Patient Safety Tip of the Week
November 24, 2015
Door Opening and Foot Traffic in the OR
We’ve done several previous columns that have discussed the
potential negative impact of increased OR foot traffic.
In some of our prior articles on the relationship between
surgical duration and SSI rates (see our March 10, 2010 Patient Safety Tip of
the Week “Prolonged
Surgical Duration and Time Awareness” and our January 2010 What’s New in
the Patient Safety World column “Operative
Duration and Infection”), we have noted that OR traffic typically increases
in longer duration cases. That likely increases the risk of bacterial
transmission as well. As cases go on longer, foot traffic in and out of the OR
increases, both as staff go on breaks or change shifts and as interruptions for
questions, etc. begin to affect the surgeons and anesthesiologists. Long
duration of surgery has long been known to be a factor associated with
increased risk of surgical site infection and increased foot traffic may be one factor that increases the likelihood of
surgical site infections (Lynch 2009).
Then in our March
17, 2015 Patient Safety Tip of the Week “Distractions
in the OR” we discussed a study on distractions in the OR (Wheelock
2015). Not surprisingly,
distractions occurred in 98% of cases. They occurred at a rate of 10.94
distractions per case or one distraction every 10 minutes. The most frequent
types of distraction were those initiated by external staff entering the
operating room. The researchers note that such distractions were unnecessary in
81% of cases! While those researchers actually attributed less significance to
their major outcome variables (like teamwork, stress, etc.), they do
acknowledge the potential impact on surgical infection rates, which they did
not monitor. In several Patient Safety Tips of the Week (“HAI’s:
Looking in All the Wrong Places”, “Prolonged
Surgical Duration and Time Awareness”, “Operative
Duration and Infection”) we’ve noted the risk of infection increases each
time the OR door is opened and foot traffic in and out of the OR increases.
Now a new study from Johns Hopkins has 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.
Unfortunately, the Hopkins study did not assess the reasons
for frequent door opening (the study was done in a manner that the OR staff was
unaware such observations were being made). But if we extrapolate from the
Wheelock study (Wheelock
2015) we’d expect a large percentage of the door openings may be from
external staff and that most of these may not be necessary.
Mears and colleagues in the Hopkins study note that such
frequent door openings are often a sign of OR inefficiencies pertaining to
equipment, logistics, and personnel management. They note that the Lynch study
correlated the number of door openings with the number of people in the OR.
Mears et al. did not record that number. However, we would suspect that number
may well be higher in teaching institutions than in community hospitals.
The next step would be to find out the reasons for such
frequent OR door openings. Based on those results, possible interventions could
be planned and piloted. In our March 17, 2015 Patient Safety Tip of the Week
“Distractions
in the OR” we noted that, anecdotally, simply having everyone attempting to
enter the OR fill out a log entry with the reason for entering substantially
reduces the number of people entering.
We agree with Mears
et al. that proper planning for surgery and ensuring that all equipment and
supplies that will be needed for the procedures are available in the OR is very
important. In that regard, appropriate use of pre-op huddles/briefings and
post-op debriefings are useful in reducing equipment issues.
The impact of such excessive foot traffic in and out of the
OR and the impact of door opening on air flow into the OR is likely of
importance from an infection control perspective. But the distractions and
interruptions associated with such traffic are likely to have an adverse impact
on other efficiencies in the OR. Door openings are probably a good proxy for OR
inefficiencies and OR distractions and would be an easily measured parameter
that might find use in multiple quality improvement projects.
Note that we have often recommended organizations use video
recordings of OR cases that are then reviewed in a constructive manner to
assess how will the OR team communicates and works together. While we’ve never
looked at OR door openings during such reviews, that would be another valuable
opportunity to determine reasons for door openings. Note also that those
centers which have implemented RFID (or similar) tracking systems should be
able to determine what personnel and equipment are moving in and out of the OR
during cases and use that to get a better idea of the reasons for such
movement.
Mears and colleagues have done a good job of raising
awareness of a potential patient safety vulnerability that needs further
research. Our bet is that looking at those vulnerabilities will also provide
organizations with opportunities to improve their efficiencies – a win win situation.
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/cgi/content/abstract/24/1/45
Wheelock A, Suliman A, Wharton
RBM, et al. The Impact of Operating Room Distractions on Stress, Workload, and
Teamwork. Annals of Surgery 2015; published ahead of print January 23, 2015
Mears SC, Blanding R, Belkoff SM. Door
Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics
2015; 38(11): e991-e994
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