A BACTERIOLOGICALLY
OCCLUSIVE
USE
w.
WHYTE,
P.
From
A comparison
clothing
system
convenient
than
replacement
IN
V.
THE
BAILEY,
OPERATING
D.
the University
CLOTHING
L.
HAMBLEN,
ofGlasgow
and
SYSTEM
FOR
ROOM
W.
D.
the Western
FISHER,
I. G.
Infirmary,
KELLY
Glasgow
made
was made in a laminar-flow
operating
room between
total-body
exhaust
gowns
and a
from Fabric 450. This disposable
clothing was found to be much more comfortable
and
the
total-body
exhaust
gowns.
The
average
airborne
bacterial
counts
obtained
during
total
from each of the clothing systems were identical when the downflow method of
ventilation
was used (0.7 per cubic mefre) and no significant
difference
could be demonstrated
when the
crossflow
system
was used (2.2 per cubic mefre with the total-body
exhaust gowns and 3.1 per cubic metre
with the disposable
clothing).
Tests in a dispersal chamber were carried out to find the effectiveness
of each
item of the disposable
clothing
in reducing
bacterial
dispersion.
These tests demonstrated
the relative
ineffectiveness
of wearing a surgical gown as compared
with wearing the complete system. It was confirmed
hip
operations
bacteriologically
A recent
Medical
several
bacteria
implant
showed
that,
Research
compared
approximately
downflow
system
in
with
the
study
conjunction
carried
ofjoint
sepsis,
total-body
of
bacteria
in
the
by Whyte
et al. (1983)
counts
in the operating
and
exhaust
reduced
the rate ofjoint
A further
publication
(Lidwell
a direct
relation
between
joint
concentration
air,
that
room
in
systems
used
room
clothing,
1979)
quarters.
suggested
out
of airborne
orthopaedic
This
study
ventilated
air (UCA)
operating
with
to clothing
conventionally
rate
of ventilation
with respect
Council
ultra-clean
designed
halved
(Charnley
suggested
bacterial
the
centres
demonstrated
the importance
as a cause
of joint
sepsis
after
operations
(Lidwell
et al. 1982).
operating
rooms,
with conventionally
used
that
of this observation
importance
when
gowns
sepsis
by three
et al. 1983)
sepsis
and the
and
it has
been
very low airborne
must be achieved
in order
to minimise
sepsis
caused
by airborne
contamination
(a maximum
of 10 per cubic metre
but 1 per cubic
metre
if possible.)
To achieve
the lowest
counts
of airborne
bacteria
in
a laminar-flow
operating
room,
clothing
occlusive
to
bacteria
available
gown.
cation,
must
be worn.
The most
efficacious
up till now has been
the total-body
However,
it makes
such
clothing
movement
often
around
hampers
the
for reprints
© 1983 British
0301-620X/83/41
502
should
be sent
Editorial
Society
39 $2.00
to Mr
of Bone
W.
and
Whyte.
Joint
communi-
operating
W. Whyte,
BSc, Research
Fellow
and Bacteriologist
P. V. Bailey,
Senior
Technician
Building
Services
Research
Unit,
University
of Glasgow,
Gardens,
Glasgow
G12 8RZ,
Scotland.
D. L. Hamblen,
PhD,
FRCS,
Professor
W. D. Fisher,
FRCS,
Senior
Lecturer
I. G. Kelly,
FRCS,
Lecturer
University
Department
of Orthopaedic
Surgery,
Western
Dumbarton
Road,
Glasgow
Gl 1 6NT,
Scotland.
Requests
clothing
exhaust
Surgery
table
was
more
and sepsis
efficient
Infirmary,
the
crossflow
type;
the
in this paper.
more
difficult,
and it may cause
muscular
soreness
in
people
of slight
build.
Normal
operating
room garments
made
of cotton
are comfortable
to wear but, because
of
the large
holes
between
the threads
(often
about
80
micrometres),
usually
ride
the airborne
on skin scales)
; it has
prevent
bacteria
(despite
the fact they
have little difficulty
in passing
through
gowns
the cloth
will only
people
being
Hodgson
Ventile
1976). Very tightly
woven
cotton
cloth
(which
is the cloth used in the total-body
been found
one third
dispersed
into
the
that cotton
operating
of the bacteria
from
air
(Whyte,
Vesley
and
such as
exhaust
gowns),
if made
into conventionally
designed
operating
room
suits
and
gowns,
will greatly
reduce
bacterial
dispersion.
