Evidence Based Design nel blocco operatorio

Studies on infection control demonstrate that proper hand hygiene is the single most effective method of reducing Hospital Acquired Infections (HAIs). In particular hand hygiene in operating theatre is essential to avoid Site Surgery Infection (SSI). Operating hand hygiene takes place in the scrub room: this area may have various size and architectural features depending also on the characteristic of the surgery block where it is located. The research question concerns the distance between scrub room and operating room, investigating if there is an acquisition of further bacteria after the hand hygiene due to the distance between these areas. The PhD thesis aims to get support from Evidence Based Design (EBD), a discipline based on the assumption that environment influences users’ feelings / behavior / habits and that this influence can be scientifically measured and proved. EBD is widely used in various architectural fields: in educational design to improve students’ attention, in commercial buildings to encourage the purchase. EBD is mainly used in healthcare design, both to improve patients’ health status (improving the healing process and the experience during the hospital stay) and to enhance staff’s working performances (reduction of medical errors, improving safety, reduction of stress level and reduction of turnover). In particular the research work concerns the field of infection control in surgery block within the operating rooms, investigating if there is any correlation between environment and the presence of bacteria in operating room. Staff’s hands are considered the main vehicle for bacteria. Therefore, starting from a review of scientific literature, it is well-known that poor hand hygiene is one of the main cause of HAIs. The scrub up in operating room might be highly performed since the patients’ conditions are more immunocompromised. Operating area dedicated to hand hygiene is the scrub up area: it may assume various characteristics due to the layout of its operating theatre. The study individuates some kinds of operating theatre according to their main characteristics: Type A: unique dirty/clean flow and common utilities for patients and staffs’ preparation Type B: different dirty/clean flows and common utilities for patients and staffs’ preparation Type C: different dirty/clean flows and dislocated utilities for patients and staffs’ preparation Type D: unique dirty/clean flow, dislocated utilities for staffs’ preparation and dirty utilities for goods, common utility for patient’s preparation Type E: unique operating theatre (barn theatre) with common dirty/clean flow and common utilities According to the different type of surgery blocks, scrub rooms may be common or dislocated and included in operating theatres only one or more corridors. In order to respond to the research question, the methodology was based both on quantitative and qualitative analysis. Quantitative analysis includes bacteria analysis on environment and on staff’s hands; differently, qualitative analysis includes both architectural/technical survey for each block and scrub up area and the direct observation of hand hygiene procedure during the preparation activities. The bacteria analysis has to be performed in several working days during surgery block activities, using sterile sticks to be later analyzed in biological laboratory. The environment specimens were collected in different moments of the day in order to monitor the spectrum of bacteria on basins’ surface. The staffs’ specimens were collected in three moments: 1- before the hand washing, 2-immediately after that, and 3- once arrived in operating room. This third collection was performed in the specific moment that precedes the glows wearing, after the hands’ drying with a sterile towel. The drying represents also a mechanical removing of bacteria, thus providing a further barrier (after the hand washing) for the spread of infections. This sequence allowed to register the presence of bacteria on staffs’ hands on different moments, therefore monitoring if any further bacteria has been collected between the moment 2 and 3. Data gathered have been after summarized in matrixes showing by chromatic symbols the presence of bacteria in these different moments. The methodology was applied on some surgery blocks (S.B.) of two private orthopedic hospitals in Italy. The case studies are characterized by different layouts and scrub up areas’ localization. In particular, according to the previous description: Hospital 1: S.B. 1: Type C; S.B. 2: Type A; S.B. 3: Type D Hospital 2: S.B. 4: Type D; S.B. 5: Type A In general, the PhD thesis proved that there is no correlation between distance and presence of bacteria on staffs’ hands in