The Effect of Door Openings on Numbers of Colony Forming Units in the Operating Room during Hip Revision Surgery

Automated traffic monitoring of neurosurgical operating room

BACKGROUND

Operating room (OR) traffic disrupts airflow and increases particle count, which predisposes patients to surgical site infections, particularly in longer surgeries with hardware placement. The aim of this study is to evaluate the rate of traffic during neurosurgical procedures, as well as reasons for and perceptions of OR traffic.

METHODS

This is a single-center, multimethod study monitoring neurosurgical OR traffic through direct observation, automated monitoring, and interviews. Traffic was observed between the skin incision and closure. Personal interviews with OR teams including surgeons, anesthesia, and nurses were conducted to evaluate their perceptions of the frequency of OR traffic and reasons for OR traffic.

RESULTS

Direct observation reported OR door opening an average of 18 times, with 20 people entering or exiting per hour. The exact reason for traffic was not verified in all traffic cases and was able to be confirmed in only a third of the cases. Automated monitoring resulted in an average of 31 people entering or exiting the OR per hour. The procedure length was significantly associated with the number of people entering or exiting the OR per hour (P < .0001). Interviews highlighted that OR teams reported traffic to be significantly lower than observed and automated monitoring results, with approximately <6 people entering or exiting per hour.

CONCLUSIONS

OR traffic is higher than staff expected, and updated processes are required to reduce the number of times the OR door opens. Implementing automated observation of OR traffic could reduce the OR traffic and the risk for surgical site infection.

Infection Prevention and the Protective Effects of Unidirectional Displacement Flow Ventilation in the Turbulent Spaces of the Operating Room

BACKGROUND

Unidirectional displacement flow (UDF) ventilation systems in operating rooms are characterized by a uniformity of velocity ≥80% and protect patients and operating room personnel against exposure to hazardous substances. However, the air below the surgical lights and in the surrounding zone is turbulent, which impairs the ventilation system's effect.

AIM

We first used the recovery time (RT) as specified in International Organization for Standardization 14644 to determine the particle reduction capacity in the turbulent spaces of an operating room with a UDF system.

METHODS

The uniformity of velocity was analyzed by comfort-level probe grid measurements in the protected area below a hemispherical closed-shaped and a semi-open column-shaped surgical light (tilt angles: 0°/15°/30°) and in the surrounding zone of a research operating room. Thereafter, RTs were calculated.

RESULTS

At a supply air volume of 10,500 m3/h, the velocity, reported as average uniformity ± standard deviation, was uniform in the protected area without lights (95.8% ± 1.7%), but locally turbulent below the hemispherical closed-shaped (69.3% ± 14.6%), the semi-open column-shaped light (66.9% ± 10.9%), and in the surrounding zone (51.5% ± 17.6%). The RTs ranged between 1.1 and 1.7 min below the lights and 3.5 ± 0.28 min in the surrounding zone and depended exponentially on the volume flow rate.

CONCLUSIONS

Compared to an RT of ≤20 min as required for operating rooms with mixed dilution flow, particles here were eliminated 12-18 times more quickly from below the surgical lights and 5.7 times from the surrounding zone. Thus, the effect of the lights was negligible and the UDF's retained its strong protective effect.

Traffic Cameras-An Effective and Sustainable Method of Reducing Traffic and Airborne Particles During Arthroplasty Surgery

BACKGROUND

Traffic in the operating room (OR) create turbulence and contaminates air by bacterial shedding. Therefore, we examined: (1) if the number and duration of door openings were associated with increased particles during arthroplasty surgery; (2) if traffic cameras installed in the operating room were an effective intervention to decrease traffic and particles during arthroplasty surgery; and (3) the effectiveness of traffic camera over time.

METHODS

Fifty cases were included between November 3, 2021, and June 22, 2022, with 25 cases in each group. Two particle counters were used to count particles sized 0.5 to 10 µm. One counter was positioned within the sterile field, and another between the OR doors. Two door counters were mounted to count door openings. For the intervention, traffic cameras were mounted facing each door and took snapshots with door openings.

RESULTS

The number of door openings/minute was 30% less in the Intervention group (P < .001). The Intervention group had significantly lower particles by 26 to 43% in the operative field (0.5 μm, P = .01; 0.7 μm, P = .008; 1 μm, P = .007; 2.5 μm, P = .006; 5 μm, P = .01; and 10 μm, P = .01). The particles between the OR doors were decreased by 2 to 42% in the Intervention group and the difference was significant for (0.5 μm, P = 0.03; 0.7 μm, P = .02; and 1 μm, P = .03). The decrease in door openings and particles were sustained over the study period.

