Reducing OR Traffic Using Education, Policy Development, and Communication Technology
Abstract
A bundled approach to surgical site infection (SSI) prevention strategies includes reducing OR traffic. A nurse-led quality improvement (QI) team sought to reduce OR traffic through education and a process change that included wireless communication technology and policy development. The team measured OR traffic by counting the frequency of door openings per hour in seven surgical suites during 305 surgical procedures conducted during similar 22-week periods before and after the QI project intervention. Door openings decreased significantly (P < 0.05) from an average of 37.8 per hour to 32.8 per hour after the QI project intervention. This suggests that our multifaceted approach reduces OR traffic. The next steps of this project include analyzing automatically captured video to understand OR traffic patterns and expanding education to departments and external personnel frequently present in our surgical suites. Future research evaluating the effectiveness of this OR traffic initiative on SSI incidence is recommended.
Surgical site infections (SSIs) continue to be a serious health risk and are associated with a mortality rate of 3%.1 Surgical site infections are the most common form of health care-associated infection2 and can result from diverse factors.3, 4 Characteristics influencing the risk for SSI include patient health and nutrition; perioperative preparation, including preoperative bathing and using clean linen; the OR environment and operative procedure; and postoperative care.3
In 1999, Mangram et al3 published the “Guideline for prevention of surgical site infection,” and specific recommendations of this guideline included optimizing the patient's preoperative health and nutrition, surgical site preparation (ie, cleansing, hair removal), antimicrobial prophylaxis, asepsis and surgical technique, sterilization of equipment, and positive-pressure ORs that provide laminar flow ventilation.3 Since this seminal publication, SSI prevention efforts have focused on a “bundle” of practices that fall into three general areas: “the patient, the surgical technique, and the surgical environment.”5
The use of bundles to improve the reliability of care and prevention of specific clinical outcomes has been demonstrated successfully for the past decade.6 Research supports the bundled approach for SSI prevention. A Dutch study found that increased compliance with a bundled SSI approach led to a 50% reduction in cardiovascular SSIs.7 The Joint Commission Center for Transforming Healthcare found a 32% reduction in colorectal SSIs when health care providers used a bundled approach.8
Problem Description
Since opening our new perioperative department in June 2011, surgical personnel noted an increasing number of personnel in the surgical suite (eg, surgical personnel, vendors, sales representatives, students) and an increase in movement into and out of the suite during surgical procedures. Within our organization, there were no clear guidelines regarding expectations for efficient traffic within the intraoperative area and personnel were uncertain whether these traffic factors contributed to negative outcomes, particularly SSIs.
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preoperative body hygiene,
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antibiotic prophylaxis,
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perioperative normothermia, and
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reduction in OR traffic during surgical procedures.
The SSI prevention team assigned responsibility to the OR Patient Safety Committee (ORPSC) to investigate current OR traffic patterns, formulate a plan for traffic reduction, implement practice changes by educating personnel regarding efficient and meaningful movement, and monitor OR traffic patterns to assess for the assimilation of new practices. The ORPSC reported recommendations, education implementations, and quality improvement (QI) data to the OR nurse manager.
Project Setting
Gillette Children's Specialty Healthcare is an independent not-for-profit health system located in St Paul, Minnesota, that provides specialized health care for children with medically complex disabilities. Services include a 60-bed hospital and a perioperative department that includes seven surgical suites. The perioperative department has two sets of double doors leading into a restricted area where appropriate surgical attire is required. Within each surgical suite, there is a double door that leads to the main intraoperative corridor and a core door that leads to the sterile supply core area. The internal team responsible for designing the new perioperative department requested door opening counters in every OR doorway and created a new observation deck with an integrative video technology system incorporated into several surgical suites. During the first year of use, surgical personnel performed 3,831 procedures in the new perioperative department, and in 2012, this increased to 3,917 procedures. The procedures ranged from outpatient (ie, same-day) surgical procedures to complicated surgical procedures that required inpatient recovery.