However,
the tight weave ofthe
cloth prevents
air exchange,
fortable
making
to wear
Fabrics
clothing
made
worn
the
(Hill,
of
cals ; these
materials
bacteria
and yet are
Unfortunately,
such
and therefore
of anti-static
clothing
Howell
during
very
hot
and Blowers
synthetic
the
and
materials
manufacture
uncom-
1974).
are
used
fabrics
often
in
of pharmaceuti-
greatly
reduce
the dispersion
reasonably
comfortable
to
a high static
regulations
have
poor
of
wear.
conductivity
electrical
charge
; thus, because
they
cannot
be used
in the
operating
room.
However,
450*, which
is a disposable
these
difficulties.
and Johnson
and
3 Lilybank
than
is discussed
a material
non-woven
known
fabric,
as Fabric
overcomes
It is supplied
worldwide
by
in the UK by Surgikos
Limited.
Johnson
Most
woven
cloths
depend
on a tight
weave
and
small
pore
size
to prevent
the passage
of airborne
bacteria.
Fabric
450 is not woven;
it is manufactured
by
pressing
a slurry
of fibres
together
and therefore
has a
deep,
randomised,
open-fibre
structure.
This allows good
air exchange
Bacteria-carrying
5The
trade
name
and
is therefore
particles
from
for this
THE
disposable
JOURNAL
comfortable
personnel
material
OF
BONE
are
is “FABRIC
AND
JOINT
to wear.
forced
to
450”
SURGERY
A BACTERIOLOGICALLY
twist
and
Because
tial size
turn
their
way
OCCLUSIVE
through
the
maze
of
bacteria
are carried
on skin particles
they have a high inertia
; they cannot
way through
This property
(Lidwell
and
and Graham
CLOTHING
fibres.
the cloth and are impacted
on to the fibres.
of Fabric
450 is fully discussed
elsewhere
Mackintosh
1978; Whyte,
Hodgson,
Bailey
1978). Studies
in dispersal
chambers
and in
reduction
in
the
count
of
airborne
bacteria
FOR
noted
of substantwist their
operating
rooms
have shown
this cloth to be as efficient
as the closely woven
Ventile
material
in reducing
bacterial
dispersion.
A surgical
gown of Fabric
450 has been tested
in a downflow
laminar-flow
operating
room : it gave a 2.9
times
SYSTEM
that
USE
IN THE
a mask
was
OPERATING
worn
hood in place and that the
the gown
to minimise
air
area.
Dispersal
chamber tests. In
clothing
in preventing
the
air,
a specially
designed
which
volunteers
fully in previous
1978)
and
503
ROOM
over
the
shoulder
leakage
hood
yoke
from
previous
dispersion
dispersal
chamber
features
the
studies
of the role of
of bacteria
into the
was
exercised.
This chamber
papers
(Whyte
et al. 1976;
its important
to keep
was worn under
round
the neck
are
used
in
is described
Whyte
et al.
shown
in Figure
1.
e
as
compared
with a cotton
gown (7.3 per cubic metre
to 2.5
per cubic
metre).
The airborne
count
was not reduced
to
the low level achieved
by the total-body
exhaust
suit (0.63
per cubic
metre)
But, at the time
(Whyte,
Vesley
these experiments
garments
other
this disposable
In
view
than
surgical
material.
of the
bacteria
and
joints
(Lidwell
system
should
total-body
system
purpose
strong
were
link
in reducing
was
be
between
in
airborne
the count
of airborne
made
study
from
Fabric
It was
of a
450.
The
was to test the effectiveness
system.
It has
that
been
the
downflow
than
in
downflow
(Lidwell
system
a
demonstrated
(Whyte,
airborne
concentration
UCA system
crossflow
system
was
et al.
is often
Shaw and Barnes
of bacteria
in a
is between
3.5 and nine times less
system.
