Journal of Hospital Infection (2005) 59, 138–147

www.elsevierhealth.com/journals/jhin

Ventilation performance in the operating theatre

against airborne infection: numerical study on an
ultra-clean system
T.T. Chow*, X.Y. Yang

Division of Building Science and Technology, City University of Hong Kong, Tat Chee Avenue, Kowloon,
Hong Kong SAR, China

Received 28 November 2002

KEYWORDS Summary A laminar airflow study was performed in a standard operating

Operating theatre;
Ventilation; Airborne
infection
theatre in Hong Kong, the design of which followed the requirements of the
UK Health Technical Memorandum. The study of the ultra-clean ventilation
system investigated the effectiveness of the laminar flow in: (i) preventing
bioaerosols released by the surgical staff from causing postoperative
infection of the patient; and (ii) protecting the surgical team against
infection by bacteria from the wound site. Seven cases of computer
simulation are presented and the sensitivity of individual cases is discussed.
Air velocity at the supply diffuser has been identified as one of the most
important factors in governing the dispersion of airborne infectious
particles. Higher velocity within the laminar regime is advantageous in
minimizing the heat-dissipation effect, and to ensure an adequate washing
effect against particulate settlement. Inappropriate positioning of the
medical lamps can be detrimental. Omission of a partial wall may increase
the infection risk of the surgical team due to the ingression of room air at the
supply diffuser periphery. This paper stresses that a successful outcome in
preventing airborne infection depends as much on resolving human factors
as on overcoming technical obstacles.
Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

