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Informal Papers of a Workshop on Control of Operating Room Airborne Bacteria flu] The National Research Counti m 3 rmmittee on Prosthetics Research and Development/ Committee on Prosthetic-Orthotic Education Assembly of Life Sciences

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Informal Papers of a Workshop on CONTROL OF OPERATING ROOM AIRBORNE BACTERIA November 8-10, 1974 Washington, D.C. COMMITTEE ON PROSTHETICS RESEARCH AND DEVELOPMENT •COMMITTEE ON PROSTHETIC-ORTHOTIC EDUCATION ASSEMBLY OF LIFE SCIENCES-NATIONAL RESEARCH COUNCIL NATIONAL ACADEMY OF SCIENCES Washington, D.C. 1976 NAS-NAE SEP 7 1976 L1BRARY

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NOTICE The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the Committee responsible for the report were chosen for their special compe- tences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This report was prepared as part of the work under Contracts No. V101(134)P-75 and V101(1S4)P-350 between the Veterans Administra- tion and the National Academy of Sciences, and Contracts No. SRS- 500-75-0001 and HEW-10S-76-4103 between the Department of Health* Education, and Welfare and the National Academy of Sciences. The content of this publication does not necessarily reflect the views or policies of the Department of Health, Education, and Welfare, nor does mention of trade names, commercial products, or organi- zations imply endorsement by the U.S. Government.

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FOREWORD The American Academy of Orthopaedic Surgeons (AAOS) established a committee under the chairmanship of Dr. J. Phillip Nelson on November 29, 1972, to study the systems available for providing filtered air to reduce or eliminate bacterial content at the wound site. Establishment of the committee reflected the AAOS' concern about the incidence of deep wound sepsis in clean, refined wounds. AAOS also requested, through the Committee on Prosthetics Research and Development (CPRD) of the National Academy of Sciences, that the role of airborne bacterial contamination in the operat- ing room be reviewed. Approval for CPRD to organize a multidisciplinary meeting to discuss this subject was given by the National Research Council on November 30, 1973. A steering committee was formed on January 18, 1974; its members were: Dr. George T. Aitken, Mr. Kenneth Credle, Dr. Jo Miller, Dr. J. Phillip Nelson, and Dr. John Ulrich. The steering committee recognized from the outset that there are many factors in wound sepsis, such as the competency of host resistance, virulence and numbers of organisms, and use of antibiotics. They also rec- ognized that endogenous or direct contagion may be significant causes of sepsis. The committee quickly agreed that the magnitude and complexity of the sepsis issue was too extensive for consideration at a single conference. Therefore, they agreed to a narrower charge—to examine the control of air- borne bacteria in the operating room. Given this more manageable subject area, the committee decided that the meeting would be a workshop with participation by invitation only and limited to 40 persons. The participants would be representatives of general and orthopedic surgery, microbiology, and engineering, and would be chosen to present varied opinions within each discipline. The Workshop on Control of Operating Room Airborne Bacteria was held at the National Academy of Sciences on November 8-10, 1974. It was attended

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by over 50 individuals interested in surgical asepsis, and 31 papers were read. The conferees represented an international cross section of the knowledgeable in this area. Their discussion reflected a frank presenta- tion and documentation of their work, and an objective assessment of the work of others. This report has been divided into two parts. The first part is an overview, a summary of objectives, conclusions and recommendations for further research. It represents a consensus of the steering conmittee. The second section is an appendix of individually prepared papers on spe- cific aspects of controlling airborne bacteria in the operating room. George T. Aitken Chairman

