- Email: [email protected]
An observational study of door motion in operating rooms
Accepted Manuscript An observational study of door motion in operating rooms Ehsan S. Mousavi, Roxana Jafarifiroozabadi, Sara Bayramzadeh, Anjali Joseph, Dee San PII:
S0360-1323(18)30526-2
DOI:
10.1016/j.buildenv.2018.08.052
Reference:
BAE 5665
To appear in:
Building and Environment
Received Date: 21 May 2018 Revised Date:
27 July 2018
Accepted Date: 24 August 2018
Please cite this article as: Mousavi ES, Jafarifiroozabadi R, Bayramzadeh S, Joseph A, San D, An observational study of door motion in operating rooms, Building and Environment (2018), doi: 10.1016/ j.buildenv.2018.08.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
An Observational Study of Door Motion in Operating Rooms
2
Ehsan S. Mousavi, Ph.D. 1, Roxana Jafarifiroozabadi, M.Sc. 2, Sara Bayramzadeh, Ph.D.,
3
M.Arch. 2, Anjali Joseph, Ph.D., EDAC 2, 3, and Dee San, MBA, BSH, BSN, RN, CSSBB 4
4
1
5
USA, 29634
6
2
School of Architecture, Clemson University, Clemson, SC, USA, 29634
7
3
Department of Public Health Sciences, Clemson University, Clemson, SC, USA, 29634
8
4
Perioperative Quality & Safety, Medical University of South Carolina, Charleston, SC, USA,
9
29625
M AN U
SC
RI PT
Department of Construction Science and Management, Clemson University, Clemson, SC,
Corresponding Author:
11
Ehsan S. Mousavi, Ph.D., Department of Construction Science and Management, 2-132 Lee
12
Hall, Clemson University, Clemson, SC, USA, 29634, [email protected], +1864-656-7473
13
Fax:+1864-656-0204
EP
15 16 17 18 19 20 21 22 23 24
AC C
14
TE D
10
25 26
1
ACCEPTED MANUSCRIPT
ABSTRACTS
2
Door openings have been shown to increase bacterial counts in the operating room (OR) as a
3
result of air exchange between the OR and adjacent spaces, potentially increasing risks for
4
Surgical Site Infections (SSIs). A deeper understanding of door opening behavior and patterns
5
is necessary to develop interventions that will have sustained impacts. Twenty-eight surgical
6
procedures were recorded and closely watched. Accordingly, duration, intent, and destination of
7
people involved in all door openings were identified and analyzed with respect to operation
8
phase (i.e., pre-incision, incision-to-closure, and post-closure phases). Results suggest that the
9
distribution of door opening duration in the incision-to-closure phase is independent of surgery
M AN U
SC
RI PT
1
type and room layout. The door was opened by someone other than the core surgical staff
11
around 23% of the time. There seems to be a need for improvement in communication and
12
design efficiency to manage traffic through the OR door.
13
Keywords
14
operating room, door opening, surgical site infection, foot traffic
15
TE D
10
1. INTRODUCTION
Airflow in the Operating Room (OR) must be carefully designed to move contaminants away
17
from the surgical site to the less sterile parts of the room along the edges. Studies have
18
confirmed that 80% to 90% of bacterial contaminants in the OR come from the ambient air [1,2]
19
specifically via bacterial shedding by OR occupants [3] and unsterile equipment [4]. ORs are
20
maintained at a positive pressure with adjoining spaces to impede external contaminants from
21
entry [5–7]. However, disturbance in airflow can lead to increased contamination rates [8–10].
22
Frequent door openings and moving bodies in the OR may interrupt the positive pressure inside
23
the room, reducing the effectiveness of the ventilation system and pressurization scheme [8,11].
AC C
EP
16
2
ACCEPTED MANUSCRIPT
The number of OR door openings during surgical procedures can be as high as 37 [12] to 40
2
[13] or even 56 [8] openings per hour with the peak occurring during pre-incision phase [12].
