650,000+
DATA POINTS
110+ MOCK
PROCEDURES
16,000,000+ SQ.FT OF
CLIENT HOSPITALS
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.
Analyzing Environmental Quality Controls to Enhance Asepsis and Prevent Disease Transmission in the Intensive Care Unit
This study assessed Environmental Quality Indicators (EQI) and compared two air flow control systems in dynamic
procedural environments (10). The air flow control systems compared were a variable air volume (VAV Box) and a
Venturi type air valve (Venturi). Both VAV Box and Venturi were challenged with the release of controlled contaminants,
Baker’s yeast, S. cerevisiae (microbes) and tracer gas, sulfur hexafluoride (SF6), at a point of origin in the adjacent hallway.
During each simulation, the initial room air flow control system was set at 3 ACH with the doors closed to simulate the
unoccupied mode. To transition to occupied mode, the doors were opened and closed as the patient entered the room and
the air changes increased to 6 ACH. A Code Blue simulation was initiated and the control systems entered procedure
mode by increasing the air changes to 15 ACH and creating positive pressure to the corridor. Doors were opened and
closed to simulate entry of additional support staff. Finally, at the conclusion of the procedure, the room returned to
occupied mode at 6 ACH with neutral pressure. This study demonstrates that a properly designed and engineered
procedure ready ICU room reduces the necessity to move critically ill patients to operating rooms by changing the room’s
environment to mimic the protective environment of a procedure room quickly and effectively. The Venturi valve system
outperformed the more conventional VAV Box by transitioning and stabilizing more quickly which provided better
protection from contaminants in the hallway.
EQI Method to Compare Air Delivery Methods in Three Functional ORs During Dynamic Simulated Surgical Procedures
In this study, the OnSite team employed the EQI method to compare three OR air delivery concepts with respect to
airborne particles, microbial loads, air velocity, temperature and CO2 levels, within the sterile field and outside the sterile
zone at the instrument table. Two newly constructed ORs were compared to each other (AirFrame SLD to MDA) and to
an older OR (4TD). The two new ORs were identical with respect to construction materials, HVAC units, dimensions
(55 M2), air change rates (26ACH), pressurization (min. 10 pa), HEPA filtration, return grille placement (4 low wall),
surgical table and equipment placement. Both ORs had been actively used for surgery for approximately three months
prior to testing. The two ORs differed only in the air delivery method. The AirFrame, was constructed as a 9 diffuser,
contiguous ceiling air distribution system, a concept based on semiconductor clean room technology, in which blockages
to air flow from boom mounts and gaps between filters, had been minimized. The MDA was constructed as a
conventional array of multiple diffusers (MDA) in the ceiling separated by non-air delivery hard ceiling surfaces with
booms mounted between the diffusers. The MDA had 6 diffusers and the longitudinal axis of the array was perpendicular
to the longitudinal axis of the surgical table. The older OR, 4TD, was 6.9 Pa positive to the anesthetic bay, HEPA filtered
with four 4-way throw diffusers (4TD) in the ceiling and two low wall returns. The 4TD room did not have air
distribution over the surgical table/sterile field as per ASHRAE 170 but did have air distribution outside the sterile field
over the back, instrument table, though the coverage was not unidirectional, downward. The EQI study took place in
January 2018 in Sydney, Australia. Based on this study, the SLD resulted in a significantly cleaner airborne environment,
with respect to microbes and CO2, within the sterile field, on the surgical table, as compared to the array of diffusers in
the ceiling. SLD and MDA both provided a cleaner environment than the 4TD OR. The SLD also had a significantly
higher velocity at the sterile field than the MDA. Both SLD and MDA had cleaner environments with higher air velocity
within the sterile field than their respective back tables, outside the sterile zone.
Wagner et al., AJIC Jan 2018
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
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: 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
room.
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 sp.
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.