The "six sigma approach" to the operating room environment and infection

Best Practice and Research: Clinical Anaesthesiology

Volumn 22, Issue 3, 2008, Pages 537-552

  Thiele, Robert H ^a   Huffmyer, Julie L ^a   Nemergut, Edward C ^a  

^a UNIVERSITY OF VIRGINIA HEALTH SYSTEM   (United States)

Author keywords

anesthesiology; evidence based medicine; hypothermia; operating room design; surgical site infection

Indexed keywords

2 PROPANOL; ALCOHOL; ANTIINFECTIVE AGENT; CEFALOTIN; CHLORHEXIDINE; DISINFECTANT AGENT; INFUSION FLUID; POVIDONE IODINE; TRICLOSAN; VASODILATOR AGENT;

AEROBIC BACTERIUM; AIR QUALITY; ANAEROBIC BACTERIUM; ANESTHESIA; BACTERIAL INFECTION; BACTERIAL STRAIN; BACTERIAL TRANSMISSION; BACTERIUM CONTAMINATION; BACTERIUM CULTURE; BODY TEMPERATURE; CLINICAL TRIAL; COLONY FORMING UNIT; COMORBIDITY; ENVIRONMENTAL FACTOR; ENVIRONMENTAL TEMPERATURE; ERGONOMICS; HAND WASHING; HEALTH PERSONNEL ATTITUDE; HEAT TRANSFER; HIP DISEASE; HOSPITAL DESIGN; HOSPITAL PERSONNEL; HOSPITAL POLICY; HUMAN; HYPOTHERMIA; INFECTION RISK; KNEE ARTHROPLASTY; KNEE DISEASE; MICROFLORA; MYCOSIS; NONHUMAN; OPERATING ROOM; OPERATING ROOM PERSONNEL; PATHOPHYSIOLOGY; PATIENT SAFETY; PERSONAL HYGIENE; PRACTICE GUIDELINE; PREOPERATIVE CARE; PRIORITY JOURNAL; PROTECTIVE EQUIPMENT; REVIEW; RISK ASSESSMENT; RISK FACTOR; RISK MANAGEMENT; RISK REDUCTION; STANDARDIZATION; SURGEON; SURGICAL INFECTION; THERMODYNAMICS; TOTAL HIP PROSTHESIS; WOUND INFECTION;

AIR MICROBIOLOGY; AIR POLLUTION, INDOOR; BODY TEMPERATURE; CROSS INFECTION; HEALTH FACILITY ENVIRONMENT; HUMANS; HYPOTHERMIA; INFECTION CONTROL; OPERATING ROOMS; SURGICAL WOUND INFECTION; UNITED STATES;

EID: 49349091094     PISSN: 15216896     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.bpa.2008.06.002     Document Type: Review

References (84)