The
superiority
of the
confirmed
during
the MRC
study
1982). This is unfortunate,
the only one which
can
existing
operating
room
(architectural
considerations
often make it difficult
system).
ness
available
more comfortable
to use.
achieved
by development
of clothing
of the present
of this
1973)
gown
but which
this could
complete
gowns
1976).
out, no
sepsis
after
orthopaedic
implantation
of
et al. 1982),
it was felt that a clothing
be developed
which
was as efficient
as the
exhaust
bacteria,
felt that
very
and Hodgson
were carried
It was
therefore
of the
occlusive
as downflow
UCA
possibility
trations
as a crossflow
be installed
in an
and
to install
decided
to assess
clothing
system
systems
to obtain
engineering
a downflow
the
effective-
in crossflow
information
as well
on the
of achieving
acceptably
low airborne
of bacteria
in crossflow
systems.
Fig.
Diagram
concenAir
MATERIALS
AND
METHODS
Charnley-Howorth
total-body
exhaust
gown. These
gowns
were purchased
from Howorth
Air Engineering
Limited.
They
were made
of Ventile
L34 material
and were used
as suggested
turer.
Disposable
made
in the
clothing.
of
bacterial
instructions
Fabric
Trousers,
450
dispersion
around
VOL.
the
neck
the
the escape
of the
were designed.
and supplied
65-B,
shirts
were
from
as well as to reduce
yokes
tions
supplied
No. 4. AUGUST
gown,
and
In
skin
of the
surgical
order
neck
of bacteria-laden
full
These
were
by Surgikos
1983
by the manufac-
worn.
hoods
with
of
gowns
to
reduce
and
face,
air from
shoulder
made
to our specificaLimited.
It should
be
was
dispersal
(c) sampling
supplied
and bacterial
height
similar
situated
air taken
conditions
laminar-flow
sampled
dispersed
bacterial
carried
described
Four
chamber.
chamber:
ports:
in a downward
samples
to that
1
(a) HEPA
(d) shelf:
and
filter:
(b)
(e) air supply.
unidirectional
taken
at both
of the operating
found
at the surgical
wound
operating
room ; the sum
port at a
at a port
The samples
to simulate
of
the
in a downflow
of the bacteria
both ports
would
give the total
bacteria
the volunteer.
The
bacterial
samplers,
medium,
incubation
out by the volunteers
in previous
papers.
ofthe
They
manner
a sampling
table and
at the bottom
of the chamber.
at table
height
were assumed
from
by
metronome:
authors
stripped
times and type
were
exactly
of exercise
as those
agreed
to exercise
in the dispersal
to their
underpants
and socks
504
W.
and
donned,
clothing
in
of disposable
with gown
and
sequence,
P. V. BAILEY,
the
: (1) hospital-issue
trousers
and
conventional
and trousers,
following
and
D.
four
operating-room
L. HAMBLEN,
sets
cotton
surgical
gown
together
hood
(Surgikos
Limited);
disposable
conventional
(4) shirt,
disposable
disposable
WHYTE,
of
shirt,
with
a disposable
(2) cotton
shirt
hood and a gown
of
shirt and trousers
but
of disposable
fabric;
throughout
final suture.
trousers,
gown
special
Air
and
hood
A surgical
mask,
surgical
were worn throughout
made
the
volunteers
carried
out
of
gloves
and
these experi-
more
dispersal
set of clothing.
room
tests.
These
experiments
installed
General
were
the
permeabifity
fabrics.
allow
1978.
exactly
in
as
outlined
of millilitres
counts
experiments
to compare
(P<
to
the
new
system
with the Charnley-Howorth
gowns
during
both
downflow
and
To reduce
experimental
variability
special
gowns.
total attendance
wore,
for the
disposable
Sampling
clothing
of airborne
at these operations.
entire
operation,
either
or
The
the
the total-body
exhaust
bacteria
was carried
out
throughout
the operation
by sampling
within
30 centimetres
of the wound
using
a high-volume
Casella
slit
sampler
(sampling
700
litres
per
minute)
Table
I. Airborne
bacterial
numbers
per minute)
Type
of surgical
Cotton
shirt,
conventional
Cotton
gown
dispersion
and
gown,
hood
shirt and trousers,
Fabric
and conventional
disposable
Cotton
shirt and trousers,
450 gown and hood
and
Fabric
hood
gown
450
with
shirt,
trousers,
an
through
clothing
trousers
disposable
exchange
by testing
employed
standard.