3
Although the frequency of door openings can significantly differ based on the type of surgery
4
[12,13], the factors contributing to the openings remain consistent across surgery types. Several
5
studies have shown that obtaining supplies, information issues (e.g., paperwork),
6
communication (e.g., consulting with other surgical team members), staff breaks, shift changes
7
[12–14] are common reasons for OR door openings. Further, door openings are also known to
8
influence patient safety indirectly via increased chance of distraction [15]. For example, door
9
openings can lead to surgical flow disruptions, which are events with different levels of severity
M AN U
SC
RI PT
1
interrupting staff work flow or the surgical procedure.
11
Similar studies have been conducted in other settings such as clean rooms [16–19]. Although
12
increasing the pressure differential across the door can somewhat mitigate the effect of door
13
swing, traffic transition still allows contamination transport to a positively pressurized room. The
14
positive pressure control method has shown little effectiveness for keeping contaminants out of
15
the room [20–22].
16
There is ample evidence indicating a relationship between increased bacterial level and higher
17
SSI risk in the OR and door motion attributes, such as frequency and duration of door openings
18
and traffic flow upon entering the OR [14,23,24]. However, attributes of the door opening itself
19
and factors associated with it are not closely investigated [25]. This study aims to characterize
20
door motion attributes and traffic patterns in the OR to understand the factors that contribute to
21
door openings from an organizational perspective (i.e., role and behavior of personnel) and an
22
environmental perspective (i.e., location and type of doors). Such understanding can help in
23
reducing unnecessary door openings in the OR, and therefore decreasing bacterial level and
24
SSI risks. Worthy to note that characterizing these risks and their impacts on patient outcome is
25
beyond the scope of this paper.
AC C
EP
TE D
10
3
ACCEPTED MANUSCRIPT
1
2. METHODS
2
2.1.
Design and Setting
An observational method was adopted to study the OR door openings. A convenience sample
4
of 28 surgeries from a major hospital in the South-East region of the United States was
5
collected. The sample included 10 pediatric, three orthopedic surgeries, as well as 15 general
6
adult procedures performed in three different ORs. While all the ORs were equipped with a
7
laminar airflow ventilation system, they differed in their size and overall configuration, which
8
allowed a greater assessment of door openings across different environments. In each of the
9
three ORs under study, there were two doors, one connecting the OR to the corridor (Corridor
M AN U
SC
RI PT
3
Door) and the other connecting the OR to the clean core (Clean Door) (Figure 1).
11
Since door opening events are ephemeral and yet each includes many details such as number
12
and role of personnel who pass through the door, a videography observational method was
13
selected. The videography approach also allowed for playback of the scenes to ensure all the
14
necessary information is captured. All 28 surgeries were simultaneously video recorded using
15
the Observer® XT (version 12.5), an observational analysis software. To maximize visibility to
16
all parts of the OR, four cameras were placed in each corner of the OR. Door openings were
17
observed only inside the ORs and were not extended beyond the boundaries of the room. The
18
surgeries were recorded from the point of patient entry to the OR to exit. Approval for this study
19
was obtained from the institutional review boards of the healthcare system under study as well
20
as the researchers’ institution.
AC C
EP
TE D
10
4
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Figure 1 Operating room layout and position of sterile and corridor doors
1
2.2.
Definitions
Using The Observer® XT (version 12.5), a team coded each door opening event and variables
3
of interest associated with each door opening including duration, type of the door (corridor door
4
or clean door), number of agents passed through the door, and the role of the subjects crossing
5
the door. The subject roles included surgeons, anesthesia personnel, surgical residents,
6
circulating nurses, scrub nurses, and external personnel. External personnel referred to those
7
individuals in the OR that were not a core member of the OR team. External personnel’s
8
behaviors were categorized based on the observations and are presented in Table 2.
9
Additional information such as phase of the surgery was also coded. Phases of surgery included
AC C
EP
TE D
2
10
(1) pre-incision: the time between patient entering the OR and incision to start the surgery, (2)
11
incision-to-closure: the time between the starting incision to when the area under surgery is
12
closed, and (3) post-closure: the time between the closure of the patient’s body and when the
13
patient is wheeled out of the OR.