1. Edwards P.S., Lipp A., and Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews (2004) CD003949
2. Altemeier W.A., Culbertson W.R., and Hummel R.P. Surgical considerations of endogenous infections-sources, types, and methods of control. Surgical Clinics of North America 48 (1968) 227-240
3. Whyte W., Hodgson R., and Tinkler J. The importance of airborne bacterial contamination of wounds. Journal of Hospital Infection 3 (1982) 123-135
4. Barwolff S., Sohr D., Geffers C., et al. Reduction of surgical site infections after Caesarean delivery using surveillance. Journal of Hospital Infection 64 (2006) 156-161
5. Rodriguez J.F.G., Trobo A.R., Garcia M.V.L., et al. The effect of performance feedback on wound infection rate in abdominal hysterectomy. American Journal of Infection Control 34 (2006) 182-187
6. Kasatpibal N., Jamulitrat S., Chongsuvivatwong V., et al. Impact of surgeon-specific feedback on surgical site infection rates in Thailand. Journal of Hospital Infection 63 (2006) 148-155
7. Vote D., and Huston J. Six sigma approach to improve surgical site infections: a key variable. American Journal of Infection Control 33 (2005) E167-E168
8. Calia F.M., Wolinsky E., Mortimer Jr. E.A., et al. Importance of the carrier state as a source of Staphylococcus aureus in wound sepsis. Journal of Hygiene 67 (1969) 49-57
9. Dineen P., and Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet 2 (1973) 1157-1159
10. Mastro T.D., Farley T.A., Elliott J.A., et al. An outbreak of surgical-wound infections due to group A streptococcus carried on the scalp. New England Journal of Medicine 323 (1990) 968-972
11. Ford C.R., Peterson D.E., and Mitchell C.R. An appraisal of the role of surgical face masks. American Journal of Surgery 113 (1967) 787-790
12. Letts R.M., and Doermer E. Conversation in the operating theater as a cause of airborne bacterial contamination. Journal of Bone & Joint Surgery - American Volume 65 (1983) 357-362
13. Centers for Disease C. Postsurgical infections associated with nonsterile implantable devices. MMWR - Morbidity & Mortality Weekly Report 41 (1992) 263
14. Soto L.E., Bobadilla M., Villalobos Y., et al. Post-surgical nasal cellulitis outbreak due to Mycobacterium chelonae. Journal of Hospital Infection 19 (1991) 99-106
15. Berkelman R.L., Godley J., Weber J.A., et al. Pseudomonas cepacia peritonitis associated with contamination of automatic peritoneal dialysis machines. Annals of Internal Medicine 96 (1982) 456-458
16. Stamm W.E., Feeley J.C., and Facklam R.R. Wound infections due to group A streptococcus traced to a vaginal carrier. Journal of Infectious Diseases 138 (1978) 287-292
17. Gryska P.F., and O'Dea A.E. Postoperative streptococcal wound infection. The anatomy of an epidemic. JAMA: The Journal of the American Medical Association 213 (1970) 1189-1191
18. McIntyre D.M. An epidemic of Streptococcus pyogenes puerperal and postoperative sepsis with an unusual carrier site-the anus. American Journal of Obstetrics & Gynecology 101 (1968) 308-314
19. Mangram A.J., Horan T.C., Pearson M.L., et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infection Control & Hospital Epidemiology 20 (1999) 250-278 quiz 79-80
20. Laufman H. Design, devices, and discipline in operating room infection control. Medical Instrumentation 12 (1978) 158-160
21. Romney M.G. Surgical face masks in the operating theatre: re-examining the evidence. Journal of Hospital Infection 47 (2001) 251-256
22. Orr N.W. Is a mask necessary in the operating theatre?. Annals of the Royal College of Surgeons of England 63 (1981) 390-392
23. Lipp A., and Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database of Systematic Reviews (2002) CD002929
24. Chamberlain G.V., and Houang E. Trial of the use of masks in the gynaecological operating theatre. Annals of the Royal College of Surgeons of England 66 (1984) 432-433
25. Tunevall T.G. Postoperative wound infections and surgical face masks: a controlled study. World Journal of Surgery 15 (1991) 383-387 [discussion: 7-8]
26. Alwitry A., Jackson E., Chen H., and Holden R. The use of surgical facemasks during cataract surgery: is it necessary?. British Journal of Ophthalmology 86 (2002) 975-977
27. Tunevall T.G., and Jorbeck H. Influence of wearing masks on the density of airborne bacteria in the vicinity of the surgical wound. European Journal of Surgery 158 (1992) 263-266
28. Skinner M.W., and Sutton B.A. Do anaesthetists need to wear surgical masks in the operating theatre? A literature review with evidence-based recommendations. Anaesthesia & Intensive Care 29 (2001) 331-338
29. Mitchell N.J., and Hunt S. Surgical face masks in modern operating rooms-a costly and unnecessary ritual?. Journal of Hospital Infection 18 (1991) 239-242
