Das System der operativen Planung (German Edition)
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Part Time - Temporary. Apprenticeship outside of Germany. Bosnia and Herzegovina. Czech Republic. Hong Kong. South Africa. United Kingdom. Receive the latest job offers via RSS How does this work? Job Category 0 All. Job offers worldwide. The room temperatures stipulated by the standards cannot do justice to all of the OR personnel because they work and must dress differently.
Each institution has to reach a consensus on temperature. Hypothermia, except for when therapeutically indicated, is to be avoided pre-, intra- and post-operatively, since it is a risk factor for surgical site infections SSI  ,  , . There is no evidence that a specific air-conditioning concept expedites the hypothermic process. In order to avoid hypothermia, medical-technical heating systems must be used that do not reduce the air quality in the OR, e.
Active warming, e.
Research on the epidemiological benefit of RK Ia on the SSI rate has been conducted only for the implantation of alloplastic hip- and knee-joint replacements; the results are conflicting. Prospective controlled studies  ,  showed proof that RLTA air conditioning systems with LAF laminar airflow had a prophylactic influence on infections; however, this influence was rendered statistically irrelevant when perioperative antibiotic prophylaxis was administered  ,  , .
New, albeit retrospective non-controlled studies showed no protective influence in comparison to TML mixed flow ventilation  ,  ,  ,  , . All studies are marked by a number of limitations  ,  , and thus do not lead to conclusive evidence at this point in time . In addition, low-grade infections have not been taken into account and therefore present a further limitation of all studies to date.
Low-grade infections develop in up to one-third of the hip endoprostheses only after the regular surveillance term of one year, i. However, the RK Ia indubitably compares favorably with any mixed ventilation system room class Ib , i. Therefore, from the perspective of prevention, an RK Ia OR is generally recommended for all operations that have the highest requirements for very low germ rates e. In addition, carcinogenic smoke from intraoperative combustion processes is removed faster and more effectively . Both facts lead to preventive consequences that are, for instance, implemented in the aseptic production of cytostatic drugs.
Their production strictly follows the principle of primary prevention, despite epidemiological evidence. For pharmacies, for example, it would be unthinkable not to prepare an aseptic medicine under clean room conditions, although, due to the comparatively short exposure time, the risk of contamination is much smaller than during implantation of a hip endoprosthesis.
Along those lines and regarding the consequences for patients, it is recommended to make use of all options that prevent implant-associated infections after hip- and knee-joint replacements . The characteristics of the air-conditioning concept room class Ia are influenced by the size of the ceiling field that creates a protective space, by surgical lights that should be aerodynamically optimized, and by air that should be discharged into the lower part of the room.
If a coordinated choice of components is impossible, the advantages of the entire system may be lost. Tables for instruments, implants, and test parts adjacent to the OR table are protected by the adequate size of the ceiling field; a small size diminishes the protected area and reduces the diluting flow of air  ,  , . A decision on the type of air-conditioning concept should be made based on the current state of knowledge and the current and future needs of all user groups; the decision should be documented. It must be borne in mind that ORs are used for at least 20—30 years, the requirements for low germ rates will rise due to demographic developments, the number of immunocompromised patients will rise, and the number of medical interventions fraught with risk will rise as well.
In addition, OR frequencies as well as OR types, institutional structures and leadership are marked by dynamic change. In light of future developments and the advantages listed above, it is recommended to equip several ORs in a new OR department with the same air-conditioning ceilings and the same surgical lights, and to subject all of the equipment to ventilation and air-conditioning tests.
In addition, the costs of the consolidated balance sheets of room class Ib and la do not differ significantly  ,  , . A stable displacement ventilation creates a protected space in which the OR table, the OR team in sterile clothing, the sterile instruments, and other sterile tables can be placed. Pollutants emitted within this protected area are discharged directly into the back of the room by a directional flow.
The entry of pollutants emitted outside of this protected area is blocked to such a degree that it not even necessary to disinfect the floor in between ophthalmological operations . In this concept, a supply air flow that is virtually free of germs and particles diminishes by diluting and discharging the air all pollutants emitted inside the room at a high dilution speed.
Guide Das System der operativen Planung (German Edition)
Air hygiene test: Since the efficiency of TAV ventilation displacement or ultra-clean ventilation is influenced significantly by the flow permeability of the surgical lights and the arrangement of the air circulation openings, air-hygiene testing should employ the degree-of-protection method according to  , appendix C or  , which includes the testing of surgical lights.
A turbulent mixed flow ventilation brings supply air into the room via terminal H13 air filters and distributes it almost homogeneously. The dilution velocity depends on the amount of air supplied into the room. This air-conditioning concept does not provide for a protected space. Air hygiene test: A mixed flow ventilation does not create a protected area in the room. Therefore, an air hygiene test has to determine the time it takes for a particle load to be reduced to one hundredth of its original value recovery time according to .