Introduction

Different countries have adopted different engin-

eering standards for the design of operating
theatres: for example, France X44101; Germany,
* Corresponding author. Tel.: C852 2788 7622; fax: C852 2788
9716. VDI2083; Australia, AS1386l; and Japan, B9920.
E-mail address: bsttchow@cityu.edu.hk These engineering standards are reviewed
0195-6701/$ - see front matter Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2004.09.006
Ventilation performance in the operating theatre against airborne infection
periodically by specialist teams. In Hong Kong, the
design of operating theatres is based on the UK
Health Technical Memorandum (HTM).1 According
to HTM 2025, the downflow of supply air from a
laminar flow ventilation system should cover a
minimum projected area of 2.8 m by 2.8 m, which
accommodates the surgical site and instruments.
The zone boundary enclosing the supply air diffuser
should be provided with either a full wall or a
partial wall; the latter should terminate at a
maximum of 2 m from floor level. Pressure stabil-
izers on partition walls have the dual purpose of
directing excess air to neighbouring spaces and
maintaining the room pressure differentials.
In many operating theatres around the world, air
conditioning and ventilation performance do not
comply with up-to-date engineering standards.
Problems include different forms of terminal
devices, different air velocities at the supply
diffuser, different levels of room pressurization,
and omission of the partial wall. An important
reason for this is periodic renovation work at older
hospitals where the site and financial constraints
lead to deviations. Another reason lies in the
differences in user behaviour. It is noted that flow
obstructions and heat dissipation from people,
lamps and equipment can easily disturb air
movement.
In our study, computational fluid dynamics (CFD)
simulation was used to examine the dispersion of
colony forming units (cfu) in a standard operating
theatre in Hong Kong. The investigation examined
the effectiveness of the laminar flow system in: (i)
preventing infectious particles on staff from reach-
ing the patient’s wound; and (ii) protecting the
surgical staff from bacteria released from the
wound site. The effects of the following design
aspects on cfu dispersion were also investigated:
† reduced flow velocity at the supply diffuser;
† no partial walls around the supply diffuser;
† change of medical lamp position; and
† reduced medical lamp heat flux.
Airborne infection risk
The major source of airborne contaminants in the
operating theatre is from the surgical team.2 A
person releases about 10 million particles/day. The
release rate is 10 000 particles/min when walking.
About 5–10% of these particles (2.5–20 mm in size)
carry bacteria.3 The patient is not usually a
significant contaminant source because his/her
movement is minimal. However, power tools have
the potential to create an aerosol from the tissues
139
and any microbes within them.4 Woods et al.
described the boundary layer that carries skin
flakes from a standing person to the surrounding
air.5 From these data, a typical generation rate of
6 g/min of 7.5 mm (mean diameter) skin flakes for a
clothed staff member standing in front of an
operating table was estimated. Obviously, the
tightness and coverage of the clothing, masks and
caps have a significant effect on the amount of skin
flakes transferred to the air. Zamuner referred to
the findings of Kethley that a surgeon bending over
the wound site in a laminar airflow (LAF) system
could be a source of as many as 1000 airborne
particles/min.6 When the surgical team is working
near the operating table, everyone is subject to an
airborne infection risk, particularly the patient
because of his/her weakness and open wound.
The possible number of infectious particles that can
be released during the use of power tools at the
wound site has not been quantified to date.
There are two routes of infection from infectious
particles: (i) inhalation, and (ii) by settling directly
on a susceptible area, such as a wound, or on
instruments or dressings that subsequently come
into contact with the wound. Small particles
emitted from sterilized items do not carry bacteria
and therefore will not cause a problem. This
renders meaningless any tests using a particle
counter to indicate the presence of airborne
contaminants during surgery.7 Consequently, test-
ing for the absence of bacteria must be carried out
by a culture method.
Whyte et al. suggested the following standards at
three locations in the ultra-clean operating theatre
for joint replacement surgery:8
† 0.5 cfu/m3 for the filtered air supply;
† 10 cfu/m3 within 0.03 m of the wound during the
operation; and
† 20 cfu/m3 in the rest of the working area of the
clean air system.
Lidwell stated that a fully effective system,
including special clothing, should aim for air
contamination levels below 1 cfu/m3.9 In general
consensus with this target, Whyte further suggested
a count of 10 cfu/m3 as the acceptable maximum
value.10 These recommendations formed the basis
of the HTM 2025 specification.
Effectiveness of an LAF system is accomplished
by the provision of a high-efficiency particulate air
filter (and pre-filters) upstream from the supply air
diffuser. The flow velocity at the supply diffuser is
crucial to ensure sufficient air movement at the
operating plane, i.e. at the level of the patient on
the operating table. HTM quotes the average
140
minimum air velocity as 0.38 m/s at 2 m from the
floor when a partial wall is used. The corresponding
air velocity at the operating plane will then provide
a washing effect against settlement of airborne
particles. With a minimum velocity of 0.2 m/s, the
air stream can readily remove contaminants
released from the human body. The design target,
