Blog: Operating room inefficiencies could pose patient safety risk

A new study exploring efforts to keep operating rooms free of contamination ended up revealing some interesting findings about inefficiencies.

In 190 surgeries lasting from about an hour-and-a-half to just over three hours, researchers found doors opened every 2.5 minutes and remained ajar for nearly 10 minutes on average.

In most cases, they were open “long enough for positive room pressure to be defeated, causing air to flow into the operating room.” This reversed air flow essentially undercut ventilation and other sophisticated systems designed to keep airborne contaminants out.

The staff's effect on what are supposed to sterile surroundings were surprising to the authors.

“Excessive operating room traffic may indicate logistical and personnel management inefficiencies,” the authors wrote in the study published this week in the journal Orthopedics.

In fact, inefficiencies in the OR care-delivery processes are pretty common and can be “remarkably chaotic,” suggested Dr. John Toussaint, CEO of the ThedaCare Center for Healthcare Value.

His group educates healthcare leaders on Lean quality improvement, a method of reducing waste that hails from manufacturing but is frequently being applied to healthcare. They have also found “a huge amount of movement out the door and around the room,” often because the OR team members don't have what they need in the right place.

For example, in a previous role as CEO of the ThedaCare health system, Toussaint timed how frequently nurses spent their time looking for supplies. “It was about 3 ½ hours per 8-hour shift,” he said. “Until you've actually tracked the inefficiencies, it's hard to understand how bad the problem really is.”

This summer, Modern Healthcare observed how one Chicago-area hospital used Lean to make the surgical floor workflow more efficient. Frontline staffers were given only one week to generate solutions. The team identified the inconvenient location of surgical supplies as one major reason nurses and others spent valuable time looking for stuff instead of attending to patients.

In the study posted this week in Orthopedics, the researchers retrospectively analyzed how many times doors opened and closed, indicating how frequently staff came in and out of the surgical suite, during 91 primary hip and 100 knee arthroplasty procedures. The operating room staff was not aware data was being collected at the unnamed academic teaching institution between March and June 2011.

The door openings and closings were tracked by a sensory device that read the pressure in the room, and allowed researchers to follow the rates without staff knowing. But this method did not allow them to get to the root causes of the “excessive room traffic.”

While some of the door openings were undoubtedly unavoidable, “what we know for sure is that there was a whole lot more traffic ... than seems necessary or easily explained,” said Stephen Belkoff, the senior study author and associate professor in the Johns Hopkins University School of Medicine.

In about 40% of the surgeries, the opened doorways led air flow from outside the room into the suite. The longer the surgery, the more frequently people would step out and the longer the doors were left open, thus “jeopardizing operating room sterility,” the study found.

At the same time, however, only one knee surgery patient who underwent an operation during the time period got an infection.

"Perspective is important," said Russell Olmsted, a past president of the Association for Professionals in Infection Control and Epidemiology. The frequency of infections was too low to link the problem to traffic in the OR, and there are many other risk factors for surgical site infections, he said.

The study also found that when the doors were closed, sterile conditions quickly returned to normal. But the goal is to keep disruption of the normal flow to a minimum, Olmsted added. In light of that, more research is needed.

The only way to find out why there was so much traffic, and ultimately how much harm it causes, is to track it, Toussaint added.

"When we actually follow people and do diagrams, we find a tremendous amount of wasted movement ... which does end up having a negative impact on quality,” he said.