The Effect That Time, Touch and Environment Have Upon

Bacterial Contamination of Instruments During Surgery

MERRILL A. RITTER, M.D.,* HAROLD E. EITZEN, PH.D.,t MORRIS L. V. FRENCH, PH.D.,t JACK B. HART, PH.D.t

Hemostats were evaluated for frequency of contamination and

such contamination was correlated with increasing operating room
exposure time. The studies were performed under surgical conditions in operating rooms with and without laminar air flow. The
study was also designed to show whether contamination of
hemostats were influenced by the scrub nurse's handling. Hemostats were more frequently contaminated in the conventional
operating room without laminar air flow (P < 0.001). Handling by
the scrub nurse's gloved hand statistically increased the number of
contaminated hemostats (P < 0.01). Laminar air flow reduced the
frequency of contamination statistically (P < 0.001) to a point
where time and touch by a gloved hand of the scrub nurse
were not important factors.

URING an on-going evaluation of the sources of

exogenous microbial contamination of surgical
wounds, the hemostat, so frequently used within the
depths of the wound, seemed to be the most likely
instrument to relate to contamination during surgery.
Accordingly, a study was designed to determine if
sterile hemostats placed on an instrument table became
contaminated during surgery, and if so, whether the
probability of hemostat contamination was affected by
exposure time, touch and operating room environmental
controls, i.e., a new type of ventilation such as laminar
air flow.

From the Departments of Orthopedics

and Clinical Pathology,
Indiana University School of Medicine,
and the Department of Mechanical Engineering,
Indiana University-Purdue University of Indianapolis, Indiana

hip arthroplasty procedures. The hemostats were neither

used nor moved during the procedures except when
removed for microbiological sampling. One hemostat
was removed at time 0 and then one every 15 minutes
thereafter for a total of three hours and placed into a jar
of thioglycolate broth. Hemostats were sampled in 20
open-heart procedures without laminar air flow (conventional ventilation with 10 to 15 air changes per hour
with the air HEPA filtered prior to entry into the room)
and 20 bilateral total hip arthroplasties with horizontal
laminar air flow. The hemostats were placed into jars
of thioglycolate broth by the gloved hand of the scrub
nurse in 10 cases in each environment and with sterile
pickups by the circulating nurse in 10 cases for both
types of operating room environments. The jars were incubated at room temperature for 14 days and then tested
for microbial contamination.

Materials and Methods

Results
Racks of 13 hemostats were placed upon the instruFig. 1 reveals the percentage of hemostats conment table for clean open-heart and bilateral total taminated every 15 minutes for the four separate conditions sampled. There were no instruments contaminated
at
time 0. Instruments in the conventional operating
Submitted for publication February 16, 1976.
room
were more frequently contaminated than those in
Reprint requests: Merrill A. Ritter, M.D., 1815 North Capitol, Suite
the laminar air flow operating room (P < 0.001) (Table 1).
214, Indianapolis, Indiana 46202.
* Associate Professor, Department of Orthopaedics Indiana UniThe contamination rate increased with time in the conversity School of Medicine.
ventional operating room. Spearman's correlation coeft Assistant Professor, Department of Clinical Pathology Indiana Uni- ficient revealed a
positive association between the number
versity School of Medicine.
hemostats and time in the conventional
of
contaminated
1 Assistant Professor, Department of Mechanical Engineering Indiana University-Purdue University of Indianapolis.
operating room environment when placed into the jars

642

Vol. 184 . NO. 5

Fe

100

90

CONTAMINATION OF SURGICAL INSTRUMENTS

-A CONVENTIONAL

R. -

0.

GLOVE PICK UP
CONVENTIONAL O. R. -

0O

STERILE PICK UP

LAMINAR AIR FLOW

GLOVE PICK UP
7060 -0 LAMNARAAR
O. R.

0.

R.

14
I

L
\

STERILE

PICK UP

50

643
predominantly Staphylococcus epidermidis. However,
there was a wide variety of types of skin microflora recovered, including diphtheroids, Moraxella sp., Neisseria
sp., Bacillus sp., Mima polymorpha, Micrococcus luteus,
alpha hemolytic streptococci, and fungi. Staphylococcus
aureus was isolated from the hemostats when picked
up with gloves on one occasion when tested in the operating room with the conventional air-handling system, and
on one occasion when laminar air flow was employed.