therefore, is to achieve a contaminant level of less
than 10 cfu/m3 in the critical area when the staff
wear conventional cotton clothing, or less than
1 cfu/m3 when special clothing or a body exhaust
system is in use.
Direct measurement and numerical computation
are the two main approaches used in the assess-
ment of operating theatre airflow pattern and
airborne particle concentrations. The most realistic
information on airflow can be obtained by direct
measurement. The relevant studies contributing to
design of ultra-clean ventilation (UCV) systems
were mainly conducted between the 1960s and
the 1980s.11,12 For examining the airflow perform-
ance in relation to a given UCV design or renovation
work, CFD is extremely useful. This technique
underwent rapid development in the 1990s, and is
now well recognized as a powerful and economical
tool in parametric studies that involve indoor air
distribution and contaminant dispersion. Readers
can refer to standard texts such as Awbi, and
Etheridge and Sandberg for technical details of the
applications of CFD in building-related studies.13,14
The following section serves as a brief introduction
of the technique.
Numerical analysis by CFD
CFD is a complex and rapidly evolving field of
development. It refers to the numerical technique
that provides solutions to a set of conservation
equations governing a fluid flow field, such that the
flow variables (e.g. temperature and velocity) at all
points in the field can be determined.
In the prediction of airflow in an operating
theatre, the flow equations must account for
turbulence and buoyancy. The starting point is to
subdivide the flow field (room space) into a number
of finite volumes (cells), so that the conservation
equations for mass, momentum, energy and species
concentration can be established for each cell. For
some given boundary conditions and assumptions,
the set of equations are solved together by iteration
for the temperature, pressure and velocity vectors.
It is also possible to determine the distribution of
water vapour (hence relative humidity) or particu-
lates (e.g. cfus), and to assess the mean age
T.T. Chow, X.Y. Yang
(freshness) of air at discrete locations. The bound-
ary conditions for a UCV system can be the relative
pressures of the neighbouring spaces, the flow
velocity at terminal units (diffusers, stabilizers and
grilles), temperature and humidity levels of air at
the entry and exit points, and the surface tempera-
tures and heat fluxes of the enclosing walls, lamps,
equipment and human beings. When the flow is
steady (i.e. the boundary conditions are fixed),
results such as velocity and temperature represent
the time averages, but when the flow is unsteady
(i.e. the boundary conditions change with time),
the results are ensemble averages.
Using CFD analysis, Chen et al. showed that a
higher air inflow rate and a larger air inlet area are
desirable for contaminant control, but these are
detrimental to the thermal comfort of the staff.15
Particle concentrations in different parts of the
room were found to be very sensitive to the location
of the particle sources. Higher heat sources had
little or negligible effect on particle distribution
and thermal comfort. This finding concurred with
the work of Luscuere et al., which pointed out that
the physical obstruction of the lamp seemed to be
far more important than its heat dissipative
disturbance.16 Tinker and Roberts applied the
standard CFD model in an operating theatre in the
UK; the convective plume caused by the medical
lamp was only noticeable in low-velocity airflows,
typically below 0.1 m/s.17 At 0.3 m/s or more, the
plume was found to be non-existent. They also
carried out full-scale experimental validation of the
simulation results, and found that the discrepancies
between simulation and measurements in tempera-
ture and air speed were of the order of 2% and 5%,
respectively. It was highlighed that the length of
the partial wall would not affect the contamination
around the wound site. More reviews of previous
work in this area can be found elsewhere.12
There are limitations in the application of CFD
such as grid-dependent solutions, slow or uncertain
convergence, and the need for a skilled operator.
However, with improvements in user-friendliness of
the software, the difficulties are gradually being
reduced. Other limitations, which are more related
to physical science, are the empiricisms employed
for the coefficients in the equations and, particu-
larly, the empirical wall functions.
The majority of CFD applications in ventilation
design are likely to be for steady flow, but there is
no fundamental limitation to such flows. In prin-
ciple, any type of unsteady flow can be treated. A
transient flow occurs when an initially steady state
is disturbed by a change in the boundary conditions.
An example of this is when a door between two
rooms is opened. The changing boundary conditions
Ventilation performance in the operating theatre against airborne infection
of the flow field are then at the positions of the door
and the pressure stabilizers.
The computer simulation model
The physical arrangement of the operating theatre
used in this study was based on a typical layout in a
relatively new hospital in Hong Kong. Figure 1 shows
the isometric view. The overall dimensions were
7.8 m (L)!6.6 m (W)!2.7 m (H) in the X, Y and Z
directions, respectively. All surgical staff members
(Staff 1–7) were assumed to be in upright stationary
positions surrounding the patient, who lay on the
operating table with the head towards the positive
Y direction. In this model, the locations of the staff
members, medical lamps and equipment relative to
the operating table were according to the DIN 4799
specification.18
In the numerical grid, the surgical staff and
patient were treated as rectangular solid boxes,
