Evaluation of The Environment in Operating Theater and Delivery Unit and Neonatal Care Unit at Al-Zahra Hospital for Women and Children

The study aimed to assess the efficiency of the sterilization process and the process of controlling contamination within the environment in AL-Zahra Hospital for women and children in AL-Muqdadiya located at Diyala province-Iraq, which extends at latitudes (-3.33 and -36.6) north and longitudes (-44.22 and 45.56) east, during the period from 25 December 2021 to 19 February 2022 due to deficiency of studies that are interested in this field. One hundred ninety - two of air sample was taken distributed to the hospital halls such as the surgical hall and its corridor that leads to it, the delivery hall and its corridor that leads to it, the sterile preterm unit and its corridor leds to it, the main hall of the units, and the air outside the hospital environment, where the samples were divided into two groups, the first one includes 96 samples collected in the morning before the beginning of work at 8 :00am and the second include 96 samples collected during the work at peak time 12:00 noon. The result was expressed by colony forming unit (CFU/m 3 ). Bacterial microbial loads in hospital air ranged between 2-131 CFU/m3. Air bacterial loads in surgical hall ranged between 5-40, in a range 19.04 CFU/m3 and in the delivery hall ranged between 19-55.5, in a range 35.8 CFU/m3 and in the preterm infant hall 23.5-41.5, in a range30.5 CFU/m3 and in the main hall ranged between 34.

Nosocomial infection was defined as the infections that the patient acquires during his stay in the hospital, whether those infections have an exogenous source, Among the most important external sources of infection in hospitals, air, medical staff, devices and equipment, floors, walls, disinfectant and cleaning powders, constructing and design of halls, In addition to other factors such as wash basins, waste baskets, lamp and other source of the contamination, which are among the most important sources of infection and transmission of infection [1].or they are endogenous sources, which means the existing microorganism in or on the body of the normal flora, where the problem of nosocomial infection has been one of the most important and most dangerous health problems that still face the whole world as more than 50% of patients who have asleep in the hospitals dies from these infections [2].
The importance of aerobic environmental control in hospitals has increased since 2003 with the onset of acute pulmonary infection (Severe acute respiratory syndrome (SARS), and therefore air conditioning has been used extensively and most of this use air conditioners, which leds to an increase in the use of recycled air with reduced air change rates to save money and fuel, as air quality in hospitals is amajor risk factor as well as it has health consequences for both the working staff and the patients and therefore there are efforts to search for alternatives to mechanical ventilation that help to prevent transmission, especially in developing countries [3].
After improvements in living conditions and infection control strategies, especially for tuberculosis and smallpox diseases and the emergence of antibiotics, airborne diseases safe waste management, cleaning of equipment and cleaning of the surrounding environment in addition to ensuring that personal care providers apply pollution control measures where they wear personal protection equipment (long-sleeved gloves, eye protection masks, appropriately tested breathing masks, tight and non-implementable particles compatible with N95 masks or their equivalent), and whenever well-ventilated individual rooms can be used for patients in the sense of working in rooms with negative pressure with air change at least 12 times per hour or at least 160 liters/second for the patient in rooms with natural ventilation in addition to avoiding the presence of people not to be present they need to be in the room [4].
Many factors affect patients entering health care institutions who are usually in poor health with poor defenses against bacteria and other infection factors, including advanced age, incomplete birth or immunodeficiency (due to medications, disease, radiation) as well as chronic obstructive pulmonary disease that increases the risk of respiratory infection, as these factors have been associated with an increased risk of health care-related infections including malignant diseases, immunodeficiency viruses, severe burns and some skin diseases, severe malnutrition, diabetes, bronchial disease, lethargy of the circulatory system, open wound, shock (5).In addition to environmental factors related to infection related to health care, which includes the mobile and non-mobile environment of patients where mobile environment includes health care staff, other patients in the same unit accompanying patients and visitors, the non-mobile environment refers to medical devices, environmental machinery and surfaces, and other risk factors associated with the health care environment ventilation, heat and humidity, therapeutic and diagnostic interference [6].
This study is one of the first studies at the level of Diyala province /Iraq to study the air microbial load of hospitals halls effectively (Active sampling).The method used in Iraqi hospitals depends on the principle of depositing air particles on surfaces or surfaces of dishes placed in spaces (passive sampling) which gives quality values only, and on the other hand there are no environmental standards in Iraq for microbial load levels in the air can be adopted for comparison purposes.The research problem lies in the fact that hospitals, as they are places of the hospitalization but at the same time they are an incubator environment for many risks to the public health of the patients as despite the efforts to make the closed environments protected, it can become contaminated with microorganisms forming different risks, and some times more dangerous when their concentrations exceeds the permissible limits for human living in (1000) air born biological units that can cause air contamination [7].One of the most important bacterial species that cause hospital infection are Pseudomonas spp., Klebsiella spp., Escherichia coli, Staphyllococcus aureus, Haemophilus influenzae, Enterobacter spp., Proteus spp., Serratia spp., Enterococcus spp.[8].So because of aggravation of the problems of nosocomial infections and the suffering of many patients from delayed recovery after surgical interventions, in addition to the lack studies in Diyala governorate in this field and the importance of the clinically isolated pathogen was designed this study is at the level of AL-Muqdadiya district hospitals and which aims to: Evaluating the degree of microbial load in the operating theaters, preterm infants and child birth, by measuring microbial load from selected places and identifying the most common bacterial species, sample taking by air sampling device and diagnosing them using the available biochemical testes.Evaluate method of taking swabs for non-living surfaces and compare them with the method of taking swabs used in hospital used to monitor contaminants in the operating room, birth and preterm infants' halls.Monitoring isolated bacterial species and observing their proportions, whether they are isolated from the air microbial load or from non-living surfaces.