This
each
was
method
through
one
square
centimetre
and
tests.
I gives
bacteria
the
obtained
for each of the clothing
difference
exists between
room
tests.
average
from the
systems
studied.
each set of results
Fourteen
seven
in which
and seven
in
total hip operations
were
the total-body
exhaust
gowns
which
the special
disposable
clothing
sets were used. Ninety-four
700-litre
samples
of
air were
taken,
each
sampling
period
lasting
for ten
minutes.
The average
counts
(median)
obtained
when
the two clothing
systems
were worn in either
downflow
or crossflow
conditions
are
It is usual to find that
of airborne
samples
taken
a log-normal
distribution.
shown
in Table
II.
the distribution
of the results
in hospital
areas conforms
to
This was so with the results
we
obtained
and an analysis
was carried
out with logarithms
taken
of each
result.
The standard
deviations
given
Table
II are therefore
geometric
standard
deviations.
A statistical
analysis
revealed
that
with
significant
difference
the
crossflow
and
(P<0.0l).
However,
surgical
clothing
Conditions
simulated
Downward
air supply
laminar-flow
(t-test)
of the
results
in
obtained
both
sets of clothing
there
was a
between
the results
obtained
from
downflow
methods
of air supply
no statistical
difference
could
be
(bacterial
dispersion
measured
as
in chamber
Total
from
71
329
25
222
Fabric
12
149
and
2
18
450
hood
Table
of airborne
0.01).
Operating
only total hip replacement
operations
were studied,
and
to minimise
experimental
variability
caused
by any
alteration
in the dispersion
rate
of different
surgical
teams
the experimental
observations
were
confined
to
one such team.
Eight
individuals
accounted
for over 80
of the
team
ofair
to
second.
chamber
monitored,
were
used
per cent
operating
The amount
incision
RESULTS
Dispersal
(median)
the
clothing
exhaust
ventilation.
first
was assessed
The method
that
of air passing
in one
four volUnteers
A significant
disposable
total-body
crossflow
from
measures
the amount
of air that pa’sses through
a known
area
of fabric
at a given
pressure
(1 centimetre
water
gauge).
The air permeability
is then given as the number
of the
Glas-
fully elsewhere
features
of the
the
operation,
ofthe
design,
which
were used during
these experiments,
were
the system’s
ability
to change
the air speed and direction
during
an operation
(from
crossflow
to downflow
and
vice versa).
The air speed,
as measured
one metre
from
filters,
was adjusted
throughout
0.35 metres
per second.
The aim of the experiment
was
whole
of the air was
sample
taken.
continuously
carried
in one
Hospital,
gow.
This
system
has been
described
(Whyte,
Shaw
and Barnes
1971).
Two
sterile
cone. This apparatus
has been
(Whyte
et a!. 1973). A ten-minute
that the fabrics
would
according
to BS.5636:
of fabric
out in the laminar-flow
system
operating
rooms
at Gartnavel
I. G. KELLY
duct and
elsewhere
(3) cotton
hood made
tests than the other
three.
He wore each set of clothing
eight
times.
The other
three
volunteers
wore
each
set
twice.
Thus,
a total of 14 results
were obtained
from each
Operating
extension
described
material;
special
fabric.
overshoes
D. FISHER,
air sample
was taken ; then the direction
changed,
its velocity
adjusted
and a further
Bacterial
sampling
was carried
out almost
ments.
One
W.