14
Next, these event-based data were converted into a time-based dataset to determine the status
15
of every agent, as well as the door, in one-second intervals for the duration of the surgery. The 5
ACCEPTED MANUSCRIPT
time-based dataset identified an opening event, duration of the opening, and the user(s) of the
2
door for both corridor and clean doors. Three graduate students were trained to use The
3
Observer® XT software and the coding scheme. The training involved follow-up discussions to
4
calibrate inconsistencies with coding.
5
Table 1. Purpose of door opening by external personnel
RI PT
1
Description of activity
Taking out an instrument, equipment, or other items
Exited the room while taking out an instrument or equipment that was brought in during the surgery (e.g., C-arm)
Bringing in an instrument, equipment, or other items
Entered the room while bringing in an instrument or equipment that was to be used in that particular surgery (e.g., C-arm, IV bag)
Shortcut
Entered the OR from one door and exited the OR from another door without engaging in any other activity
Patient transport/transfer
Entered the room while transporting patient in or out of the OR
M AN U
SC
Type of activity
TE D
Entered the room to help transferring the patient bed to bed
Shift change
Entered and exited the room due to end of start of their working shift
Observing
AC C
Whiteboard activity
Entered the room and made conversations with the personnel working in the OR
EP
Talking
Entered the room and passively observed the procedure or personnel
Entered the room and wrote on the whiteboard
Holding the door open
Opened the door and held it open
Borrowing an item
Entered the room and took an item with no identifiable purpose
Computer activity
Entered the room and worked with a computer
Hand in
Handed in an item without passing the door
6 7
6
ACCEPTED MANUSCRIPT
As a result of a transition from event-based to time-based data, erroneous data points were
2
generated with extremely long opening durations (>50s). The coding team revisited the original
3
videos and manually corrected these data points.MS Excel and IBM SPSS were used to draw
4
descriptive summaries and conduct statistical analyses from the aforementioned dataset. Since
5
the data were not normal, A Kruskal–Wallis test was used to conduct analysis on group
6
comparisons. An α value of 0.05, equivalent to 95% confidence interval, assumed statistical
7
significance. Further, a computer code was developed to delineate the immediate destination of
8
surgical staff upon entry to the OR.
SC
3. RESULTS
M AN U
9
RI PT
1
A total of 28 surgeries with a total time of 65.5 hours were observed and analyzed. Across all
11
surgeries, 1,532 door openings (23 door openings per hour) occurred, among which 361
12
(23.5%) instances were attributed to external personnel. The duration of door openings has a bi-
13
modal distribution with 5s and 27s peaks. The latter was due to the use of automatic button.
14
Sub-distributions for different types of surgeries were statistically similar (p = 0.52), meaning
15
that the door opening duration was independent of the type of surgery. However, the number of
16
door openings per hour varied among surgery type. The time spent for the users to walk through
17
the door was also calculated and compared with the corresponding duration of the door
18
opening. On average, the door was open for four seconds (SD = 3.98) after cleared, roughly
19
40% of an average opening, indicating a considerable amount of time the door was open
20
without being used. Further, results of a Chi-squared analysis showed that the traffic entering
21
the OR had a similar distribution, regardless of the operating room (p = 0.07).
EP
AC C
22
TE D
10
23
7
ACCEPTED MANUSCRIPT
Surgery Type
Surgery Number [count]
Total Duration (SD) [hour]
Ave. Duration [hour]
Number of Openings [count]
Door openings [count/hour]
Ave. Opening Duration (SD) [s]
General
15
36.8 (0.9)
2.45
863
23.5
10.5 (8.3)
Orthopedic
3
11.7 (1.3)
3.92
186
15.8
9.5 (7.3)
Pediatric
10
17.0 (1.4)
1.70
483
28.4
10.1 (7.0)
3.1.
