Original research Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks Dirk F de Korne, 1,2 Jeroen D H van Wijngaarden, 2 Jeroen van Rooij, 3 Linda S G L Wauben, 4 U Frans Hiddema, 5 Niek S Klazinga 6 ABSTRACT Objective: To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned. Methods: The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20- month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics. Results: Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR. Conclusions: OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non- technical skills. INTRODUCTION Operating rooms (ORs) are high-risk areas for preventable patient harm, 1e3 surgical site infection being one of its major cate- gories. 1 3e5 Bacterial air contamination is generally accepted as the main causal factor of surgical site infections. 4e7 Proper ventila- tion in and near the OR is the single most important component in establishing an environment that stops the spread of infec- tion. 8 Since, in the 1980’s, a correlation between airborne bacteria contamination levels and the incidence of postoperative wound infections was demonstrated, the use of ultra-clean ORs with laminar air flow (LAF) ventilation has been recommended for many types of surgery. 4e6 With LAF, cold, clean air is blown into the OR from a ceiling system and contaminated air is sucked out through wall grids. Different studies have shown the effects of LAF ventilation on the number of contaminations in samples from different OR areas. 4e6 In the past 30 years, much attention has been given to the proper installation of LAF systems as well as details about its size, posi- tion, concentration, efficiency, degree of filter, temperature and other technicalities. 9 The actual effect of the clean air, however, is largely dependent on the correct positioning of the surgical table and instruments in its flow as well as staff traffic behaviour and patterns (eg, the number of people standing within the flow or against wall vents). 6e11 Energy from devices and movement of devices and staff decrease the volume of clean air and all these hinder the flow. 8 10 In most literature on hygiene and infection and in many patient safety studies, the focus is on teaching, training and changing staff 1 Rotterdam Ophthalmic Institute, The Rotterdam Eye Hospital, Rotterdam, The Netherlands 2 Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands 3 Corneal Diseases and Infection Prevention and Control, Rotterdam Eye Hospital, Rotterdam, The Netherlands 4 Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands 5 Executive Board, The Rotterdam Eye Hospital, Rotterdam, The Netherlands 6 Department of Social Medicine, University of Amsterdam, Amsterdam, The Netherlands Correspondence to Dirk F de Korne, Rotterdam Ophthalmic Institute, The Rotterdam Eye Hospital, and Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 70030, 3000 LM Rotterdam, The Netherlands; d.dekorne@oogziekenhuis.nl Accepted 16 July 2011 746 BMJ Qual Saf 2012;21:746–752. doi:10.1136/bmjqs-2011-000138 Published Online First 18 August 2011 group.bmj.com on August 23, 2013 - Published by qualitysafety.bmj.com Downloaded from