Project Goal
The goal of this QI project was to reduce OR traffic by 10% within four months. The team measured traffic by counting the frequency of door openings during surgical procedures. The ORPSC implemented multifaceted educational strategies, environmental changes, and policy and process changes in an attempt to modify the foot traffic behavior of frontline surgical personnel.
Literature Review
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necessary door openings (eg, necessary personnel and/or equipment),
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seminecessary door openings (eg, personnel breaks after incision and/or before closure), and
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unnecessary door openings (eg, unrelated to the procedure, social visits, or no detectable reasons).5
In one study, unnecessary door openings accounted for 32% of traffic flow.5 Another study reported that the most frequent reason given for OR traffic was information requests.13 A study of OR traffic during total joint arthroplasty found that 47% of door openings occurred for no identifiable reason,11 while a study of orthopedic trauma implant surgeries found 32% of door openings to be unnecessary.5 Missing from the literature are investigations of OR traffic during pediatric surgical procedures.
Traffic in the OR during surgical procedures must be kept to a minimum. For example, movement into and out of the OR can disrupt laminar airflow.9 Laminar airflow introduces a steady column of clean air directly over the surgical field.14 Studies of OR air quality found a positive association between door opening frequency and OR bacterial counts.5, 10, 12, 14 Research also found that excessive OR traffic is a modifiable risk factor for SSIs and that reducing OR traffic is a core intraoperative SSI prevention strategy.15, 16 This evidence supports the inclusion of OR traffic reduction in an SSI prevention bundle.
Methods
Our QI project empowered frontline surgical personnel to change practices contributing to unnecessary OR traffic. The ORPSC implemented recommendations from the literature5, 13 that addressed unnecessary door openings and championed the importance of efficient, effective, and multitasked movements to reduce traffic.
Education
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visual education about laminar flow and the ideal environment within the surgical suite;
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AORN recommendations, including rationale for best practices;
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results from previous research studies outlining the top three traffic impetuses for staff members; and
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recommendations with tools to optimize practice changes.
The team provided these presentations to circulating nurses, first assistants, surgical technicians, and nurse anesthetists during regularly scheduled staff meetings over a one-month period, using one-to-one discussions or small group discussions for individuals who were absent from staff meetings. The team did not assess learning by using prepresentation and postpresentation tests. Instead, each team member was given the opportunity to discuss what was learned with the group or during 1:1 conversations.
The team provided research articles5, 11, 13 to personnel via e-mail and posted the articles on the staff bulletin board for review. These articles described how traffic within the surgical suite increases the risk for contamination of the sterile surgical field, the link between increased traffic and increased colony-forming units, and the various reasons that staff members contribute to traffic into and out of the OR.
Staff members participated in small group mock teach-back sessions in our simulation and training laboratory and in vacant surgical suites during the same one-month period. They modeled alternative ways of communication and meaningful and efficient movements in the surgical environment. Approximately 75% of intraoperative surgical personnel attended these sessions.
Clinical Process Changes
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Signs placed on each surgical suite door reminded personnel to be mindful of personal traffic and encouraged the use of alternative methods to communicate outside of the room when possible.
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Surgery department personnel purchased wireless telephones for designated float personnel to communicate with the OR team in each room to avoid unnecessary entry into the surgical suites.
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The team changed the surgical observation policy to implement the use of new surgical suite observation decks and required all observations to occur from the observation deck, which is equipped with a camera system to provide a view of the surgical field/incision and a telephone system to communicate with personnel in the room.
Description of Sample and Sampling Techniques
The team measured door openings for this QI project after determining that this was an objective measure of OR traffic. These data samplings were limited to door openings during orthopedic single-event multiple-level surgical (SEMLS) procedures, where multiple surgical teams operate simultaneously on one or both sides and at various levels of the patient's body. More than 30 different surgical procedures on bones and soft tissues can be included in an SEMLS surgery.