THE
bacteria
person
JOURNAL
dispersed
OF BONE
AND
JOINT
SURGERY
A BACTERIOLOGICALLY
Table
II.
operation
Median
wounds
OCCLUSIVE
and
when
geometric
total-body
Downflow
permeability
(operating
according
and
that
the
0.7
0.62
25
2.2
2.6
Fabric450
system
21
0.7
0.73
22
3.1
2.2
the total-body
clothing.
method
However,
when
in BS.5636:
1978.
much
more
comfortable
body
exhaust
system
respectively
centimetre
garment
everyone
and
who
more
than
to
the
to the cotton
be
total-
clothing.
is achieved
and hood
chamber
It
is clear
disposable
mance
from
these
experiments
downflow
bacteria
ventilation
at the wound
clothing
(0.7
ventilation
per
it was
for total-body
the
was
the
cubic
metre);
and
identical
(2.2
gowns
clothing
system).
results
will interest
surgeons
who
find
fortable
and
inconvenient
occlusive
clothing
and
and
the
can
hence
total-body
minimise
reduce
with
many
are
the
the
crossflow
cubic
cubic
exhaust
but
metre
metre
for
orthopaedic
gowns
aware
uncomthat
number
sepsis
of
perforWith
of airborne
both
sets of
per
3. 1 per
the
system
equal,
gowns.
concentration
identical
with
almost
exhaust
the disposable
These
bacteria
that
clothing
gave a similar,
if not
to that
of total-body
exhaust
only
Total-body
exhaust
gowns
reduce
the dispersion
of bacteria-carrying
particles
because
Ventile
cloth is tightly
woven
and has a
small
pore
size.
However,
tests
show
that
the
air
permeability
of Ventile
cloth
is only 0.39 millilitres
per
square
millilitres
centimetre
for cotton
disposable
comfort
fabric.
Air
and to make
system
comfortable,
per
second
cloth
and
compared
with
15.1
32.7 millilitres
for the
exchange
is an important
an all-enveloping
Ventile
artificial
ventilation
factor
in
clothing
is necessary;
bacterial
reduced.
Although
systems,
lighted
VOL.
65-B,
No. 4. AUGUST
1983
more
convenient
when
trousers,
substituted
The
was
were
equiva-
significantly
concerned
the dispersal
of wearing
gown
dispersal
piece of
for a cotton
counts
study
shirt,
sampling
in the
as each additional
with
UCA
chamber
also highonly a gown
made
of
in a conventionally
ventilated
in the room and hence
may be deposited
(unlike
the dispersal
with the unidirectional
ventilation
system
wound).
Therefore,
potentialofocclusive
room,
into
operat-
the wounds
laminar-flow
where
the airflow
is away
from
the
in order
to obtain
the full protective
clothing
in a conventional
operating
appropriate
trousers
also must be worn.
We agree with previously
published
work
(Whyte
et
al. 1973 ; Lidwell
et al. 1982) that the laminar-flow
system
with a downflow
of air gives lower counts
at the wound
than the crossflow
system
(0.7 per cubic metre
compared
with
2.2 per cubic
metre
with
the total-body
exhaust
gown
cubic
and 0.7 per
metre
with
cubic
the
However,
these airborne
metre
and 3. 1 per cubic
system
was used with
uncommon
it was
exhaust
clothing.
from underneath
the gown (it is known
that the majority
of bacteria
are dispersed
from below the waist ; Whyte
et
al. 1976).
In a conventionally
ventilated
room,
the
bacteria
dispersed
from under
the gown mix with the air
participated
found
was
our
material
lower than
(around
30
those found
(values
of
study
total-body
as cotton
dispersion
results
from
the limitations
hence
the total-body
exhaust
gowns.
The air permeability
of the disposable
fabric
suggests
that
it would
be a
comfortable
clothing
system
and the surgical
staff who
in this
the
ing room.
The disposable
gown,
compared
with a cotton
gown,
only reduced
the total dispersal
rate from 235 to
160 bacteria
per minute
(a 32 per cent reduction).
The
majority
of bacteria
were obviously
still being
dispersed
of airborne
rate.
only
are worn.
Bacterial
clearly
showed
that
clothing
the
occlusive
DISCUSSION
than
as comfortable
disposable
clothing
is therefore
a suitable
alternative
to
the total-body
exhaust
suit.