Materials and methods
Air bacterial load of the environment of the operating theater, sterile preterm infant units, maternity hall and their corridors, as well as the air of outer environment of the hospital have The device is programmed to pull different volumes of air into standard mode chosen by the operator, or to choose the programmable size (User Mode).
The following amounts of air are suggested by the nature of the inspection site: 1. Contaminated areas (communities, treatment rooms, etc.) 10-200 liters of air.
In parallel pollution control swabs were collected (100 swabs) from surfaces of the same places, including the anesthesia cart, the patient's bed, fluid pullout device, ventilation outlets, walls and floors, and surgical machines.

Contamination control swabs
The total number of surface swabs (controlled on contamination) reached 100 from different places, including the natural cesarean and delivery bed, flooring, ventilation outlets, anesthesia device, fluid withdrawal device, preterm incubators, ventilator and bandage cart.

Samples cultures
Planting of air samples and pollution control swabs was implanted directly on blood, MacConkey and mannitol agar dishes.All dishes were incubated at 37° C temperature for 24 hours, after which biochemical and apparent diagnostic tests were conducted for isolated bacteria in laboratories of AL-Zahra hospital.

Diagnosis of bacterial isolates:
Isolated bacterial species were studied by observing the general characteristics of their growth on the blood, MacConkey and mannitol agar the colonies were identified and studied on the basis of color, size, textures and shape in addition to other general characteristics such as the ability of bacteria to produce catalase enzyme, presence of blood hemolysis on the blood agar or not.

Microscopic examination
Microscopic examination of bacterial cells after they were staining with gram stains and examined under the oil lens of the optical microscope.

Calculating the results
The number of colony forming units observed on plates was calculated in cubic meters of halls and their corridors and outer air environment, the values of the constituent units of the colonies from 500 liters of hall air, which was prepared according to the statistical equation of the work done by J. Maker (8) Which was expressed by the statistical probability of passing several particles through the same hole on the surface of the counting dish, the potential number Pr is then used to calculate the number of colony units of CFU per cubic meter of the air sample according to the equation x = (pr x 1000) / v, where pr = cfu per dish, V = 500 liters of air.

Statistical analysis
The data were statistically analyzed using the Spss "Version 20" program, and chi square

Results and Discussion
There are two types methods of monitoring air quality within hospitals: Ineffective method: In which the method of deposition is used on petri container dishes that contain suitable media for growth of the microbes and after the completion of the collection process is incubated under appropriate conditions, the results of this method are qualitative because only the vital particles deposited on the surface exposed to the air are monitored.
Effective method: Effective monitoring differs from ineffective monitoring in that it requires the use of modeling devices to draw microbial air samples, and to draw a known volume of air such as the SAS.sampler device used in the study [9].