30. Shaw J.A., Bordner M.A., and Hamory B.H. Efficacy of the Steri-Shield filtered exhaust helmet in limiting bacterial counts in the operating room during total joint arthroplasty. Journal of Arthroplasty 11 (1996) 469-473
31. Bohn W.W., McKinsey D.S., Dykstra M., and Koppe S. The effect of a portable HEPA-filtered body exhaust system on airborne microbial contamination in a conventional operating room. Infection Control & Hospital Epidemiology 17 (1996) 419-422
32. Pasquarella C., Pitzurra O., Herren T., et al. Lack of influence of body exhaust gowns on aerobic bacterial surface counts in a mixed-ventilation operating theatre. A study of 62 hip arthroplasties. Journal of Hospital Infection 54 (2003) 2-9
33. Ayliffe G.A. Role of the environment of the operating suite in surgical wound infection. Reviews of Infectious Diseases 13 Suppl. 10 (1991) S800-S804
34. Lidwell O.M., Elson R.A., Lowbury E.J., et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthopaedica Scandinavica 58 (1987) 4-13
35. Gruenberg M.F., Campaner G.L., Sola C.A., and Ortolan E.G. Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system. Spine 29 (2004) 2330-2334
36. Allo M.D., and Tedesco M. Operating room management: operative suite considerations, infection control. Surgical Clinics of North America 85 (2005) 1291-1297
37. Weber D.O., Gooch J.J., Wood W.R., et al. Influence of operating room surface contamination on surgical wounds: a prospective study. Archives of Surgery 111 (1976) 484-488
38. U.S. Department of Labor OSaHA. Occupational exposure to bloodborne pathogens; final rule (29 CFR Part 1910.1030). Federal Register 56 (1991) 64004-64182
39. Nelson J., Bivens A., Shinn A., et al. Microbial flora on operating room telephones. AORN Journal 83 (2006) 607-611
40. Waked W.R., Simpson A.K., Miller C.P., et al. Sterilization wrap inspections do not adequately evaluate instrument sterility. Clinical Orthopaedics & Related Research 462 (2007) 207-211
41. Mauermann W.J., and Nemergut E.C. The anesthesiologist's role in the prevention of surgical site infections. Anesthesiology 105 (2006) 413-421 quiz 39-40
42. Bratzler D.W., Houck P.M., and Surgical Infection Prevention Guideline Writers W. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. American Journal of Surgery 189 (2005) 395-404
43. Garibaldi R.A. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. Journal of Hospital Infection 11 Suppl. B (1988) 5-9
44. Webster J., and Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. [update of Cochrane Database Syst Rev. 2006;(2):CD004985; PMID: 16625619]. Cochrane Database of Systematic Reviews (2007) CD004985
45. Kalantar-Hormozi A.J., and Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study. Plastic & Reconstructive Surgery 116 (2005) 529-531
46. Ellenhorn J.D.I., Smith D.D., Schwarz R.E., et al. Paint-only is equivalent to scrub-and-paint in preoperative preparation of abdominal surgery sites. Journal of the American College of Surgeons 201 (2005) 737-741
47. Ritter M.A., French M.L., Eitzen H.E., and Gioe T.J. The antimicrobial effectiveness of operative-site preparative agents: a microbiological and clinical study. Journal of Bone & Joint Surgery - American Volume 62 (1980) 826-828
48. Yoshida M., Nabeshima T., Gomi H., and Lefor A.T. Technology and the prevention of surgical site infections. Journal of Surgical Education 64 (2007) 302-310
49. Lowbury E.J., and Lilly H.A. Use of 4 per cent chlorhexidine detergent solution (Hibiscrub) and other methods of skin disinfection. British Medical Journal 1 (1973) 510-515
50. Seropian R., and Reynolds B.M. Wound infections after preoperative depilatory versus razor preparation. American Journal of Surgery 121 (1971) 251-254
51. Hingst V., Juditzki I., Heeg P., and Sonntag H.G. Evaluation of the efficacy of surgical hand disinfection following a reduced application time of 3 instead of 5 min. Journal of Hospital Infection 20 (1992) 79-86
52. Selden E. Rubber gloves as a factor in modern surgery. The American Journal of Nursing 18 (1918) 527-530
53. Tanner J., and Parkinson H. Double gloving to reduce surgical cross-infection. [update in Cochrane Database Syst Rev. 2006;3:CD003087; PMID: 16855997]. Cochrane Database of Systematic Reviews (2002) CD003087
54. Sanders R., Fortin P., Ross E., and Helfet D. Outer gloves in orthopaedic procedures. Cloth compared with latex. Journal of Bone & Joint Surgery - American Volume 72 (1990) 914-917
55. Sebold E.J., and Jordan L.R. Intraoperative glove perforation. A comparative analysis. Clinical Orthopaedics & Related Research (1993) 242-244
56. Knobben B.A.S., van Horn J.R., van der Mei H.C., and Busscher H.J. Evaluation of measures to decrease intra-operative bacterial contamination in orthopaedic implant surgery. Journal of Hospital Infection 62 (2006) 174-180
