Understanding the Challenge of Surgical Site Infections in Operating Rooms
Hospital operating rooms (ORs) are highly critical facilities, classified as ultraclean environments. However, surgical site infections (SSIs) following surgical procedures continue to pose a significant challenge globally, including in Indonesia. A comprehensive analysis of surgical data from 2018 to 2022 across various European countries revealed tens of thousands of postoperative SSI cases. These infections are classified as organ/space infections and deep and superficial incisional infections. The importance of controlling particle transmission in the OR environment cannot be overstated, considering that the human body can emit millions of biological particles per hour. Some of these biological particles are capable of carrying harmful bacteria such as Staphylococcus aureus, Coagulase-negative staphylococci, Enterococcus species, and Escherichia coli, all of which can trigger SSIs. To prevent the influx of particles from outside, the OR must maintain a higher space pressurization than adjoining spaces.
It is crucial to understand that particle generation from medical staff’s skin shedding or clothing heavily depends on the clothing material, design, and staff’s activities, such as walking or body movement. These factors can be adjusted to reduce emissions. Therefore, attention to detail in OR design and operational protocols is paramount to minimizing the risk of contamination and infection. Effective management of the OR environment requires a multifaceted approach, encompassing not only advanced ventilation systems but also a deep understanding of particle movement dynamics and personnel contributions. Given this complexity, continuous innovation and research in OR design and operation are essential for a safer and more effective healthcare future.
Air Distribution Strategies for Ultraclean Environments
Currently, the two most commonly used OR supply air distribution configurations are laminar airflow (LAF) and mixing ventilation (MV) supply airflow. LAF is designed to generate a laminar supply airflow above the operating table with minimal entrainment and mixing with the surrounding OR air. Meanwhile, MV aims at reducing the bacteria-carrying particle concentration in the room air overall. Extensive research, including physical measurements and computational fluid dynamics (CFD) simulations, has been performed to investigate the performance of these two supply air distribution strategies under different conditions. However, the importance of human activities, such as walking and body movement, for particle generation, as well as the supply airflow pattern and particle distribution in the OR, particularly in the vicinity of the surgical site, are not yet well understood under real-life scenarios.
A cutting-edge hospital operating room (OR), designed for advanced research in reducing postoperative site surgical infections, is now operational in Indonesia. The knowledge learned from this facility will be used to improve present practices and develop new strategies for optimizing supply airflow distribution in operating rooms. The goal is to reduce surgical site exposure to particulate in dynamic, real-world circumstances. Additionally, this specialized OR facility will serve as a dedicated space for developing training tools that will make it possible for medical staff to reduce their impact on supply airflow distribution and minimize personnel particle generation and transmission. This initiative marks a significant step forward in Indonesia’s efforts to enhance patient safety and reduce the incidence of SSIs.
The dimensions of the OR in this research facility are 7.0 m×8.7 m×3.1 m, with a volume of 188.79 m3. A hybrid supply air distribution system can be evaluated using both LAF and MV together. Supply air can be supplied from the ceiling via either LAF or MV or both. For LAF, the supply air volume ranges from 10,000 m3/h to 14,530 m3/h, with a supply air temperature range of 17∘C to 26∘C. For MV, the supply air volume ranges from 13 to 20 air changes per hour (ach), with the same temperature range. The OR typically maintains a positive pressure of 15 Pa to 30 Pa (0.06 in. w.g. to 0.12 in. w.g.) between the OR and the corridor. Research performed in this OR can be conducted under either steady-state or dynamic conditions.
Advanced Research Methods for Airflow and Particle Analysis
During steady-state experiments, full-size, dressed, breathing thermal manikins that resemble medical staff are used. The heat generated by the manikins is controlled to be the same as the heat generated by the medical staff. Transient breathing with a controlled breathing mode (inhalation/exhalation through the mouth/nose or opposite), different pulmonary ventilation rates, and breathing frequencies can be simulated. OR supply air velocities and temperature are measured simultaneously at several locations with multichannel temperature and wireless low-velocity thermal anemometers. Simultaneous particle concentration measurements at 12 locations in the OR, including locations close to the surgical site, are performed by optical particle counters. These measurements are complemented with flow visualization. Special attention is given to understanding the supply flow pattern and particle dynamics in the vicinity of the surgical site under steady-state and dynamic/transient conditions. For this purpose, comprehensive supply air velocity measurements are performed using a particle image velocimeter (PIV).
An important parameter of the OR supply airflow research is the use of extended reality (XR), which is a collective term for technology that combines reality with virtual elements. XR includes virtual reality (VR), augmented reality (AR), and mixed reality (MR), which are differentiated on the basis of the combination of the real and the virtual. The XR technology provides medical personnel a visual and comprehension of space particle and supply airflow, thereby motivating them to regulate their actions with the aim of reducing the risk of surgical site infection (SSI) due to surgical site contamination with viable airborne particles. The XR tool helps researchers understand the interaction between the medical personnel’s movements, the airflow distribution, and particle distribution to develop solutions leading to reduced SSI.
