F Arnaout, A Ismail and P Shewell examine laminar flow areas to help reduce post-operative infections
Abstract
Introduction
The consequences of deep infection following orthopaedic operations can be catastrophic. A low incidence of infection depends upon operating theatre design, meticulous surgical technique and rigid aseptic discipline within the operating theatre suite.
The Department of Health has recommended in the Health Technetium Memorandum (HTM) that the use of lines or a coloured area on the floor delineating the extent of the clean zone is essential.
Purpose
We conducted an audit in one of the orthopaedic theatres in our District General Hospital before and after the implementation of DH guidelines to mark the floor corresponding to the laminar flow area. We also contacted all hospitals in the region to find out who is implementing the recommendations.
Methods
Theatre team members, except surgeons, were blinded to the study and the patients selected were all lower limb arthroplasty cases. We used a scoring system based on the position of the trolleys in the marked area.
Results
This re-audit has shown significant improvement in theatre staff practice following the implementation of DH guidelines. Therefore, we recommend that all regional and national hospitals should have the floor corresponding to laminar airflow marked.
Key words
Laminar, flow, theatre, infection
Introduction
The consequences of deep infection following orthopaedic operations can be catastrophic. Revision arthroplasty following infection is technically difficult and both the operating time, duration of hospital admission and costs may be two to three times higher than for primary joint replacement.
The early infection rate following total hip replacement in standard operating theatres without modern aseptic precautions was as high as 11%, but a combination of prophylactic antibiotics and clean air can reduce the infection rate to 0.3%.3
In a multi-centre study of sepsis after total hip or knee replacement,1 the operations performed by each surgeon were allocated at random between control and ultraclean-air operating rooms. Records were obtained from over 8,000 such operations. In the patients whose prostheses were inserted in an operating room ventilated by an ultraclean-air system the incidence of joint sepsis confirmed at re-operation within the next one to four years was about half that of patients who had had the operation in a conventionally ventilated room at the same hospital.
A low incidence of infection depends upon operating theatre design, meticulous surgical technique & rigid aseptic discipline within the operating theatre suite. Therefore, the British Orthopaedic Association recommends the use of ultraclean theatres and laminar airflow.
In the Laminar Air Flow (LAF) system, the entire body of air within a designated space moves with uniform velocity in a single direction along parallel flow lines, and is restricted to an area in the centre of the operating theatre (room within a room principle). Theatres are usually designed with a vertical downward airflow concept. This results in statistically significant reduction in colony-forming unit per cubic metre (CFU/m3) in the air.
The Department of Health (DH) has recommended in the Health Technetium Memorandum (HTM), that the use of lines or a coloured area on the floor delineating the extent of the clean zone will assist staff and is therefore essential, as any air outside this zone cannot be guaranteed to be ultra-clean.5
The aim of study is to look into the practice of orthopaedic theatres and whether theatre staff has improved their practice of placing instruments trolleys within the laminar air flow area, following the implementation of the national guidelines by marking the floor.
Aims & objectives
- To close the audit cycle and re-audit the practice in the orthopaedic theatre before and after marking the floor corresponding to the laminar air flow area.