57. Duguid J.P., and Wallace A.T. Air infection with dust liberated from clothing. Lancet 2 (1948) 845-849
58. Pryor F., and Messmer P.R. The effect of traffic patterns in the OR on surgical site infections. AORN Journal 68 (1998) 649-660
59. Culver D.H., Horan T.C., Gaynes R.P., et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. American Journal of Medicine 91 (1991) 152S-157S
60. Kleinert J.M., Hoffmann J., Miller Crain G., et al. Postoperative infection in a double-occupancy operating room. A prospective study of two thousand four hundred and fifty-eight procedures on the extremities. Journal of Bone & Joint Surgery - American Volume 79 (1997) 503-513
61. Sangrasi A.K., Leghari A.A., Memon A., et al. Surgical site infection rate and associated risk factors in elective general surgery at a public sector medical university in Pakistan. International Wound Journal 5 (2008) 74-78
62. Leong G., Wilson J., and Charlett A. Duration of operation as a risk factor for surgical site infection: comparison of English and US data. Journal of Hospital Infection 63 (2006) 255-262
63. Sandberg W.S., Daily B., Egan M., et al. Deliberate perioperative systems design improves operating room throughput. Anesthesiology 103 (2005) 406-418
64. Sessler D.I. Perioperative heat balance. Anesthesiology 92 (2000) 578-596
65. Sessler D.I. Complications and treatment of mild hypothermia. Anesthesiology 95 (2001) 531-543
66. Sessler D.I. Mild perioperative hypothermia. New England Journal of Medicine 336 (1997) 1730-1737
67. Kurz A., Sessler D.I., and Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of wound infection and temperature group. New England Journal of Medicine 334 (1996) 1209-1215
68. Flores-Maldonado A., Medina-Escobedo C.E., Rios-Rodriguez H.M., and Fernandez-Dominguez R. Mild perioperative hypothermia and the risk of wound infection. Archives of Medical Research 32 (2001) 227-231
69. McAnally H.B., Cutter G.R., Ruttenber A.J., et al. Hypothermia as a risk factor for pediatric cardiothoracic surgical site infection. Pediatric Infectious Disease Journal 20 (2001) 459-462
70. Hedrick T.L., Turrentine F.E., Smith R.L., et al. Single-institutional experience with the surgical infection prevention project in intra-abdominal surgery. Surgical Infections 8 (2007) 425-435
71. Miles A.A., Miles E.M., and Burke J. The value and duration of defence reactions of the skin to the primary lodgement of bacteria. British Journal of Experimental Pathology 38 (1957) 79-96
72. Babior B.M. Oxygen-dependent microbial killing by phagocytes (second of two parts). New England Journal of Medicine 298 (1978) 721-725
73. Babior B.M. Oxygen-dependent microbial killing by phagocytes (first of two parts). New England Journal of Medicine 298 (1978) 659-668
74. van Oss C.J., Absolom D.R., Moore L.L., et al. Effect of temperature on the chemotaxis, phagocytic engulfment, digestion and O2 consumption of human polymorphonuclear leukocytes. Journal of the Reticuloendothelial Society 27 (1980) 561-565
75. Clardy C.W., Edwards K.M., and Gay J.C. Increased susceptibility to infection in hypothermic children: possible role of acquired neutrophil dysfunction. Pediatric Infectious Disease 4 (1985) 379-382
76. Wenisch C., Narzt E., Sessler D.I., et al. Mild intraoperative hypothermia reduces production of reactive oxygen intermediates by polymorphonuclear leukocytes. Anesthesia & Analgesia 82 (1996) 810-816
77. Allen D.B., Maguire J.J., Mahdavian M., et al. Wound hypoxia and acidosis limit neutrophil bacterial killing mechanisms. Archives of Surgery 132 (1997) 991-996
78. Hopf H.W., Hunt T.K., West J.M., et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Archives of Surgery 132 (1997) 997-1004 [discussion: 5]
79. Hynson J.M., Sessler D.I., Moayeri A., et al. The effects of preinduction warming on temperature and blood pressure during propofol/nitrous oxide anesthesia. Anesthesiology 79 (1993) 219-228
80. Sessler D.I., and Moayeri A. Skin-surface warming: heat flux and central temperature. Anesthesiology 73 (1990) 218-224
81. Sessler D.I., McGuire J., and Sessler A.M. Perioperative thermal insulation. Anesthesiology 74 (1991) 875-879
82. Sessler D.I., and Schroeder M. Heat loss in humans covered with cotton hospital blankets. Anesthesia & Analgesia 77 (1993) 73-77
83. Tumia N., and Ashcroft G.P. Convection warmers-a possible source of contamination in laminar airflow operating theatres?. Journal of Hospital Infection 52 (2002) 171-174
84. Zink R.S., and Iaizzo P.A. Convective warming therapy does not increase the risk of wound contamination in the operating room. Anesthesia & Analgesia 76 (1993) 50-53