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CONTENTS INTRODUCTION SUMMARY OF WORKSHOP OBJECTIVES AND CONCLUSIONS RECOMMENDATIONS FOR FURTHER RESEARCH SPECIAL RECOMMENDATION 1 3 9 10 PREPARED PAPERS REVIEW OF POSTOPERATIVE WOUND INFECTIONS W. A. Altemeier OPERATING ROOM ENVIRONMENT AND DEEP WOUND SEPSIS FOLLOWING JOINT REPLACEMENT AT UCLA Harlan C. Amstutz LOCAL AIRFLOW PROTECTION OF SURGICAL WOUNDS TO PREVENT AIRBORNE CONTAMINATION William E. Anspach, Jr. M. Bakels THE DEFINING OF BIOLOGIC CLEAN AIR AND ITS CLINICAL SIGNIFICANCE ULTRACLEAN OPERATING THEATRES VERSUS CONVENTIONAL THEATRES - A Controlled Clinical Trial William C. Beck George Bentley Andrew B. Simmonds LOW VELOCITY UNIDIRECTIONAL ULTRAFILTERED AIR SYSTEMS THE ORTHOPEDIST'S SPECIAL INTEREST IN SURGICAL INFECTION IMPROVED OPERATING ROOM BARRIER MATERIALS THE CASE FOR CLEAN AIR Lewis L. Coriell Mark B. Coventry Peter Dineen John A. Feagin, Jr. AIRBORNE BACTERIAL CONTAMINATION IN THE CONVENTIONAL OPERATING ROOM Robert H. Fitzgerald, Jr. ULTRAVIOLET LIGHT IN THE ORTHOPAEDIC OPERATING ROOMS AT DUKE UNIVERSITY—37 YEARS' EXPERIENCE, 1937-74 J. Leonard Goldner Robert W. Gaines Mary Higgins 11 28 33 45 49 62 79 82 86 93 104

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TWO CONSIDERATIONS IN THE APPLICATION OF LAMINAR CLEAN AIR STANDARD TECHNIQUES TO REDUCE OPERATING ROOM BACTERIA OPERATING ROOM AIR AS A SOURCE OF WOUND CONTAMINATION AND INFECTION WHAT IS THE HARD EVIDENCE ON THE ROLE OF AIRBORNE BACTERIA IN WOUND INFECTION? EVALUATION OF METHODS FOR THE CONTROL OF SURGICAL SEPSIS PROPOSAL FOR AN INVESTIGATION OF THE EFFECT OF ULTRACLEAN AIR IN OPERATING ROOMS ON SURGICAL SEPSIS EXPERIENCES WITH ULTRAVIOLET LIGHT IN OPERATING ROOMS ONE CLINICIAN'S THOUGHTS UPON ATTENDING THE WORKSHOP ON CONTROL OF OPERATING ROOM AIRBORNE BACTERIA UNIDIRECTIONAL AIRFLOW IN HOSPITAL OPERATING THEATERS PERSONAL ENVELOPE SYSTEM IN THE CONTROL OF OPERATING ROOM AIR CONTAMINATION Edward 0. Goodrich, Jr. Howard P. Hogshead Ruth B. Kundsin CLEAN AIR SYSTEMS HORIZONTAL FLOW OPERATING ROOM CLEAN ROOMS HELMET ASPIRATOR SYSTEMS FACTORS TO BE CONSIDERED IN ANALYZING POST- OPERATIVE CLEAN, REFINED WOUND INFECTIONS 1 HUMAN BACTERIAL SHEDDING HORIZONTAL LAMINAR AIRFLOW - ITS EFFECTS ON REDUCING POSTOPERATIVE WOUND INFECTIONS Harold Laufman 0. M. Lidwell 0. M. Lidwell J. Drennan Lowell J. Drennan Lowell George F. Mallison Jo Miller Geoffrey Richards G. Ross Murphy John Prentis C. L. Nelson T. L. Gavan J. Schwartz J. Phillip Nelson J. Phillip Nelson J. Phillip Nelson Dick K. Riemensnider Merrill A. Ritter Harold Eitzen Morris L. V. French Jack B. Hart Page 152 157 167 173 183 195 203 207 209 214 228 243 252 259 265 267

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LOCALIZED SURGICAL ISOLATORS (STERILE ENVIRONMENT CAPSULE) VERTICAL LAMINAR AIRFLOW SYSTEM MICROBIOLOGY OF HUMAN SKIN AND ITS RELATION TO POSTSURGICAL INFECTIONS LOCAL CONTROL OF AIRBORNE BACTERIA PRINCIPLES OF HIGH VELOCITY DIRECTIONAL AIRFLOW SYSTEMS ULTRACLEAN ENVIRONMENTS - A BRITISH POSITION Dana M. Street 274 Robert S. Turner 281 John A. Ulrich 289 J.C.N. Westwood 304 E. Griddle E. J. Synek P. Neals Willis J. Whitfield 311 W. Whyte 316 APPENDIX A - WORKSHOP AGENDA APPENDIX B - PARTICIPANTS 333 337