CONCLUSION

The use of traffic cameras was an effective and sustainable method to limit OR traffic and door openings, which resulted in a reduction in particles in the operating room.

Decreasing Foot Traffic in the Orthopedic Operating Room: A Narrative Review of the Literature

INTRODUCTION

Surgical site infections (SSIs) are implicated in poor outcomes in orthopedic surgical patients. Decreasing foot traffic in orthopedic surgical suites is correlated with the reduction of SSI risk. This review aims to understand the background and significance of the problem, isolate factors contributing to the movement in and out of operating rooms, and identify interventions that decrease traffic in procedure areas.

METHODS

A comprehensive search was completed using the databases Embase and Medline (Ovid). A PICOT question was used in the literature search to evaluate the efficacy of a standardized guideline on operating room door opening frequency. The Mixed Methods Appraisal Tool was used to appraise the literature critically, and conventional content analysis methodology identified themes within the publications.

RESULTS

The literature search yielded 18 articles providing 3 different themes of evidence: airborne bacterial counts and their association with foot traffic; specific personnel, namely, nurses demonstrating the greatest amount of foot traffic; and interventions aimed at minimizing this foot traffic.

CONCLUSIONS

Implementing multiple evidence-based interventions can decrease foot traffic and reduce the risk of SSIs in orthopedic patients. Further studies are needed to directly link airborne bacterial counts to SSIs, increase the level of evidence, and isolate interventions.

3D printed anatomical (bio)models in spine surgery: clinical benefits and value to health care providers

The applications of three-dimensional printing (3DP) for clinical purposes have grown rapidly over the past decade. Recent advances include the fabrication of patient specific instrumentation, such as drill and cutting guides, patient specific/custom long term implants and 3DP of cellular scaffolds. Spine surgery in particular has seen enthusiastic early adoption of these applications. 3DP as a manufacturing method can be used to mass produce objects of the same design, but can also be used as a cost-effective method for manufacturing unique one-off objects, such as patient specific models and devices. Perhaps the first, and currently most widespread, application of 3DP for producing patient specific devices is the production of patient specific anatomical models, often termed biomodels. The present manuscript focuses on the current state of the art in anatomical (bio)models as used in spinal clinical practice. The biomodels shown and discussed include: translucent and coloured models to aid in identification of extent and margins of pathologies such as bone tumours; dynamic models for implant trial implantation and pre-operative sizing; models that can be disassembled to simulate surgical resection of diseased tissue and subsequent reconstruction. Biomodels can reduce risk to the patient by decreasing surgery time, reducing the probability of the surgical team encountering unexpected anatomy or relative positioning of structures and/or devices, and better pre-operative planning of the surgical workflow including ordered preparation of the necessary instrumentation for multi-step and revision procedures. Conversely, risks can be increased if biomodels are not accurate representations of the anatomy, which can occur if MRI/CT scan data is simply converted into 3DP format without interpretation of what the scan represents in terms of patient anatomy. A review and analysis of the cost-benefits of biomodels shows that biomodels can potentially reduce cost to health care providers if operating room time is reduced by 14 minutes or more.

Motion-capture system to assess intraoperative staff movements and door openings: Impact on surrogates of the infectious risk in surgery

OBJECTIVES

We longitudinally observed and assessed the impact of the operating room (OR) staff movements and door openings on surrogates of the exogenous infectious risk using a new technology system.

DESIGN AND SETTING

This multicenter observational study included 13 ORs from 10 hospitals, performing planned cardiac and orthopedic surgery (total hip or knee replacement). Door openings during the surgical procedure were obtained from data collected by inertial sensors fixed on the doors. Intraoperative staff movements were captured by a network of 8 infrared cameras. For each surgical procedure, 3 microbiological air counts, longitudinal particles counts, and 1 bacteriological sample of the wound before skin closure were performed. Statistics were performed using a linear mixed model for longitudinal data.

RESULTS

We included 34 orthopedic and 25 cardiac procedures. The median frequency of door openings from incision to closure was independently associated with an increased log10 0.3 µm particle (ß, 0.03; standard deviation [SD], 0.01; P = .01) and air microbial count (ß, 0.07; SD, 0.03; P = .03) but was not significantly correlated with the wound contamination before closure (r = 0.13; P = .32). The number of persons (ß, -0.08; SD, 0.03; P &lt; .01), and the cumulated movements by the surgical team (ß, 0.0004; SD, 0.0005; P &lt; .01) were associated with log10 0.3 µm particle counts.

CONCLUSIONS

This study has demonstrated a previously missing association between intraoperative staff movements and surrogates of the exogenous risk of surgical site infection. Restriction of staff movements and door openings should be considered for the control of the intraoperative exogenous infectious risk.