each of size 0.5 m!0.2 m!1.7 m. Each person
released a heat flux of 100 W from the exposed
surfaces. At the same time, each surgical staff
member released infectious particles at a rate of
100 cfu/min from his/her surface facing the
patient. A power tool was assumed to be working
on the wound, with an arbitrary bacterial release
rate of 400 cfu/min at the patient’s waist position
(on the upper surface). Heat energy was considered
to be released from each of the two pieces of
Figure 1 Isometric view of a typical operating theatre in Hong Kong.
141
medical equipment at 650 W on all exposed
surfaces. Heat flux from each of the two medical
lamps was 250 W, released at the downward sur-
face. All heat and contaminant sources were
assumed to be uniform at the emitting surfaces.
In this CFD model, a non-uniform rectangular grid
of approximately 140 000 cells was used. Simu-
lations were executed using the standard k–3 model
of the commercial software CFX4.3.19 A detailed
description of this simulation approach including
the validation work can be found in Chow et al.20
Seven simulation cases were performed, as
follows.
Case 1
This was the reference condition, as shown in Figure
1. The design complied fully with the HTM require-
ments, with the partial wall terminating at 2 m
from floor level, an air velocity of 0.38 m/s at the
supply diffuser (hence the same flow velocity at the
partial wall outlet position), the main medical lamp
at the centre plane of the operating table near to
the patient’s head, and the satellite lamp at one
side of the operating table.
Case 2
Design as in Case 1, but with the flow velocity
reduced by one-third (0.25 m/s).
142
Case 3
Design as in Case 1, but with the flow velocity
reduced by 50% (0.19 m/s).
Case 4
Design as in Case 1, but with the flow velocity
reduced by two-thirds (0.13 m/s).
Case 5
Design as in Case 1, but without the partial wall.
Case 6
Design as in Case 1, but with the two medical lamps
at opposite sides of the operating table.
Case 7
Design as in Case 1, but with the heat flux from
the two medical lamps reduced by 50% (125 W
each).
In Case 6, only the position of the main medical
lamp was changed, and it became the mirror image
of the satellite lamp, making reference to the
vertical plane cutting across the midplane of the
operating table at xZ4.2 m. The supply air tem-
perature was 20 8C for all seven cases.
Simulation results and discussions
Figure 2(a–f) shows the airflow patterns at the
vertical section cutting across the midplane of the
operating table (at xZ4.2 m) for Cases 1–6,
respectively. The simulation results of Case 7
were found to be virtually the same as those for
Case 1, and are therefore not included in these
figures. The arrowheads show the airflow direc-
tions—a cross indicates that the flow direction is
more or less perpendicular to this vertical plane.
Due to the low position of Stabilizer 3 on the
partition wall, the air velocity was relatively high at
the top surface of the equipment table at one end
of the operating table, for all cases.
Figure 3(a–f) shows the contours of integrated
bacterial concentration at the operating plan (zZ
1.1 m) for Cases 1–6, respectively; the seven
surgical staff members were the source of infec-
tious particles. The square in the middle of the
room marked the location of the partial wall and
hence the ‘clean’ zone. The bacterial concen-
tration level over the patient’s body as well as
T.T. Chow, X.Y. Yang
over the equipment table can be visualized on this
operating plan.
Figure 4(a–f) shows the contours of bacterial
concentration at the breathing level (zZ1.6 m) of
the surgical staff for Cases 1–6, respectively; the
wound site was the source of infectious particles.
The revised medical lamp positions in Case 6 are
indicated in Figure 4(f).
Reference condition
Under the reference condition of Case 1, in full
compliance with the HTM requirements, the con-
centration at the patient’s body is 2–10 cfu/m3,
with the maximum at the head and decreasing
gradually towards the feet, as shown in Figure 3(a).
Inside the room, the concentration at this zZ1.1 m
level is below 10 cfu/m3, and is lower than 4 cfu/m3
in most positions. Within the ‘clean’ zone, the
bacterial concentration is higher on the right-hand
side (i.e. greater than 10 cfu/m3 at the positions of
Staff 1, 2 and 3); this is because the satellite lamp
physically blocked a portion of the supply air from
reaching the operating plane. It can be seen that
the bacterial concentration over the equipment
table is below 2 cfu/m3.
For the particles released from the wound site, as
shown in Figure 4(a), concentrations at the ‘breathing
positions’ of individual staff are less than 10 cfu/m3,
except for Staff 2 who is blocked by a satellite lamp.
Supply velocity
Flow velocity at the supply diffuser has been
identified as an important factor governing particu-
late dispersion. The effect can be visualized by
comparing the results of Cases 1–4. Figure 2(a)
shows that the buoyant forces caused by the heat
fluxes released by the medical lamps and equip-
ment are not apparent in Case 1 (supply velocity:
0.38 m/s). The thermal plume at the medical
equipment can be seen in Cases 2–4 [Figure 2(b–
d)], whereas that at the medical lamp can only be
visualized in Case 4 (supply velocity: 0.13 m/s).
When the supply velocity meets the HTM require-
ment, the heat flux from the medical lamps shows
minimal effect on airflow pattern. Hence the flow
patterns of Cases 1 and 7 are almost identical, even
when the heat flux changed by 50%. These obser-
vations on thermal plume behaviour are in line with
the findings of Chen et al.15 and Tinker and
Roberts,17 although the exact velocity magnitude
that triggers the change does vary from one
Ventilation performance in the operating theatre against airborne infection 143

