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Opening
and closing doors to the OR is of concern for two primary reasons:
1.
The risk of surgical site infections is
increased
2.
Consequent distractions can lead to other errors
in the OR
Our
November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” discussed a study from Johns Hopkins that
formally studied how often OR doors are opened during joint arthroplasty
surgeries and the impact on OR air flow (Mears 2015). The effects of the door opening on OR
pressure and air flow clearly has implications for surgical infections. Our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed”
discussed a Canadian study on a program to reduce unnecessary door
openings and reduce surgery-related infections (Camus 2016). They achieved an amazing reduction in OR
traffic from between 42 and 70 door openings to 3.2 door openings per case.
They felt this intervention may have contributed to a decrease in orthopedic
SSI’s from 2.8 percent to 2.1 percent.
Regarding
distractions, our January 11, 2022 Patient
Safety Tip of the Week “Documenting
Distractions in the OR”
discussed a recent pilot study used Operating Room Black Box (ORBB)
technology in a Canadian tertiary care academic hospital (Nensi
2021). The researchers documented an
incredible average 89 door openings per case! That translates to an OR door
opening every 1.8 minutes!
A
recent article in AORN Journal (AORN 2022) highlighted a quality improvement project
at one large hospital that substantially reduced the number of OR door openings.
Nurses at Houston Methodist Hospital gathered baseline data on the frequency of
door openings during procedures, the job titles of staff members who were
responsible for the door openings, and the reasons for the door openings. They
also did an online survey to all perioperative staff members to determine their
knowledge regarding OR traffic and to identify reasons for door openings
The
most common reason to open doors was to retrieve supplies and equipment. The staff
members most commonly opening doors were the RN circulators and scrub nurses. More
than 95% of respondents knew that door openings alter OR airflow and contribute
to SSI’s. Suggested interventions to reduce OR door openings were more accurate
surgeon preference cards, verification of equipment and supplies during the
time out, and signs on the doors to remind staff to keep OR traffic to a
minimum.
They found
that almost 70% of staff members did not feel comfortable speaking up about
unnecessary traffic in the OR. Therefore, during inservices, they focused on
calling OR traffic a patient safety issue and speaking up and holding others
accountable for unnecessary traffic in and out of the OR.
They
designed a sign to place on each OR door, with the slogan “Mo’ Traffic Mo’
Problems”, a photo of a construction worker, and message that foot traffic
should be limited.
Because
of a hurricane, the COVID-19 pandemic, and a lack of staffing and resources, they
were only able to obtain follow-up data in one OR suite. But an audit in that
suite showed that the average number of door openings decreased by 32%. Door
openings for the top five job roles contributing to door openings also
decreased.
The
signs on the doors served as a “conversation starter” and helped staff members
educate each other about the importance of minimizing door opening.
One
barrier they encountered was that the door signs sometimes fell or otherwise
disappeared. Future plans include having more signs available and designating
someone in each unit to ensure the signs are posted on the doors.
In
our thinking, two of the most important opportunities to reduce OR door openings
are the pre-op huddle and the post-op debriefing. During the pre-op huddle
it is imperative that the team ensure that all necessary equipment, supplies
(and implants if applicable), medical records, documents, and images are present
in the OR. During the post-op debriefing concerns about equipment and
supplies should be discussed. Did we have to go outside the OR to get any
equipment or supplies during the case? Were there problems with any of the
equipment we already had in the OR. We can’t tell you the number of times, when
a piece of equipment fails, that staff says “yeah, we had a problem with that
last week” and no one did anything about it.
We’ve
previously suggested two “nudges” that could reduce OR door openings: (1) using
a sign akin to the “On Air” signs recording studios use to indicate a procedure
is in progress and (2) requiring those opening and closing the OR doors to
record the reason for their action. Having data is essential for any quality
improvement project. The Houston Methodist project collected data on both the
frequency of and reasons for OR door opening. You can’t get buy-in from OR
staff if you can’t convince them you have a problem. And you can’t fix the
problem unless you understand the reasons behind frequent OR door opening.
Video recording in the OR, as described in our January 11, 2022 Patient Safety Tip of the Week “Documenting
Distractions in the OR” can
provide a good estimate of the frequency of door opening and might give you a
good idea of the reasons for door opening, but more formal recording of the
reasons is important. That may mean putting someone outside the OR to actually
record those reasons or having the person opening the door record the reason(s)
in a log.
The
Canadian study by Camus et al. (Camus 2016) that we discussed in our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed”
found reasons for entering and exiting the OR during their total joint operations
included retrieving charts, instruments, or equipment, and taking a break. Their CUSP (Comprehensive Unit-Based
Program) team brainstormed and came up with key changes, including stopping all
traffic in and out of the OR between total joint capsule opening and closure,
communicating by phone, and increasing the use of templates to identify implant
size prior to each operation. They also put a sign on the OR door reminding
staff to minimize traffic and asking them to record why they are entering the
OR during an operation.
Reducing
OR door opening is important for reducing surgical infections and reducing
distractions that can lead to errors in the OR. Not enough hospitals or other
surgical venues have paid attention to the frequency of and reasons for OR door
opening. This remains an important patient safety issue that merits more
attention.
Our prior columns focusing on surgical OR
foot traffic and door opening:
·
April
23, 2019 “In
and Out the Door and Other OR Flow Disruptions”
·
June 8,
2021 “Cut
OR Traffic to Cut Surgical Site Infections”
·
January
11, 2022 “Documenting
Distractions in the OR”
References:
Mears
SC, Blanding R, Belkoff
SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty.
Orthopedics 2015; 38(11): e991-e994
https://journals.healio.com/doi/10.3928/01477447-20151020-07
Camus
S. Operating Room Traffic Monitoring Improves Patient Safety. Abstract session presentation
at the 2016 American College of Surgeons National Surgical Quality Improvement
Program (ACS NSQIP®) Conference. July 18, 2016 as reported in ACS (American
College of Surgeons). Minimizing Operating Room Traffic May Improve Patient Safety
by Lowering Rates of Surgical Site Infections. ACS Press Release July 18, 2016
https://www.facs.org/media/press-releases/restricted/ssi
Nensi
A, Palter V, Reed C, et al. Utilizing the Operating Room Black Box to
Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology
Operating Room: A Pilot Study. Cureus 2021; 13(7): e16218
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341265/
AORN.
Decreasing Traffic In and Out of the OR. AORN Journal 2022; 115(6): P12-P14
First Published:26 May 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13704
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