Door openings of SEMLS surgical procedures were chosen as our QI project data sample for several reasons. First, these procedures typically involve large numbers of personnel with diverse roles (eg, students, trainees, vendors, multiple surgeons). Second, approximately 18% of inpatient surgical procedures performed at our organization are SEMLS procedures, and the high number provided adequate procedures for comparison. Last, the variety of SEMLS procedures offered a cross-section of complex surgical procedures during which to measure OR traffic. Although SEMLS procedures vary markedly, the purpose of this project was to evaluate the effect of the QI project on door openings; it was not to evaluate door openings by type of SEMLS procedure.
The team compared door openings for all SEMLS procedures conducted during a 22-week pre-QI data collection period (November 2011 to April 2012) and a 22-week post-QI data collection period (November 2012 to April 2013). The team chose these time frames to reduce seasonal confounding variables (eg, we experience fewer procedures during December and January and more procedures during the summer).
Participant Protection
Our QI project did not involve data collection from participants, and the institutional review board determined that oversight was not needed. Members of the nursing research committee, which is part of our collaborative governance structure, reviewed and approved this project.
Description of Measurement Techniques
During the construction of the new surgical suites, builders equipped each door with commercially available electronic door contacts that connect to a door control panel and door security database. When an OR door opens (defined by the manufacturer as a 1 in separation of the contact sensors on the door and its frame), an opened door signal is sent to the door control panel. When the door closes (ie, the contacts are reconnected), a closed door signal is sent to the same panel. The 1 in separation signaling a door opening is a manufacturer specification that cannot be modified. It is not known whether this separation causes a disruption in laminar flow. Personnel in the OR were aware of the automated door counters, but because the counters were part of the physical door structure, they were not visible and did not serve to remind personnel to alter their habits.
The presence of door contact technology in all surgical suites facilitated automated electronic data collection. This method differs from past OR traffic studies that used observers in the OR to record movement,5, 11, 13 but is similar to more recent OR traffic studies.9, 10, 12 Although the reliability of automated data collection compared to observational data collection was not tested during this QI project, prior research has demonstrated its reliability.12 In addition, the automated method could be less prone to bias than observational methods.
Data Collection
For both pre– and post–data collection periods, team members downloaded door opening data (ie, surgical suite number, door number, time of door opening) to an Excel® spreadsheet. Although the door contacts logged the time of every door opening, they were unable to capture the type, start time, or end time of a procedure. Team members extracted these three pieces of data from the electronic medical record. We defined type of procedure as the surgical procedure listed in the electronic medical record. Our samples only include door opening data for SEMLS procedures; the team excluded door opening data for all other surgical procedures. Procedure start time is the time logged by personnel when the room is ready (ie, the sterile field is open but the patient is not in the room). Preincision time is included in the procedure time because of concern with the exposed sterile field. Procedure end time is the time logged by personnel when the procedure is completed (ie, the surgical wound is closed with dressings being applied or already applied). Our definitions of procedure start and end time match those used by previous studies.11, 13
Data Analysis Methods
Team members used the data collection file containing door opening data, procedure type, procedure start time, and procedure end time to calculate the primary data elements used for analysis. Procedure length is defined and calculated as the difference between procedure start and procedure end times. Procedure door openings are defined and calculated as the number of door openings from procedure start to procedure end. Procedure door openings correlate to procedure length,9 and comparing procedure door openings without regard to procedure length could bias the results. We minimized this bias by defining and calculating procedure door openings per hour for each procedure and using this value to compare pre- and post-QI data samples for significance.
To perform the quantitative analysis of the door opening data samples, we used Intercooled Stata, version 9.0™. All door opening data used in the analysis (ie, procedure length, procedure door openings, procedure door openings per hour) exhibited normal distributions. Mutually exclusive pre- and post-QI project data sets comprised the door opening samples. We used Student t test to determine whether a difference existed between pre- and post-QI project procedure door openings per hour. Significance for all tests was set at P < .05.
Results
The team used the door opening data samples from 305 SEMLS surgical procedures recorded during mutually exclusive 22-week pre- and post-QI project data collection periods. The primary measurements for each SEMLS surgical procedure were procedure length and door openings. The SEMLS procedures in the pre-QI and post-QI data samples were conducted in all seven of our surgical suites and took place between the hours of 7:30 AM and 5:30 PM.