Figures 1—3 show the basic flow patterns of displacement and turbulent mixed flow ventilation. Regarding displacement ventilation, Figure 1 [ Fig. In comparison, Figure 2 [ Fig.
The flow arrows in Figure 3 [ Fig. Special operations that are conducted at a high room temperature e. The preparation room must have the same room-class classification as the OR for which the instruments are prepared and may only be used as a storage space for sterile goods that go into the assigned ORs. Preparatory areas protected by TAV in room class Ia must provide sufficient work space. The temporary storage of tables that are ready for OR use requires sterile, recontamination-safe covers in the preparation room.
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Prepared instrument tables must not be transported through spaces of room class II with the exception of spaces used as sterile corridors with supply air filter H Under these conditions, prepared instrument tables may be stored until the end of the regular business hours max. The activities in this room must be reduced to a minimum.
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When air flows between the rooms of an operation unit, the air must only flow in the direction of the spaces that are less clean. The entire operation unit must be kept at a pressure differential overpressure to the adjoining areas connected by doors, with the cleaner areas at a higher pressure. After the final operation and the closing of all OR doors, a shutdown time of ca. A timely restart of the equipment has to be guaranteed e. The recovery time must be determined as stipulated by the qualifying measurements of each OR. The recovery time must be completed before the start of the first operation; this has to be guaranteed.
For logistic or technical reasons, it might make sense to maintain air hygiene constantly in certain ORs and their preparation rooms, keeping them available for emergency purposes in case the ORs and preparation rooms are TAV ventilated. Air cleanliness is always defined by medical tasks, and the regulations have to be followed in case of rooms for patients with severe burns, the regulations for room temperature and interior air humidity must also be observed. Air hygiene classifies rooms for the protective isolation of immunosuppressed patients as room class II and adds the following requirements: In addition to the norms specified by DIN  , rooms for patients of risk groups 2 and 3 must be supplied with terminal H13 filters following the KRINKO Commission for Hospital Hygiene and Infectious Disease Prevention suggestion  and must be run on higher pressure than all adjacent rooms.
Window ventilation is not allowed. Air hygiene test: A test of the recovery time of inside the room is not necessary, assuming that the room did not pollute itself. The entry of germs from the outside must be precluded. The effectiveness of the overpressure must be tested annually by testing the direction of the airflow according to DIN  The goal is to protect the environment from the spread of aerosols containing highly contagious, dangerous pathogens e. These rooms are classified as room class II and have a lower pressure than all adjacent rooms.
If necessary, the exhaust air must be directed through an H13 filter before it is transported off into an exhaust air-duct system.
Emergency rooms are generally classified as room class II. If possible, it is recommended to keep waiting rooms at negative pressure in order to minimize the potential spread of contaminated aerosols. These rooms are generally classified as room class II. It is recommended to keep them at negative pressure. Requirements for room climate properties must be met.
For intensive care units in wards that focus on treating highly immunosuppressed or infectious patients, see chapters 3. These rooms are classified as room class II. German forces would mass against the Russian invasion force and defeat it in a counter-offensive, while conducting a conventional defence against the French.
Rather than pursue the Russians over the border, 50 percent of the German force in the east about 20 percent of the German army would be transferred to the west, for a counter-offensive against the French. Aufmarsch I Ost became a secondary deployment plan, as it was feared a French invasion force could be too well established to be driven from Germany or at least inflict greater losses on the Germans, if not defeated sooner.
The counter-offensive against France was also seen as the more important operation, since the French were less able to replace losses than Russia and it would result in a greater number of prisoners being taken. The plan assumed that France would be neutral at first and possibly attack Germany later. If France helped Russia then Britain might join in and if it did, Italy was expected to remain neutral. About 60 percent of the German army would operate in the west and 40 percent in the east. Russia would begin an offensive because of its larger army and in anticipation of French involvement but if not, the German army would attack.
After the Russian army had been defeated, the German army in the east would pursue the remnants. The German army in the west would stay on the defensive, perhaps conducting a counter-offensive but without reinforcements from the east. Aufmarsch II Ost had the same flaw as Aufmarsch I Ost , in that it was feared that a French offensive would be harder to defeat, if not countered with greater force, either slower as in Aufmarsch I Ost or with greater force and quicker, as in Aufmarsch II West.
After amending Plan XVI in September , Joffre and the staff took eighteen months to revise the French concentration plan, the concept of which was accepted on 18 April The document was not a campaign plan but it contained a statement that the Germans were expected to concentrate the bulk of their army on the Franco-German border and might cross before French operations could begin.