dynamic ORs. Airborne particulate and bacterial contaminants were sampled throughout the room. Tested groups included instrument tables covered with sterile impervious paper covers, sterile plastic covers, or no covers.

Results: Covering the instrument table during static and dynamic operating room conditions resulted in a significantly decreased bacterial load on the instrument table. No differences were seen between paper and plastic covers.

Conclusion: A significant decrease in bacterial bioburden on the instrument table when the table was covered during static and dynamic periods was observed, suggesting a utility for covering the instrument table during periods of non-use as well as during active surgeries.