The pre-QI project data sample contains 171 SEMLS procedures and the post-QI project data sample contains 134 SEMLS procedures. Despite similar data collection durations, the post-QI project data sample had fewer procedures than the pre-QI project data sample. The only difference in personnel during the two data collection periods was the absence of five surgeons for a two-week medical mission trip during the post-QI project period. These surgeons primarily conduct SEMLS procedures and their absence could explain the difference in procedure numbers.
There was no significant difference in procedure length between the pre- and post-QI periods. The average procedure length for both periods was more than four hours. These findings are expected because the sample for both periods includes only SEMLS procedures, which tend to be longer and more complex than other surgical procedures performed at our organization.
Despite similar procedure lengths for the pre- and post-QI project data collection periods, a comparison of procedure door openings per hour showed a significant decrease (P = .001) in door openings during the post-QI period. The average rate of procedure door openings per hour decreased from 37.8 to 32.8 (Table 1). The 13% reduction exceeded our 10% QI goal and during the average 261-minute SEMLS procedure, translates to 22 fewer door openings.
| Quality Improvement Data Collection Period | Number of Procedures | Procedure Time (minutes) | Door Openings Per Procedure | Door Openings Per Hour | ||||
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| Mean | Median∗ | Mean | Median∗ | Mean | Median∗ | P | ||
| Preintervention | 171 | 279 | 278 (29,640) | 167 | 164 (26,392) | 37.8 | 36 (16,96) | .001 |
| Postintervention | 134 | 257 | 240 (56,569) | 136 | 124 (39,278) | 32.8 | 32 (17,70) | |
- Student t test used. P < .05 is considered significant.
- ∗ The numbers in parentheses indicate the range for the median value.
Discussion
We chose SEMLS procedures to evaluate the QI project because the complexity of these procedures makes them prone to excessive door openings and the frequency of these procedures provided adequate numbers for comparison. Our evaluation of the door opening data found a 13% reduction in OR door openings between the pre- and post-QI project data collection periods. This significant finding suggests that our OR traffic reduction interventions were effective.
Operating room traffic reduction is a component of the SSI prevention bundle recommended by the Centers for Disease Control and Prevention.15 Previous research shows a relationship between increased bundle compliance and decreased SSIs.7, 8 Our project focused solely on the OR traffic aspect of the SSI prevention bundle and empowered frontline surgical personnel to change practices that contribute to unnecessary OR traffic. This focus on reducing OR traffic is supported by the literature, which recommends the development of protocols to reduce door openings.5, 10, 11 Our findings suggest that OR traffic, as measured by door openings, can be reduced with a multifaceted QI process. Although ours is the first known report of OR traffic in a pediatric setting, a previous study of an adult-focused SSI bundle that included OR traffic reduction supports our findings.7 Although we did not measure the effect of OR traffic on the rate of SSIs during this QI project, this has been documented in the literature,5, 10, 16 and a positive correlation between OR traffic and air quality (ie, defined as colony-forming units per cubic meter) has been found.5, 10 Future evaluations of OR traffic reduction should include the SSI rate and a measure of air quality.
As documented in the literature, understanding the reasons for OR traffic is essential to reduction efforts.12, 13 During the planning phase of our QI project, we used the first-hand knowledge of committee members and discussions with frontline surgical personnel to identify reasons for OR traffic, and we designed our implementation to address these reasons. Two areas of identified unnecessary OR traffic included visitors in the surgical suite for observation and the inefficient movement of surgical float personnel. Enforcing the observation deck policy moved observers out of the surgical suite, eliminating the associated unnecessary door openings. Float personnel noted that the size and layout of the perioperative area reduced “line of sight” visibility for these staff members. It was not uncommon to have multiple float personnel enter a surgical suite for similar reasons and within minutes of each other because they were unable to see the previous person's entry. Providing all float personnel with a secure wireless telephone allowed them to communicate with surgical suite personnel without entering the room and allowed communication among float staff members, which helped eliminate unnecessary entry into the surgical suite.