Door opening by phase of surgery
RI PT
2
Table 2 Descriptive Statistics of Door Openings
SC
1
The average duration of door openings varied across the three phases of surgery. For corridor
4
door, the average (M) duration of door openings was highest in the post-closure phase (M =
5
15.83s), 95% CI [13.48, 18.18], followed by pre-incision (M = 11.89), 95% CI [10.83, 12.95] and
6
incision-to-closure phases (M = 10.24s), 95% CI [8.95, 11.52]. The average duration of door
7
openings for clean door across all three phases was (M = 9.01s), 95% CI [8.31, 9.72] for
8
incision-to-closure; (M = 8.93s), 95% CI [8.47, 9.39] for pre-incision and (M = 9.02s), 95% CI
9
[7.93, 10.12] post-closure phases.
TE D
M AN U
3
Corridor door opened 24.7 times per hour in the pre-incision phase, 17 times in post-closure,
11
and six times in incision-to-closure. In contrast, clean door accounted for 15.3 openings per
12
hour in the incision-to-closure phase. The number of clean door openings was similar with 20.3
13
openings per hour in post-closure and 20.2 openings per hour in pre-incision phases. Results of
14
the Kruskal–Wallis analysis showed that distribution of corridor door opening duration is
15
statistically different across three phases (p <0.001). Unlike the corridor door, the clean door did
16
not show any significant differences in the duration of door openings across three phases (p =
17
0.70) (Table 3).
AC C
EP
10
18
8
ACCEPTED MANUSCRIPT
Table 3 Comparison of door opening duration between corridor and clean doors across surgery phases Pre-incision
incision-to-closure
Post-closure
Total
11.89
10.24
15.83
12.28
(10.83~12.95)
(8.95~11.52)
(13.48~18.18)
(11.45~13.11)
9.01
8.93
9.02
9.03
(8.31~9.72)
(8.47~9.39)
(7.93~10.12)
(8.64~9.42)
< 4.0E-5
< 1.2E-3
Corridor door Mean /range 95% CI
/range 95% CI p-value
3
3.2.
< 5.2E-7
< 10.0E-10
M AN U
Clean door Mean
RI PT
Door location
SC
1 2
Door opening by personnel role
Different cluster of users (e.g., anesthesia personnel, circulating nurse) used the door in a
5
similar manner. In fact, no statistical difference was found between the duration of door opening
6
when operated by different groups for the corridor door (p = 0.082). The null hypothesis was not
7
rejected for the clean door (p = 0.053) indicating the relative similarity between the distributions
8
of door opening with respect to door operator.
9
The number of staff simultaneously passing through the door was also analyzed. The duration
10
of corridor door did not change with respect to the number of agents passed through the sterile
11
door (p = 0.225). In fact, regardless of the number of staff passing through the door, the
12
distributions of door opening durations were not statistically different. This was not true for the
13
clean door where the average duration of door opening significantly increased with the number
14
of staff passing through the door (p < 0.001). A closer look revealed that there was no difference
15
between the corridor and clean door opening distributions when only one person passed
16
through the door (p = 0.234) while the difference was significant for higher traffic rates (p <
17
0.001) (Figure 2).
AC C
EP
TE D
4
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
1 2
Figure 2. Corridor and clean door opening distributions
10
ACCEPTED MANUSCRIPT
In addition to the core surgical team members, the external personnel were studied to get an
2
insight into their behaviors. A total of 361 door openings were associated with external
3
personnel. No identity was recognized for nearly one-third of the external agents that used the
4
corridor (41%) and clean (33%) doors throughout the surgery. External personnel who entered
5
the OR through the corridor door mainly observed the OR without direct interactions with
6
surgical staff (44%, n = 158). They were also engaged in talking to surgical staff (23%, n = 78),
7
followed by transferring items such as c-arm (20%, n = 71), borrowing items (7%, n = 24), and
8
patient transfer (5%, n = 17). External personnel opened the door manually 288 times across
9
all surgeries and used the automatic button to open this door 39 times.
SC
3.3.