Assessing of microbial load in the hospital halls and their corridors, outer air environment
The bacterial load in the air samples of the sites included in the study ranged between 2-131 units of colonies per cubic meter, where the results showed the variations of the bacterial load by location, by time of collection and as detailed below.
The bacterial microbial load ranged in one cubic meter.From the air of the surgical procedure hall between 5-40 at a rate of 19.04 CFU/m3, and variable depending on the time of collection of the model, in the morning at the start of work ranged between 2-39 (average 14.8) and at noon in the range of 6-41 in a rate of 23.08 CFU/m3, and the differences between the times were statistically significant at a significant level P≤0.05.(Table 1).
The bacterial microbial loads outside the surgical hall in the corridor leading to it ranged from 28 to 75.5, at a rate of 50.3 CFU/m3.It was also variable depending on the time the model was collected (it was morning at the start of work between 20-81, at a rate of 43.9, and at noon at 43-82, at a rate of 53.6 CFU/m3.The Mann-Whitney test showed that the differences in bacterial air load between the surgical procedure hall and outside the hall in the corridor leading to it were statistically significant (the calculated value was 4 and the p-value was lower than the significance level of 0.05).
In the delivery hall, the bacterial loads in the air ranged from 19-55, with an average of 35.8, CFU/m3.The bacterial loads outside the hall (in the corridor leading to it) ranged from 18 to 65.5, at a rate of 38.9, CFU/m3.The difference between inside and outside the hall were not  The bacterial loads inside the hall was variable depending on the time the model was collected, in the morning at the start of work it ranged from 13-39, at the rate of 23 CFU/m3, at noon at about 2-76, at a rate of 48.6, CFU/m3.It was also variable outside the hall in the corridor to it depending on the time the model was collected, in the morning at the start of work it was between 10-58, at a rate of 30.5 CFU/m3, and at noon at about 20-73, at a rate of 45.7 CFU/m3.
However, the differences between the time the model was collected were not statistically significant (between the Mann-Whitney test that the calculated value (69,500) and the P-value error ratio was greater than the significance level of 0.05).As shown in Table 2.The bacterial loads in the air of the main hall of the hospital was estimated in order to compare it with the air of the sterile halls, the bacterial loads in the air of the main hall of the hospital ranged between 34.5 -89 at the rate of 60.4 CFU/m3, and was also variable depending on the time of collection of the model, in the morning at the start of work between 20 -88 at the rate of 52.8 CFU/m3, and at noon in the range of 39 -99 at the rate of 68.2 CFU/m3.The differences were not statistically significant.
While the bacterial microbial load outside the hospital environment (air in the garden) ranged from 39.5 to 115.5 at a rate of 75.6 CFU/m3 and was also variation depending on the time of collection of the model, in the morning between 26 -100, at a rate of 66.3 CFU/m3 and at noon between 53 -131 at a rate of 85 CFU/m3, The Man Whitney test showed that the differences were not statistically significant (the calculated value of 44 and the P-value error ratio was greater than the significance level of 0.05, as in Table 4.The analysis tests the binary variance showed in the morning bacterial microbial load in the main hall of the hospital of 52.8 and the atmospheric air outside the hospital that recorded a load rate of 66.3 CFU/m3 that there was a statistically significant difference (P-Value) below the level of significance, as it shows in table 5 below: The process of sterilization and disposal of all pathogens may be difficult, but contamination and infection control programs must work to reduce the level of their occurrence, it is not

(
infections) has become less a threat to public health and thus weak the role of ventilation as a strategy to fight infection, but with the emergence of acute respiratory syndrome (SARS) between 2002-2003 and the emergence of Corona virus causing Middle East Respiratory Syndrome (COVID-1) 2018-2019, it recalled the seriousness of airborne diseases on human health as infection prevention and control became a vital part of the clinical therapeutic of patients, which are applied immediately after the patient's admission to the hospital and include typical personal precautions hand hygiene.The use of personal protection equipment to avoid direct mixing with the blood of patients and fluids or their physical secretions including respiratory secretions or improper parts of the skin, been estimated at AL-Zahra Hospital for women and children in AL-Muqdadiya located at Diyala province, Iraq, which extends at latitudes (-3.33 and -36.6) north and longitudes (-44.22 and 45.56) east, during the period from 25 December 2021 to 19 February 2022.The air sample was collected twice a day in the morning at 8:00 am.(the start of work) and at 12:00 p.m.) Using the SAS100 sample collection device (International pbi spa Melon / Italy).
statistically significant at a significant level of P≤0.05 (between the Man test and the calculated value of 69.5 and the error ratio P-Value) (greater than the significance level of 0.05).

Table al -
Zahra hospital for woman and children from 25Dec2021 to 19feb2022

Table 2 :
Microbial load measuring CFU/m3 inside delivery hall and their corridor that leading to it in al-Zahra hospital for women and children from 25Dec2021 to 19feb2022 leading to it in bacterial microbial load (calculated value 60 and P-Value error ratio below the significance level of 0.05) as in the table 3. P-ISSN: 2958-4612 E-ISSN: 2959-5568 Volume: 1, Issue: 4, October 2023 Manuscript Code: 662B

Table 3 :
Microbial load measuring CFU/m3 inside neonatal care hall and their corridor that leading to it in al-Zahra hospital for women and children from 25Dec2021 to 19feb2022

Table 4 :
Microbial load measuring CFU/m3 inside main hall and outside air environment to in al-Zahra hospital for women and children from 25Dec2021 to 19feb2022

Table 5 :
AM and PM daily rates by CFU/m3 comparing with main hall and outside air environment