Surgical clothing systems in laminar airflow operating room: a numerical assessment

Current and potential approaches on assessing airflow and particle dispersion in healthcare facilities: a systematic review

An indoor environment in a hospital building requires a high indoor air quality (IAQ) to overcome patients' risks of getting wound infections without interrupting the recovery process. However, several problems arose in obtaining a satisfactory IAQ, such as poor ventilation design strategies, insufficient air exchange, improper medical equipment placement and high door opening frequency. This paper presents an overview of various methods used for assessing the IAQ in hospital facilities, especially in an operating room, isolation room, anteroom, postoperative room, inpatient room and dentistry room. This review shows that both experimental and numerical methods demonstrated their advantages in the IAQ assessment. It was revealed that both airflow and particle tracking models could result in different particle dispersion predictions. The model selection should depend on the compatibility of the simulated result with the experimental measurement data. The primary and secondary forces affecting the characteristics of particle dispersion were also discussed in detail. The main contributing forces to the trajectory characteristics of a particle could be attributed to the gravitational force and drag force regardless of particle size. Meanwhile, the additional forces could be considered when there involves temperature gradient, intense light source, submicron particle, etc. The particle size concerned in a healthcare facility should be less than 20 μm as this particle size range showed a closer relationship with the virus load and a higher tendency to remain airborne. Also, further research opportunities that reflect a more realistic approach and improvement in the current assessment approach were proposed.

Effects of air-conditioning systems in the public areas of hospitals: A scoping review

Almost all hospitals are equipped with air-conditioning systems to provide a comfortable environment for patients and staff. However, the accumulation of dust and moisture within these systems increases the risk of transmission of microbes and have on occasion been associated with outbreaks of infection. Nevertheless, the impact of air-conditioning on the transmission of microorganisms leading to infection remains largely uncertain. We conducted a scoping review to screen systematically the evidence for such an association in the face of the coronavirus disease 2019 epidemic. PubMed, Embase and Web of Science databases were explored for relevant studies addressing microbial contamination of the air, their transmission and association with infectious diseases. The review process yielded 21 publications, 17 of which were cross-sectional studies, three were cohort studies and one case−control study. Our analysis showed that, compared with naturally ventilated areas, microbial loads were significantly lower in air-conditioned areas, but the incidence of infections increased if not properly managed. The use of high-efficiency particulate air (HEPA) filtration not only decreased transmission of airborne bioaerosols and various microorganisms, but also reduced the risk of infections. By contrast, contaminated air-conditioning systems in hospital rooms were associated with a higher risk of patient infection. Cleaning and maintenance of such systems to recommended standards should be performed regularly and where appropriate, the installation of HEPA filters can effectively mitigate microbial contamination in the public areas of hospitals.

Thoracic Surgery in the COVID-19 Pandemic: A Novel Approach to Reach Guideline Consensus

The COVID-19 pandemic challenges international and national healthcare systems. In the field of thoracic surgery, procedures may be deferred due to mandatory constraints of the access to diagnostics, staff and follow-up facilities. There is a lack of prospective data on the management of benign and malignant thoracic conditions in the pandemic. Therefore, we derived recommendations from 14 thoracic societies to address key questions on the topic of COVID-19 in the field of thoracic surgery. Respective recommendations were extracted and the degree of consensus among different organizations was calculated. A high degree of consensus was found to temporarily suspend non-critical elective procedures or procedures for benign conditions and to prioritize patients with symptomatic or advanced cancer. Prior to hospitalization, patients should be screened for respiratory symptoms indicating possible COVID-19 infection and most societies recommended to screen all patients for COVID-19 prior to admission. There was a weak consensus on the usage of serology tests and CT scans for COVID-19 diagnostics. Nearly all societies suggested to postpone elective procedures in patients with suspected or confirmed COVID-19 and recommended constant reevaluation of these patients. Additionally, we summarized recommendations focusing on precautions in the theater and the management of chest drains. This study provides a novel approach to informed guidance for thoracic surgeons during the COVID-19 pandemic in the absence of scientific evidence-based data.

Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.

Organizing a safe operating room during a pandemic. What did we learn from COVID-19?

During the COVID-19 pandemic, multiple guidelines have been issued on hospital safety and protection measures to prevent transmission to healthcare workers and to other patients. The operating room is a high-risk environment where enhanced precautions are required. The guidelines differ and practical implementation between hospitals can also vary, according to interpretation and budget. Staff at risk may question if the local policies are sufficient and correct. This article provides an overview and theoretical background to the additional safety measures required in the operating room during a viral pandemic like the COVID-19 pandemic. This may serve as a touchstone and tool for anesthetists and OR managers.