Remote Video Auditing to Verify OR Cleaning: A Quality Improvement Project

There are many sources of contamination in the perioperative environment. Patient experience can be negatively affected by the presence of environmental contamination, especially if it is the cause of a surgical site infection. Perioperative and environmental services staff members and leaders are tasked with ensuring a clean and safe environment for their patients while maintaining an awareness of time and budgetary constraints. In addition, leaders are responsible for the competency of their staff members and must address performance issues when needed. New technological advances designed to streamline monitoring and reporting processes related to OR cleanliness are available for use. This article describes the quality improvement project that one multifacility organization completed related to the use of remote video auditing and the positive effect it had on the organization's environmental contamination.

Door openings in the operating room are associated with increased environmental contamination

Door openings in the operating room (OR) have been hypothesized to increase OR environmental contamination. This study measured average colony-forming units (CFU) in the OR as a function of door openings and other potentially important variables. Bacterial settle plates were placed inside and outside of laminar airflow (LAF) by both exit doors, on the instrument table, and on the back instrument table (if applicable) for 48 orthopedic and general surgery procedures. CFU data were paired to Staphylococcus aureus colonization status, door openings, surgery duration, time of day, OR location, number of staff, use of warming devices, temperature, and humidity. The number of door openings in the OR and surgery duration were significantly associated with increased CFU in the OR overall and outside of LAF. However, under LAF conditions, only the number of OR personnel was significantly associated with increased CFU.

Temperature-controlled airflow ventilation in operating rooms compared with laminar airflow and turbulent mixed airflow

AIM

To evaluate three types of ventilation systems for operating rooms with respect to air cleanliness [in colony-forming units (cfu/m³)], energy consumption and comfort of working environment (noise and draught) as reported by surgical team members.

METHODS

Two commonly used ventilation systems, vertical laminar airflow (LAF) and turbulent mixed airflow (TMA), were compared with a newly developed ventilation technique, temperature-controlled airflow (T_cAF). The cfu concentrations were measured at three locations in an operating room during 45 orthopaedic procedures: close to the wound (<40cm), at the instrument table and peripherally in the room. The operating team evaluated the comfort of the working environment by answering a questionnaire.

FINDINGS

LAF and T_cAF, but not TMA, resulted in less than 10cfu/m³ at all measurement locations in the room during surgery. Median values of cfu/m³ close to the wound (250 samples) were 0 for LAF, 1 for T_cAF and 10 for TMA. Peripherally in the room, the cfu concentrations were lowest for T_cAF. The cfu concentrations did not scale proportionally with airflow rates. Compared with LAF, the power consumption of T_cAF was 28% lower and there was significantly less disturbance from noise and draught.

CONCLUSION

T_cAF and LAF remove bacteria more efficiently from the air than TMA, especially close to the wound and at the instrument table. Like LAF, the new T_cAF ventilation system maintained very low levels of cfu in the air, but T_cAF used substantially less energy and provided a more comfortable working environment than LAF. This enables energy savings with preserved air quality.

A Bundle Protocol to Reduce the Incidence of Periprosthetic Joint Infections After Total Joint Arthroplasty: A Single-Center Experience

BACKGROUND

Periprosthetic joint infection (PJI) represents a devastating complication of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Modifiable patient risk factors as well as various intraoperative and postoperative variables have been associated with risk of PJI. In 2011, our institution formulated a "bundle" to optimize patient outcomes after THA and TKA. The purpose of this report is to describe the "bundle" protocol we implemented for primary THA and TKA patients and to analyze its impact on rates of PJI and readmission.

METHODS

Our bundle protocol for primary THA and TKA patients is conceptually organized about 3 chronological periods of patient care: preoperative, intraoperative, and postoperative. The institutional total joint database and electronic medical record were reviewed to identify all primary THAs and TKAs performed in the 2 years before and following implementation of the bundle. Rates of PJI and readmission were then calculated.

RESULTS

Thirteen of 908 (1.43%) TKAs performed before the bundle became infected compared to only 1 of 890 (0.11%) TKAs performed after bundle implementation (P = .0016). Ten of 641 (1.56%) THAs performed before the bundle became infected, which was not statistically different from the 4 of 675 (0.59%) THAs performed after the bundle that became infected (P = .09).

CONCLUSION

The bundle protocol we describe significantly reduced PJIs at our institution, which we attribute to patient selection, optimization of modifiable risk factors, and our perioperative protocol. We believe the bundle concept represents a systematic way to improve patient outcomes and increase value in total joint arthroplasty.