Complex and dynamic simulations are carried out, which include the movements of medical personnel. Six synchronized stereo cameras, each with its own graphics processing unit and body tracking technology, register the movements of the medical staff. The data are recorded in a computer, which in turn combines movements from all viewing angles. The data pertaining to the operating room environment serve as boundary conditions for CFD simulations. A high-resolution CFD simulation model has been developed, and a powerful computer with parallel processing is used to simulate and predict the OR airflow pattern and particle distribution. Thus, unlike the stationary CFD simulations of airflows in an OR carried out thus far, the use of the XR takes into account that the OR supply airflow pattern changes over time due to the movements of medical personnel. Human subjects trained to act like medical staff are used during the studies under dynamic conditions, thus representing realistic particle generation and airflow pattern at the surgical site.
Comparing the Effectiveness of LAF and MV in Particle Control
Studies have revealed the importance of the supply airflow distribution in the spread of generated particles at two sites in the OR: by a nurse standing away from the operating table and by surgeons next to the table. The particle concentrations measured at the surgical site and in the OR away from the operating table in the LAF and MV supply airflow distribution scenarios have been compared. The results reveal that both the location of the particle generation and the supply airflow type (LAF and MV) are important for the exposure of the surgical wound. The LAF supply airflow distribution strategy performs better than MV and is more effective when the particle generation is farther away from the operating table (the nurse) compared to when the particle source is in the laminar flow (the surgeon). The particle concentration in the OR away from the operating table is similar with the two supply airflow distribution strategies.
Understanding airflow dynamics in proximity to the surgical site is important for reducing its exposure to particles. PIV measurements compare the airflow pattern above a surgical site in the case of LAF and MV without and with a person (simulating a surgeon) moving an arm during surgery. During the temporal progression from the surgeon’s initial arm position (at time 0s) to the subsequent position (at time 1.5s) and its subsequent return (at time 3s), disruptions in the supply airflow distribution field are observed in both cases, LAF and MV, with a higher supply airflow disruption in the case of MV. In the region above the surgical site, at time 3s, the maximum velocity is 0.199 m/s (39 fpm) in the MV case, and the LAF case has a maximum velocity of 0.116 m/s (22.9 fpm). The higher velocities in the MV case indicate intensive mixing and transport of particles. For the specific conditions studied, the surgical site’s exposure to particles is higher in the MV case than in the LAF case.
The Importance of Supporting Infrastructure for OR Environments
While the primary focus of this research is on ventilation systems and particle control, it is undeniable that effective operating room function requires more than just advanced air systems. Operational reliability in the OR heavily depends on robust supporting infrastructure, especially an uninterruptible power system. Imagine a scenario where the power supply is cut during a critical surgery; the impact could be devastating. This is where the vital role of a Distributor UPS Rumah Sakit becomes highly relevant. Uninterruptible Power Supply (UPS) systems ensure that a stable and clean power supply is always available, protecting sensitive medical equipment from power fluctuations and outages. This is not just about preventing equipment failure, but also about maintaining patient safety and the smooth execution of procedures.
In the context of Indonesia, where grid stability can sometimes vary, having a reliable backup power solution such as a UPS from Climanusa is essential for every modern healthcare facility. Companies like Climanusa understand the demands of critical environments and provide solutions designed for maximum reliability. Although this article specifically discusses airflow and particles, the need for indispensable power infrastructure is the foundation that allows these advanced ventilation systems to operate continuously. Thus, investment in high-quality UPS systems is an integral part of the overall strategy to create and maintain an ultraclean environment in operating rooms, ensuring that innovations in airborne infection control can operate at their full potential, undisturbed by power issues.
Conclusion
The ongoing research in cutting-edge ORs in Indonesia promises significant advancements in understanding and mitigating surgical site infections. By leveraging advanced technologies such as CFD simulations and extended reality, researchers can gain unprecedented insights into airflow dynamics and particle dispersion within the surgical environment. The finding that laminar airflow (LAF) is more effective in reducing particle concentrations at the surgical site, especially when the particle source is further away, underscores the importance of proper ventilation system selection.
Moving forward, future research will continue to evaluate methods for mitigating postoperative SSIs, including a detailed examination of LAF and MV in both steady-state and dynamic scenarios, along with their potential for optimization. Studies will also investigate advanced supply airflow distribution techniques that surpass the limitations of LAF and MV systems while simultaneously enhancing energy efficiency. Human subject experiments will be an important part of future research directed toward human factors. A tool will be developed for operating staff to understand the importance of how they influence airflow and particle transmission due to their activities in the operating room. All these efforts, coupled with a strong foundation of supporting infrastructure, including uninterruptible power supply through a reliable Distributor UPS Rumah Sakit, will collectively contribute to a safer and more secure operating room environment across Indonesia.
Climanusa is the superior choice for your critical operating room infrastructure needs, ensuring unparalleled reliability and performance.
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–A.M.G–