40-

15

30

45

60

75 90 105

120 135

150

165

180

TIME IN MINUTES

FIG. 1. Frequency of contamination of hemostats sampled during

surgery. Hemostats were placed into thioglycolate broth with sterile
pick-ups or scrub nurse's gloved hands at time 0 and every 15 minutes
thereafter. Ten cases were employed for each of the four conditions.

with the scrub nurse's gloved hand (.7517). When sampled under laminar air flow conditions, the hemostat
contamination rate was low and remained at a low level
through the operations lasting three hours.
Table 1 also reveals the frequency of contamination of
hemostats for the four conditions studied. Since the
hemostat sampled at time 0 for all conditions was to
evaluate the sterilization processes, it was not used in
the remainder of the data. In the conventional operating
room an average of 4.3 hemostats was contaminated
out of the 12 tested per case (36%) when not touched
by the scrub nurse, and an average of 6.4 (53%) when
touched by the gloved hand of the scrub nurse. This
difference is statistically significant (P < 0.01). Under
laminar air flow conditions, there was no significant
difference between the two, 4% versus 9o.
The organisms cultured from the hemostats were

Discussion
Instruments such as hemostats which are set out for
hours and used within the depth of the wound frequently become contaminated when exposed to the environment of the operating room using conventional
air-handling systems. Also, the frequency of contamination increased with time of exposure (Spearman's correlation coefficient .7517). The number of contaminated
hemostats is statistically increased when handled by the
scrub nurse's gloved hand in the conventional operating
room environment (P < 0.01). Therefore the chances of
introducing a contaminated hemostat into a wound during
surgery without laminar air flow is 53% versus 9o when
laminar air flow is employed (P < 0.001).
It is important to note that the hemostats do statistically become progressively more contaminated with
time in a conventional room but that in an operating
room environment equipped with laminar air flow the
frequency of contamination is lower and remains rather
constant. The handling of the instruments by gloved
personnel increased the frequency of contamination
statistically only in the conventional operating room.
To date, data supporting the use of laminar air flow
in surgery are increasing rapidly.1-4 Table 2 shows the
comparisons of data in an operating room equipped with
laminar air flow compared to a room employing conventional air-handling systems. This table reveals that

TABLE 1. Frequency of Contamination of Hemostats Sampled During Surgery

Sampling
Method*

Air Handling
System

Number
Tested

Number
Contaminated

%
Contaminated

Gloves

Conventionalt

Sterile Pick-ups

Laminar Air Flow

Conventional
Laminar Air Flow

120
120
120
120

64
11
43
5

53
9
36
4

Conventional

120

64

53

Laminar Air Flow

120

15

Sterle Pick-ups
Gloves

*
Hemostats placed into sterile thioglycolate broth by either sterile pick-ups or by the scrub nurse's gloved hand.
t Ten to 15 air changes per hour. Air filtered through HEPA filters prior to entry into operating room.
t Not statistically different at the 90%o confidence level.

P Values
< 001
< 001

<.01
NSDt

644

Ann. Surg. e November 1976

RlfTER AND OTHERS
TABLE 2. Comparison of Data Collected in a Conventional
Acknowledgments
Operating Room to That From One Equipped with
Laminar Air Flow
The authors wish to acknowledge the bacteriology assistance of
Miss
Barbara Wilder and operating room sampling by Mr. Fred
Laminar
Doepher and Mr. Rick Kiovski.
ConvenAir
tional
Flow
P Value

Air (CFU/ft2/hr)*3
Knife Blade4 contamination
Hemostat contamination
Opening wound'
culture contamination
Closing wound'
culture contamination
* CFU/ft2/hr

289
50%
53%

9%O

<0.005
<0.005
<0.005

11.4%

1.07%

<0.005

22%

6.6%

<0.001

17
4%

Colony Forming Units per square foot per hour.

not only the air,3 knife blades,4 and opening and closing
cultures' but also the instruments are statistically less
contaminated in an operating room with laminar air
flow. (P < 0.001).

References
1. French, M. L. V., Eitzen, H. E., and Ritter, M. A.: Increasing
Evidence for Controlling Microbial Contamination in the Operating Room. Proceedings of the International Symposium on Contamination Control, London, Sept. 1974; pp. 52-54.
2. Nelson, J. P., Glassburn, A. R., Talbott, R. D., and McElkinney,
J. P.: Horizontal Flow Operating Room, Clean Rooms. Cleve-

land Clin. Quart., 40:191, 1973.

3. Ritter, M. A., French, M. E. V., and Hart, J. B.: Microbiological Studies in a Horizontal Wall-Less Laminar AirFlow Operating Room during Actual Surgery. Clin. Orthop., 97:
16, 1973.
4. Ritter, M. A., French, M. L. V., and Eitzen, H. E.: Bacterial
Contamination of the Surgical Knife. Clin. Orthop. 108:158,

1975.