M AN U
10
RI PT
1
Door opening by Destination
Team members had different sets of destinations, as their responsibilities entailed to follow a
12
particular movement pattern. Such movement patterns are important to study as they affect
13
airflow. The destination was selected solely based on the effect of human body motion on the
14
airflow. Since, wakes created by human movement, diminish after approximately 10 seconds
15
[26], a destination for an agent was defined as the first zone the agent occupied and spent more
16
than 10 seconds after entering the OR. Results showed that upon entering the OR, most
17
common destination for anesthesia personnel (41%) and circulating nurse (30%) was their own
18
workstations. Data also showed that nearly one of every five immediate destination was the
19
surgical table. Anesthesia personnel (28%) and surgical residents (15%) walked to the surgical
20
table immediately after they entered the OR with higher frequencies, compared to surgeons
21
(10%) and nurses (7%). Ultra clean space around the surgical table, transitional zone between
22
the door and the surgical table, and the circulating nurse’s workstation were the most frequent
23
destinations of the surgical staff upon entry (Figure 3).
AC C
EP
TE D
11
11
SC
RI PT
ACCEPTED MANUSCRIPT
M AN U
1
Figure 3. Destination of different agents after entry
3 4
A significant fraction of surgical staff walked towards the surgical table immediately after entry
5
(Figure 4). For example, anesthesia personnel frequently visited the areas around the surgical
6
table upon entry to the OR. This phenomenon could directly perturb the laminar airflow in the
7
ultra-clean zone and potentially increase the risks of airborne migration of pathogens to the
8
vicinity of an open wound.
AC C
EP
TE D
2
12
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
2 3
TE D
1
Figure 4. Heat map of the immediate destination after entry into the operating room
4. DISCUSSION
The aim of this study was to explore functionality of the door openings in the OR due to their
5
influential role on airflow [21,27] and movement patterns of staff and equipment [12]. Excessive
6
door openings can compromise patient safety by distracting staff [15] and disturbing airflow,
7
which increases the risk of contamination [28–30]. The location of doors can be a critical factor
8
in guiding the staff circulation flow in surgical rooms and can be positioned to separate the
9
sterile and circulation zones [31]. The nature of door openings differs between corridor door and
AC C
EP
4
10
clean door. This can be due to various reasons including the accessibility of staff to each of
11
these doors and the type of equipment and supplies provided through each of these doors. For
12
example, corridor door is used for entering patient gurney and larger equipment. Results
13
ACCEPTED MANUSCRIPT
showed that orthopedic surgeries had the highest average duration of openings compared to
2
other surgeries, which can be explained by the type of equipment (e.g., C-arm) necessary for
3
this type of surgery requiring the corridor door to remain open for a longer period [32].
4
The traffic entering the OR had a similar distribution, regardless of the operating room. This
5
could be due to similarities in procedure of activities, dictated by standard protocols, regardless
6
of the OR. Although the number of people crossing the door did not change the duration of
7
openings significantly, surgery phases did change the duration of the door opening. Door
8
opening durations were shorter during the incision-to-closure phase with the patient cut open
9
suggesting that the surgical staff recognized the importance of asepsis during this phase. The
M AN U
SC
RI PT
1
use of automatic button lengthened the total hold-open time of the door, and this button was
11
used more frequently during the pre- and post-closure phases. Although the surgery type was
12
not a significant factor influencing door opening pattern, the lower number of door openings in
13
the Orthopedic surgeries might be due to a different set of protocols in regards with such
14
surgeries. For example, the corridor door is often locked when a transplant is in brought in the
15
OR in a case of orthopedic surgery.
16
There were differences in the patterns of door opening between the clean and corridor doors.
17
Given that the clean door is primarily used to retrieve supplies or materials not present in the
18
OR, the frequent clean core door opening and the exchange of items between external
19
personnel and core surgical team members can be due to lack of storage in the OR or
20
preference card issues [12]. Also, quantity and quality of conversation could be improved by
21
interventions that reduce the need for door openings [12,30]. These behaviors can have
22
implications for organizational factors regarding scheduling and cultural elements of the
23
healthcare systems. From the physical environment perspective, some of the door openings
24
related to the use of OR as a shortcut can be further investigated to find design solutions that
25
accommodate more efficient circulation in the operating suite, and as a result, prevent the need
26
for using the OR as a shortcut.
