Abstract

Background Healthcare-associated infections (HAIs) constitute a significant financial strain on healthcare systems across the world, with surgical site infections (SSIs) being the costliest form. Despite the existence of diverse sources of infection in the operating room (OR), current literature focuses on human and procedural sources of contamination that could lead to an infection. Comparatively, the OR built environment is understudied as a potential disease transmission interface between the environment, patients, and surgical staff. This systematic literature review aims to investigate how the physical characteristics and components of the built environment impact airflow, infection risk, aerosols, particle counts, contamination, and pathogens in operating rooms.

Methods and Findings Literature searches were conducted in the PubMed and Web of Science Core Collection databases on December 21, 2020, ultimately retrieving 2,965 articles after duplicates were removed. During abstract screening, all abstracts were independently reviewed by two authors and conflicts were resolved by a third author. All articles published since January 1, 2010, that reported primary data investigating an aspect of the built environment inside an OR in relation to airflow, contamination, and/or infection for which the full text in English was available were included. This resulted in the inclusion of 138 articles, which includes studies conducted in ORs during active surgeries, computer modeling studies, and simulations in which a real OR was used for a mock surgical procedure. Six major built environment categories were identified based on the collected literature: OR layout, disinfection systems, surgical lights, doors, ventilation, and portable airflow devices. A survey created on Qualtrics software was used to record the aspect of the built environment and the outcome of each study, as well as the relationship between the two.

Conclusions While OR ventilation has been studied extensively, the OR built environment as a whole is understudied in relation to airflow, contamination, and infection. The current literature is inconsistent in both its findings and subsequent recommendations, making it difficult to inform hospital design in the context of SSIs. No articles were identified that discussed respiratory infection transmission in the OR, and very few addressed healthcare worker (HCW) safety in relation to the OR built environment. The significant discrepancies in the literature identified in this review highlight the need for future studies that assess the quality and bias of these studies before firm recommendations can be made. Future work should also focus on addressing the lack information regarding respiratory infection transmission in the OR, especially in the context of HCW safety.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The authors would like to gratefully acknowledge the U.S. Centers for Disease Control and Prevention (CDC) for funding this work. This material is based upon work supported by the Naval Sea Systems Command under Contract No. N00024-13-D-6400, Task Order NH076. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the U.S. Centers for Disease Control and Prevention.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

Data Availability

This is a systematic literature review, as such all data discussed has been previously published.

LIST OF ACRONYMS AND ABBREVIATIONSAADangular air distributionACHair changes per hourACOLair-conditioner outlet layoutAGPaerosol-generating procedureASHRAEAmerican Society of Heating, Refrigerating, and Air-Conditioning EngineersBCPbacteria-carrying particleCAPcold atmospheric-pressure plasmaCDCCenters for Disease Control and PreventionCEDcontinuous environmental disinfectionCFDcomputational fluid dynamicsCFUcolony-forming unitsCOVID-19coronavirus disease 2019CSFcerebral-spinal fluidC-UVCcrystalline ultraviolet CCVconventional ventilationDVdisplacement ventilationDVAFdifferential vertical airflow ventilationENTear, nose, and throatEPReffective protection ratioGNRgram-negative rodHAIhealthcare-associated infectionHCWhealthcare workerHEPAhigh-efficiency particulate airHVACheating, ventilation, and air conditioningIMAIndex of Microbial Air contaminationISOInternational Organization for StandardizationJHU/APLJohns Hopkins University Applied Physics LaboratoryLAFlaminar airflowLDACliquid desiccant air conditioningLEDlight-emitting diodeMDROmulti-drug resistant organismMLAFmobile laminar airflowMVmixing ventilationORoperating roomOToperating theaterPCNSIpost-operative central nervous system infectionPJIprosthetic joint infectionPMparticulate matterPPEpersonal protective equipmentPPX-UVDportable pulsed xenon ultraviolet disinfectionRDACrotary desiccant air conditioningRODACreplicate organism detection and countingRRrelative riskSARS-CoV-2severe acute respiratory syndrome coronavirus 2SSIsurgical site infectionTAFtemperature-controlled airflowTBCtotal bacterial countTcAFtemperature-controlled airflowTHAtotal hip arthroplastyTIturbulence intensityTJAtotal joint arthroplastyTKAtotal knee arthroplastyTMAturbulent mixed airflowTMVturbulent mixing ventilationTPCtotal particle countTVturbulent (airflow) ventilationTVCtotal viable countTVOCtotal volatile organic compoundUCVultra-clean ventilationUDFunidirectional airflow1UDFunidirectional displacement airflow2UDFunidirectional downflow3UDVunidirectional downward airflowUFCundefined4UFPultra-fine particleUVultravioletUV-Cultraviolet-CUVGIultraviolet germicidal irradiationUVLultraviolet lightUWDupward displacement airflowVPCviable particle count