In several of our
columns we’ve warned that long surgical duration has the potential to increase
surgery-related infections and that excessive OR traffic and opening of OR
doors is likely a major factor.
In our March 10,
2009 Patient Safety Tip of the Week “Prolonged
Surgical Duration and Time Awareness” we noted a study (Lynch 2009) that
suggested increased foot traffic may be factor related to prolonged procedures
that increases the likelihood of surgical site infections.
Then in our January 2010 What's New in the Patient Safety
World column “Operative
Duration and Infection” we discussed another study (Proctor
et al 2010) that 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 increased geometrically by 6% per half hour. We again
speculated that increased foot traffic may be another factor related to
prolonged procedures that increases the likelihood of surgical site infections
as suggested by Lynch et al.
And our December
30, 2014 Patient Safety Tip of the Week “Data
Accumulates on Impact of Long Surgical Duration” cited several other studies
in which surgical infections were one of several complications related to
prolonged surgery.
Then in our November 24, 2015 Patient Safety Tip of the Week
“Door
Opening and Foot Traffic in the OR” we 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 researchers measured how often and for how long OR doors were
opened during 191 hip and knee arthroplasty procedures. They also measured air
pressures in the OR and adjacent corridors. They found that, on average, OR
doors were open 9.5 minutes per case and the average time between door openings
was 2.5 minutes. As you’d expect the number and duration of door openings
correlated with the length of surgery. In 77 of the 191 cases positive pressure
within the OR was defeated. The implications are obvious. While they found only
one surgical infection in the 191 cases, the effects of the door opening on OR
pressure and air flow theoretically would predispose to surgical infections.
OR’s have positive pressure to avoid flow of air and airborne pathogens from
nonsterile adjacent areas.
Now a new study has
actually demonstrated that a program to reduce unnecessary door openings may reduce surgery-related infections (Camus 2016).
A Canadian hospital did a manual count
of door openings during total joint replacement operations and revision
procedures. They counted between 42 and 70 door openings per operation from
incision time to joint capsule closure time. Operations averaged 75 minutes.
Reasons for entering and exiting the OR during operations included retrieving
charts, instruments, or equipment, and taking a break.
Next 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. Subsequent traffic
audits taken every six months indicated 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 SSIs from 2.8
percent to 2.1 percent. The Canadian team is expanding its program to multiple
other services and other hospitals in their multi-hospital system.
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. It appears that those were two of the interventions
used in their program. Also we’ve discussed in numerous columns how use of presurgical “huddles” or briefings and postsurgical
debriefings may help identify issues that can lead to reduction in surgical
duration and unnecessary OR traffic (see our December 30, 2014 Patient Safety
Tip of the Week “Data
Accumulates on Impact of Long Surgical Duration”).
The Canadian study
only reported the impact on surgical infections. But we’re willing to bet that
their efforts reduced not only door openings but likely significantly reduced
surgical durations. That, in turn, likely reduced several other unwanted
complications seen with prolonged surgery, not to mention the economic benefits
to the hospital from improved efficiencies.
Of course, we’d like
to see validation of their study at other sites. We don’t know if every
hospital can achieve the remarkable reduction in OR door openings reported by
the Canadian researchers but it’s certainly worth your while to emulate their
efforts.
Our prior columns focusing on surgical case duration:
References:
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
http://ajm.sagepub.com/content/24/1/45.abstract
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
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Mears SC, Blanding R, Belkoff SM. Door
Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics
2015; 38(11): e991-e994
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
Print “PDF
version”