The significant reduction in door openings suggests that our educational interventions and environmental and process changes addressed the underlying causes of unnecessary OR traffic. Despite this success, our future evaluation projects will expand data collection efforts to include the length of time a door remains open and who opens the door. We will calculate the former from data captured by the automatic door counters and the latter by video cameras operating in each surgical suite.
The average rate of door openings per hour reported in this article for the pre- and post-QI data collection periods were 37.8 and 32.8, respectively. Our findings are similar to most OR traffic door opening studies conducted during adult orthopedic procedures,10, 11, 13 but differ markedly from the low rates reported by Andersson et al.5 The discrepancy in prior study door opening rates could be explained by differing definitions of procedure length. Our QI project defined procedure length as the time from preincision (ie, opening of the sterile field) to incision closure. Previous studies with door opening rates similar to our QI project used a similar definition of procedure length,10, 11, 13 whereas the study with lower door opening rates calculated procedure length as the time from incision to incision closure.5 Lynch et al13 found that the preincision period accounted for 30% to 50% of procedure door openings and could explain the variation in door opening rates across previous studies. Future studies should use the definition of procedure length used in this QI project and put forth by Lynch et al.13
Limitations
This QI project used a bundled approach to reduce OR traffic. This approach does not allow attribution of reduced door openings to any single component of the QI intervention. Our data collection and sampling strategies limit generalization. This project evaluated door opening data for only pediatric SEMLS procedures, which represent 18% of our surgical procedures. Evaluating the QI intervention for other surgical procedures could generate different findings. Future QI projects should compare door openings based on a broader sample of pediatric surgical procedures conducted at our organization.
Conclusion
The overriding purpose of this QI initiative was to demonstrate the effect of an OR traffic educational program on actual traffic patterns. Initial results indicate that the educational initiative generated a positive effect, reducing OR traffic by 13%. Although this project focused only on frontline surgical personnel consisting of RNs, surgical technicians, and certified RN anesthetists, results have been presented to the broader organization, at QI grand rounds, and to our board of directors. The team also will present the project to a newly formed perioperative surgical services committee, which includes physicians, nursing leaders, and business managers in perioperative services. To ensure continued OR traffic reduction, the ORSPC will expand education to medical staff members (eg, surgeons, anesthesiologists) and outside department personnel (eg, imaging technicians, spinal cord monitoring technicians, cast technicians, ultrasound technicians) entering the surgical suite on a routine basis, and to external personnel (eg, vendors) who frequent the surgical suites.
Future evaluation will examine the effect of the expanded educational plan on OR traffic and the long-term effect of this implementation. The team will use a broader sample of pediatric surgical procedures for this evaluation and will include identifying who opens the OR door and the length of time it remains open. Understanding the length of time and being able to identify who opens the door provides a robust evaluation of the QI project and matches recommendations from other OR traffic research.9, 11 By reducing OR traffic, we lessen disruption of the airflow in the surgical suite, and when combined with other portions of the SSI-prevention bundle, these efforts may facilitate a further reduction in our current low rate of SSIs.
Acknowledgment
The authors acknowledge Gwen Schuller-Bebus, MA, RN, manager of Perioperative and Simulation Services, Gillette Children's Specialty Healthcare, St Paul, MN.
Biographies
Jennifer Esser, MN, MS, RN, CNOR, is an education specialist at Gillette Children's Specialty Healthcare, St Paul, MN. Ms Esser has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Keonemana Shrinski, BSN, RN, CNOR, is a staff nurse at Gillette Children's Specialty Healthcare, St Paul, MN. Ms Shrinski has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Rhonda Cady, PhD, BSN, RN, is a nursing research specialist at Gillette Children's Specialty Healthcare, St Paul, MN. Dr Cady has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
John Belew, PhD, RN, is a nursing research specialist at Gillette Children's Specialty Healthcare, St Paul, MN. Dr Belew has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