AC C
EP
TE D
10
14
ACCEPTED MANUSCRIPT
1
5. LIMITATIONS Agents were defined based on their role in the surgery and included anesthesia personnel,
3
scrub nurse, circulating nurse, surgical residents, and surgeons. However, the role and number
4
of agents passed through the door were missing for 361 door opening instances. Only those
5
particular door openings were double coded to address the missing information. In the second
6
observation, additional variables including the unknown external personnel, type or door
7
(Automatic vs. Manual), and the activity of the agent were collected. This information was not
8
collected for all openings. Moreover, the role and purpose of door opening remained unclear for
9
126 cases even after the second observation. As stated earlier, only three orthopedic surgeries
10
were observed in this study. This number may be small to make a strong conclusion. However,
11
the number of door opening incidents (186) in orthopedic procedures is sufficiently large to
12
exhibit clear trends for different surgical procedures
SC
M AN U
6. CONCLUSIONS
TE D
13
RI PT
2
Door openings are complex phenomena with an interdependency on both design and
15
organizational factors. Surgery type and room type did not change the number and duration of
16
door openings. Thus, door motion behaviors could be modeled with a potential of generalizing
17
the results for a typical OR, regardless of the room design and surgical procedure. However,
18
door openings significantly differ across surgery phases where the incision-to-closure phase has
19
the fewest openings. Further, the location of the door (i.e., corridor or clean room) was found to
20
alter the frequency and duration of door openings [33]. Future research should focus on how
21
the location of the door relative to internal areas can influence traffic circulation flow and
22
disruptions within the OR. Although this study does not investigate the increased risk of
23
contamination, it can serve as a foundation for further research on the relationship between
24
airborne contaminants and door openings.
AC C
EP
14
15
ACCEPTED MANUSCRIPT
1
Three main aspects of this study could impact the building environment as well as the human-
2
building interactions: •
3
Doors were commonly used by personnel who were not a member of the surgical team to provide supplies or having conversations related or unrelated to the surgery. Providing
5
and improving communication technologies, storage in the OR, preference cards,
6
efficient circulation outside the OR are some of the strategies that can help reducing the
7
door openings.
SC
•
8
RI PT
4
There was a significant gap between the hold-open duration, and the time spent for the user to pass through the door. Excess durations could be minimized by using smart
10
doors where the automatic button communicates with a sensor and closes the door
11
readily after it is cleared. •
12
M AN U
9
The surgical table was an immediate destination for numerous door opening events. Thus, staff could be advised to spend some time in the OR periphery before walking
14
towards the surgical table. Further research is needed to investigate the potential
15
consequences of this phenomenon and strategies to control them.
TE D
13
Acknowledgement
17
The authors would like to thank the RIPCHD.OR Study Group for their contribution to the work
18
supporting the effort in this study. This work was supported by the Agency for Healthcare
19
Research and Quality [grant number P30HS0O24380, 2015].
20
REFERENCES
21
[1]
22 23
F.H. Howorth, Prevention of airborne infection in operating rooms, J. Med. Eng. Technol.
11 (1987) 263–266. [2]
24 25
AC C
EP
16
J.A. Wagner, K.J. Schreiber, R. Cohen, Improving operating room contamination control, ASHRAE J. 56 (2014) 18–27.
[3]
B. Zhao, C. Yang, C. Chen, C. Feng, X. Yang, L. Sun, W. Gong, L. Yu, How Many
16
ACCEPTED MANUSCRIPT
1
Airborne Particles Emitted from a Nurse will Reach the Breathing Zone/Body Surface of
2
the Patient in ISO Class-5 Single-Bed Hospital Protective Environments?—A Numerical
3
Analysis, Aerosol Sci. Technol. 43 (2009) 990–1005. doi:10.1080/02786820903107925.