Tests
carried
out in the dispersal
chamber
demonstrated
that the full benefit
in the reduction
of bacterial
lent
in
system
comfortable
was
; it
disposable
studied.
participated
450
convenient
similar
and
dispersion
and
experiment
systems
Fabric
and
15.1
per second.
of the
the
It was
cotton,
0.39,
out a scientific
found
The
cotton
each
Ventile,
to carry
asked,
experiments
studied.
and
testing
of the
was
and
system
disposable
assessed
by
given
comfort
gowns
of the clothing
permeability
these
exhaust
at
air supply
26
per square
the
samples
Total
body
exhaust
gowns
It was not possible
to assess
Crossflow
bacterial
used
505
ROOM
Geometric
standard
deviation
fabrics
32.7 millilitres
from airborne
clothing
were
OPERATING
Median
air
disposable
air supply
THE
IN
Number
of
observations
air of Ventile,
fabrics
was
to the
found
deviation
obtained
clothing
and disposable
USE
Geometric
standard
deviation
system
and comfort
to
room)
FOR
Median
between
disposable
permeability
Air
standard
exhaust
SYSTEM
Number
of
observations
Clothing
studied
demonstrated
the special
CLOTHING
metre
compared
with
disposable
clothing
concentrations
metre
found
the occlusive
3. 1 per
system).
of 2.2 per cubic
when the downflow
clothing
are much
the figures
with conventional
cotton
clothing
per cubic
metre)
and very much
lower
than
in conventionally
ventilated
operating
rooms
around
1 50 bacteria
per cubic
metre
are not
and
our
own
conventionally
ventilated
506
W.
operating
room
gives
WHYTE,
counts
P. V. BAILEY,
closer
to
450
D. L. HAMBLEN,
per
cubic
airborne
metre).
sepsis
The
relation
was found,
of bacterial
dosage
to joint
during
the MRC
multicentred
be
rate
defined
by
= 0.84 + 0. l87A
the
following
; where
A is the
equation
bacterial
when
These
wound
trial, to
:
W.
D. FISHER,
count
is 3. 1 per cubic
were
1982),
the small
following
operations
term “joint
sepsis
had
fact
between
linear.
airborne
from
may be reduced
from
count inaconventionally
concentration
the equation
about
three per cent
ventilatedoperating
the operating
Council,
UK.
carried
will
that
difference
carried
be reduced
the
rates
to 1 .0 per
cent
outwithout
prophylactic
antibiotics
(Lidwell
will
et al.
calculated
between
sepsis
out in different
directions
of
even
are
further.
based
confirmed
at re-operation
likely to be higher).
This
on
This
sepsis
(the true
reduction
is despite
which
deepjoint
in sepsis
the
has
been
sepsis rate is
obtained
by
use ofocclusive
clothing
with a crossflow
UCA system
is therefore
substantial
and does not differ greatly
from the
results
obtained
with
a downflow
system.
It would
the
is not
that the
when
is 150 per cubic metre (or from 4.7 per cent when
is 450 per cubic
metre),
to 1 .2 per cent when
We thank
Research
450*
airflow
where
two and
operation.
No great accuracy
is
but it is clear that the relation
sepsis
rate and
It can be calculated
sepsis rate
the airborne
room
count
original
equation
and
antibiotic
cover. As the use ofprophylactic
reduce
the rate ofjoint
sepsis to one quarter
contamination
per cubic metre
ofoperating
room and the
sepsis rate is thejoint
sepsis rate (per cent) after operations
where
no prophylactic
antibiotics
have been given.
The
a halfyears
ofthe
claimed
for this
metre,
the airborne
count is reduced
to 0.7 per cubic metre.
figures
ofjoint
sepsis are based on results
obtained
fromoperationsthat
sepsis
airborne
sepsis”
was applied
only to thosejoints
been confirmed
at re-operation
within
I. G. KELLY
therefore
appear
greatestefficiency,
the
the
system
used
that, although
ifit cannot
with
a downflow
be installed,
occlusive
clothing
system
has the
then acrossflow
is
a worthwhile
alternative.
room staffat
Gartnavel
General
Hospital
for participating
We should
also like to thank
Surgikos
Limited
for a supply
in this study,
of BARRIER1
which
was
operating
supported
by a grant from the Medical
room clothing
made
from FABRIC
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