What’s New in the Patient Safety World


January 2010


Operative Duration and Infection


Risk factors for perioperative infections are not all modifiable. However, operative duration is one risk factor that is potentially modifiable. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. A new study (Proctor et al 2010) looked at a large database of general surgical procedures and demonstrated a linear relationship between duration of surgery and infectious complications. This relationship persisted even after adjustment for a variety of other risk factors for perioperative infections. The unadjusted infectious complication rate increased by 2.5% per half hour. Hospital length of stay (LOS) also inceased geometrically by 6% per half hour.


The authors discuss some of the plausible links between infectious complications and duration of surgery such as increased exposure to airborne pathogens and greater surgical trauma. Increased foot traffic may be another factor related to prolonged procedures that increases the likelihood of surgical site infections (Lynch et al. 2009).


They also discuss some of the many factors that may lead to increased surgical durations. These include factors such as case type, emergency vs. elective nature, and proficiency of the surgeon. But they also include such modifiable factors such as presence of trainees and poor communication.


Out March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, nerve compression, compartment syndromes, and rhabdomyolysis. We recommend that the OR team, during the surgical timeout or during the presurgical huddle, should discuss issues related to prolonged cases. For example, they should discuss whether intraoperative DVT prophylaxis should begin if the procedure lasts beyond a certain duration. Or discuss at what duration a repositioning of the patient (to avoid nerve compression, compartment syndrome, or rhabdomyolysis) might be wise. And it would be very useful to have an estimate of time remaining to again trigger some discussion on the above issues. In addition to the DVT prophylaxis and repositioning issues, it might raise questions about the need to temporarily ease up on traction. It might direct attention to maintenance of the patient’s body temperature. In a very prolonged case it might raise questions about the need for further doses of prophylactic antibiotics. An IT system solution to alert clinicians to duration of surgery and estimated time remaining has been proposed (Dexter et al 2009).






Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65




Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52




Dexter F, Epstein RH, Lee JD, Ledolter J. Automatic Updating of Times Remaining in Surgical Cases Using Bayesian Analysis of Historical Case Duration Data and "Instant Messaging" Updates from Anesthesia Providers. Anesth Analg 2009; 108:929-940














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