COVID-19: impact on colorectal surgery

AIM

The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and emergency colorectal surgery, including surgery for colorectal cancer, several questions pertaining to operating room (OR) utilization and techniques needed to be rapidly addressed.

METHOD

This manuscript discusses knowledge related to the critical considerations of patient and caregiver safety relating to personal protective equipment (PPE) and the operating room environment.

RESULTS

During the COVID-19 pandemic, additional personal protective equipment (PPE) may be required contingent upon local availability of COVID-19 testing and the incidence of known COVID-19 infection in the respective community. In addition to standard COVID-19 PPE precautions, a negative-pressure environment, including an OR, has been recommended, especially for the performance of aerosol-generating procedures (AGPs). Hospital spaces ranging from patient wards to ORs to endoscopy rooms have been successfully converted from standard positive-pressure to negative-pressure spaces. Another important consideration is the method of surgical access; specifically, minimally invasive surgery with pneumoperitoneum is an AGP and thus must be carefully considered. Current debate centres around whether it should be avoided in patients known to be infected with SARS-CoV-2 or whether it can be performed under precautions with safety measures in place to minimize exposure to aerosolized virus particles. Several important lessons learned from pressurized intraperitoneal aerosolized chemotherapy procedures are demonstrated to help improve our understanding and management.

CONCLUSION

This paper evaluates the issues surrounding these challenges including the OR environment and AGPs which are germane to surgical practices around the world. Although there is no single universally agreed upon set of answers, we have presented what we think is a balanced cogent description of logical safe approaches to colorectal surgery during the COVID-19 pandemic.

Surgery in times of COVID-19-recommendations for hospital and patient management

BACKGROUND

The novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has escalated rapidly to a global pandemic stretching healthcare systems worldwide to their limits. Surgeons have had to immediately react to this unprecedented clinical challenge by systematically repurposing surgical wards.

PURPOSE

To provide a detailed set of guidelines developed in a surgical ward at University Hospital Wuerzburg to safely accommodate the exponentially rising cases of SARS-CoV-2 infected patients without compromising the care of emergency surgery and oncological patients or jeopardizing the well-being of hospital staff.

CONCLUSIONS

The dynamic prioritization of SARS-CoV-2 infected and surgical patient groups is key to preserving life while maintaining high surgical standards. Strictly segregating patient groups in emergency rooms, non-intensive care wards and operating areas prevents viral spread while adequately training and carefully selecting hospital staff allow them to confidently and successfully undertake their respective clinical duties.

Laminar Air Flow Handling Systems in the Operating Room

BACKGROUND

Surgical site infection is associated with a substantial healthcare burden and remains one of the most challenging complications to treat. Airborne particles carrying contaminating micro-organisms are responsible for the majority of these infections.

METHODS

Various operating theater ventilatory systems have been developed to prevent direct airborne bacterial inoculation of the surgical wound. Laminar air flow uses positive pressure air currents through filtration units to direct air streams away from the operative field in order to create an ultraclean zone around the operative site.

DISCUSSION

Early studies reported lower infection rates with laminar air flow and therefore it became the accepted standard for implant-related surgery. However, more recent evidence has questioned its clinical importance. The purpose of this article is to review contemporary laminar air flow handling systems and the current evidence behind their use.

Approach to Decrease Infection Following Total Joint Arthroplasty

Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.

Modelling levels of nitrous oxide exposure for healthcare professionals during EMONO usage

BACKGROUND

Computational fluid dynamics (CFD) has been used to compute nitrous oxide (N2O) levels within a room during the administration of an equimolar mix of N2O/oxygen (EMONO) in the clinical setting. This study modelled realistic scenarios of EMONO usage in hospital or primary care, in order to estimate the potential N2O exposure of healthcare professionals (HCP) with routine EMONO use and to provide guidance for EMONO users.

METHODS

Sixteen scenarios were defined by carrying out a survey of practitioners. CFD simulations were performed for each scenario and N2O concentrations over time were calculated. N2O exposures (time-weighted average of concentration over 8 h [TWA-8 h]) were calculated at the HCPs' mouth to be compared with a predefined occupational exposure limit (OEL).

RESULTS

Administration duration and ventilation type were the main factors influencing N2O levels; ventilation type also influenced wash-out time between EMONO administrations. N2O concentration showed a plume distribution towards the ceiling and was highly heterogeneous, highlighting the importance of measurement location. Although estimated TWA-8 h varied widely, 13 of the 16 scenarios had an N2O TWA-8 h of <100 parts per million.

CONCLUSIONS

Data demonstrate that EMONO usage in well ventilated rooms - as recommended - helps to ensure that N2O exposure does not exceed the OEL and does not signal any major risks for HCPs when recommendations are followed. Although these data are numerical simulations and should be considered as such, they can provide guidance for EMONO users.