operating room. Some results demonstrate the presence of bacteria in operating room, despite the use of sterile towel, but these results were found in surgery blocks both with common scrub up area and the dislocated ones and, so, they are not related by the distance between the scrub room and operating room. There have been found some non-compliance cases as well, due to non-adequate hand hygiene and therefore not strictly depending on the environment. Findings gathered have therefore refuted the research question. As a secondary result, in the common scrub rooms, further bacteria (not found before the cleaning step) were found after the scrub-up. This presence should be furtherly investigated with other analysis (including environmental analysis on water, taps, filters, etc.). However, for this study, the information found as secondary result, are not sufficient to prove any correlation due to the scrub area’s environmental unit. At the same time, qualitative analysis (architectural survey on the environment and direct observation during the scrub room) noticed crowned of people, reduction of available space and sharing of disposals in common scrub up areas. This might also led to a low-performing hand hygiene due to direct contact between personnel or indirect contact through water drops and common disposals. In relation of these findings, the study indicates possible strategies to enhance hand hygiene procedure through “design inputs”. These strategies must be included in multifactorial strategies including both environment and process, as suggested by the most authoritative studies on infection control. “Design inputs” are aimed to improve the scrub up environmental quality therefore enhancing the whole hand hygiene procedure, assigning particular attention to the crucial moments of hand hygiene procedure: the hand-washing moment and the glows wearing one. The study defines design inputs for each operating theatre’s layout (A,B,C,D,E), assigning different environments design tips in order to facilitate the hand hygiene and to create the adequate set to improve the hand washing performance. Those inputs concerns both the general layout of each scrub room (the location into the surgery block), their internal layout (according if they are common or dislocated ones) and the detailed design of each of them (with design tips regarding equipment and disposals).

Il lavoro di ricerca si sviluppa nell’ambito dell’Evidence Based Design (EBD), ambito di studio interdisciplinare che si sta diffondendo nella progettazione architettonica, in particolare nell’ambito delle architetture per la salute. L’EBD promuove una progettazione basata sull’evidenza: se nell’ambiente medico ci si riferisce all’, l’EBD si concentra sul rapporto ambiente/ utente, che viene valutato con analisi pre-post intervento, per valutaregli obiettivi raggiunti. Gli studi EBD si basano sulla teoria che l’ambiente influisca sul benessere e comportamento dell’utente, con effetti misurabili e quantificabili oggettivamente. In modo particolare, nell’ambito ospedaliero, gli studi EBD indagano su diversi aspetti, valutando, ad esempio, il ruolo della qualità ambientale nella guarigione dei pazienti oppure indagando la responsabilità del contesto architettonico al verificarsi di eventi avversi, etc. Lo studio analizza le infezioni nel blocco operatorio e indaga l’esistenza di una correlazione fra layout architettonico del blocco e diffusione delle infezioni in sala operatoria. In modo particolare, lo studio si concentra nell’area preparazione personale, luogo dedicato al lavaggio che precede l’accesso alla sala, e che quindi segna il delicato passaggio fra zona sporca e zona asettica. Alla base di una metodologia di indagine, sono stati presi in considerazione due Ospedali, comprendenti 5 blocchi operatori (tre blocchi chirurgici e 2 blocchi per chirurgia ambulatoriale), caratterizzati da layout diversi. In modo particolare, dei tre blocchi operatori chirurgici, due presentano aree di preparazioni pazienti comuni a tutte le sale, mentre il terzo ha aree di preparazione distribuite e nella misura di una per sala, così come entrambi i blocchi di chirurgia ambulatoriale. Come da metodologica, sono state condotte analisi di carica batterica, sia ambientali (sulle superfici delle aree preparazione), sia sul personale (sulle mani degli operatori prima e dopo aver compiuto il lavaggio e una volta giunti in sala, a seguito dell’asciugatura con telo sterile, prima di indossare i guanti). I risultati, insieme a dati di osservazione e di letteratura, supportano input progettuali in un approccio che metta a sistema interventi “di progetto” e interventi “di processo”, con l’obiettivo di creare un clima favorevole ad ottenere una procedura pre- operatoria più performante.