Figure 2 Airflow patterns at section xZ4.2 m cutting across the midplane of the operating table.
144 T.T. Chow, X.Y. Yang

Figure 3 Accumulated infectious particle concentration contours at zZ1.1 m operating plane for (a) Case 1
(reference condition), (b) Case 2 (supply velocity: 0.25 m/s), (c) Case 3 (supply velocity: 0.19 m/s), (d) Case 4 (supply
velocity: 0.13 m/s), (e) Case 5 (without partial wall), and (f) Case 6 (changed main medical lamp position).

occasion to another. There appears to be no good
reason to reduce the supply velocity for the sake of
thermal comfort as the comfort level can be fine-
tuned by changing the thermostat setting.
The particulate concentration in the operating
theatre (particularly in the ‘clean’ zone) is higher
when the room air change rate decreases and the
bacterial concentration at the patient’s position
increases. For a reduction of supply velocity by 33%
to 0.25 m/s, the concentration at the position of the
wound is around 8 cfu/m3, as in Figure 3(b), and
exceeds 10 cfu/m3 at the position of the head. This
indicates a failure of the washing effect. At 0.13 m/s,
as in Figure 3(d), the concentration is over 10 cfu/m3
for the entire body of the patient. The concentration
above the equipment table is about 8 cfu/m3. As the
supply velocity gradually reduces from 0.38 m/s to
0.13 m/s, the number of surgical staff experiencing
Ventilation performance in the operating theatre against airborne infection 145

Figure 4 Concentration contours of infectious particle from patient’s waist at zZ1.6 m breathing level for (a) Case 1
(reference condition), (b) Case 2 (supply velocity: 0.25 m/s), (c) Case 3 (supply velocity: 0.19 m/s), (d) Case 4 (supply
velocity: 0.13 m/s), (e) Case 5 (without partial wall), and (f) Case 6 (changed main medical lamp position).

high bacterial counts increases, as visualized from
the expansion of the unacceptably high concen-
tration region in Figure 4(a–d).
Partial wall
The purpose of the partial wall is to maintain the
unidirectional downward flow of supply air and to
prevent the ‘short circuit’ of flow between the supply
diffuser and a high-level outlet. Figure 2(e) shows the
extent of disturbance on the ingress of surrounding air
in the absence of a partial wall. Figure 4(e) indicates
that Staff 1 and 2 were exposed to bacterial
concentrations above 10 cfu/m3 due to an increased
entrainment (air ingress) effect at the supply diffuser
boundary. Notwithstanding this, a slightly better
performance at the patient’s position can be
146
observed when comparing Figure 3(e) with Figure
3(a). The results recorded a concentration reduction
at the patient’s position to below 2 cfu/m3. A short
circuit of flow at Stabilizer 2 was found in Case 5 but
the extent was not detrimental.
Medical lamp
Moving the main medical lamp from its original
position at the midplane of the operating table can
make the flow smoother over the patient in this
plane, as shown in Figure 2(f). There is no apparent
evidence of an overall improvement in bacterial
dispersion, however, when comparing Figure 3(a)
with Figure 3(f) (other than the head position of the
patient), and Figure 4(a) with Figure 4(f). The
overall airflow pattern depends on the relative
positions of personnel, lamps and equipment,
whereas the contaminant dispersion also depends
on the locations of the contaminant sources.
Obviously the obstruction effect of the medical
lamp carries more weight than its heat dissipation
effect. In principle, Cases 1 and 7 gave almost the
same results.
Human activities
An interesting point is that the medical lamp
positions and their lighting levels (hence the
power outputs) can be adjusted by the surgical
team during the operation process. These are not
controllable by the ventilation engineer unless
there are clear established working instructions.
There are also other transient flow disturbances
caused by human activities. The temporal or
extended period of door opening and the move-
ments of staff (including trainees) and equipment
are among many possibilities that could compro-
mise airborne infection. A sudden burst of particles
from a sneeze or cough can be highly significant.
Our literature search indicated that very little work
has been done in this area to date. We suggest that
the transient effects, together with the accumu-
lative effects of various determining factors and
design options, should be investigated thoroughly
and systematically to provide better operating
theatre engineering standards.
Conclusions
CFD is an economical and effective tool for analysis,
especially for parametric studies. This paper has
T.T. Chow, X.Y. Yang
demonstrated CFD in a standard operating theatre
environment in Hong Kong, and presented seven
cases of CFD simulation. Flow velocity at the supply
diffuser was identified as one of the most important
factors in governing the dispersion of airborne
infectious particles. The position of the medical
lamps was also found to be critical.
The design of an ultra-clean airflow system can
be a complex issue. A successful outcome depends
not only on overcoming the technical obstacles, but
also on solving human factors such as user habits.
More work needs to be done in this area, and in
parallel, more investigations should be conducted
on the combined effect of various determining
factors. The CFD approach, together with continu-
ous monitoring and periodic air sampling at the
surgical site, is expected to offer a new dimension
in related studies.
Acknowledgements
The work described in this paper was supported by a
grant from the Research Grants Council of the Hong
Kong Special Administrative Region, China (project
no. 7001609).
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