4
[4]
D.J. Dalstrom, I. Venkatarayappa, A.L. Manternach, M.S. Palcic, B.A. Heyse, M.J. Prayson, Time-Dependent Contamination of Opened Sterile Operating-Room Trays, J.
6
Bone Jt. Surgery-American Vol. 90 (2008) 1022–1025. doi:10.2106/JBJS.G.00689.
7
[5]
RI PT
5
S. Ridgeway, J. Wilson, A. Charlet, G. Kafatos, A. Pearson, R. Coello, Infection of the
8
surgical site after arthroplasty of the hip, J. Bone Jt. Surg. - Br. Vol. 87–B (2005) 844–
9
850. doi:10.1302/0301-620X.87B6.15121. [6]
L. Neumayer, P. Hosokawa, K. Itani, M. El-Tamer, W.G. Henderson, S.F. Khuri,
SC
10
Multivariable Predictors of Postoperative Surgical Site Infection after General and
12
Vascular Surgery: Results from the Patient Safety in Surgery Study, J. Am. Coll. Surg.
13
204 (2007) 1178–1187. doi:10.1016/j.jamcollsurg.2007.03.022.
14
[7]
M AN U
11
G. Birgand, G. Toupet, S. Rukly, G. Antoniotti, M.N. Deschamps, D. Lepelletier, C.
15
Pornet, J.B. Stern, Y.M. Vandamme, N. Van Der Mee-Marquet, J.F. Timsit, J.C. Lucet, Air
16
contamination for predicting wound contamination in clean surgery: A large multicenter
17
study, Am. J. Infect. Control. 43 (2015) 516–521. doi:10.1016/j.ajic.2015.01.026.
18
[8]
S. Scaltriti, S. Cencetti, S. Rovesti, I. Marchesi, A. Bargellini, P. Borella, Risk factors for particulate and microbial contamination of air in operating theatres, J. Hosp. Infect. 66
20
(2007) 320–326. doi:10.1016/j.jhin.2007.05.019. [9]
22 23
S. Dharan, D. Pittet, Environmental controls in operating theatres, J. Hosp. Infect. 51 (2002) 79–84. doi:10.1053/jhin.2002.1217.
[10]
R.S. Young, D.J. O’Regan, Cardiac surgical theatre traffic: time for traffic calming
EP
21
TE D
19
24
measures?, Interact. Cardiovasc. Thorac. Surg. 10 (2010) 526–529.
25
doi:10.1510/icvts.2009.227116. [11]
27
Yinnon, Incidence and risk factors for surgical infection after total knee replacement,
28 29
Scand. J. Infect. Dis. 39 (2007) 890–895. doi:10.1080/00365540701387056.
[12]
30
R.J. Lynch, M.J. Englesbe, L. Sturm, A. Bitar, K. Budhiraj, S. Kolla, Y. Polyachenko, M.G.
Duck, D.A. Campbell, Measurement of foot traffic in the operating room: implications for
31 32
Y. Babkin, D. Raveh, M. Lifschitz, M. Itzchaki, Y. Wiener-Well, P. Kopuit, Z. Jerassy, A.M.
AC C
26
infection control., Am. J. Med. Qual. 24 (2008) 45–52. doi:10.1177/1062860608326419. [13]
S.N. Parikh, S.S. Grice, B.M. Schnell, S.R. Salisbury, Operating Room Traffic: Is There
33
Any Role of Monitoring it?, J. Pediatr. Orthop. 30 (2010) 617–623.
34
doi:10.1097/BPO.0b013e3181e4f3be.
17
ACCEPTED MANUSCRIPT
1
[14]
A.E. Andersson, I. Bergh, J. Karlsson, B.I. Eriksson, K. Nilsson, Traffic flow in the
2
operating room: An explorative and descriptive study on air quality during orthopedic
3
trauma implant surgery, Am. J. Infect. Control. 40 (2012) 750–755.
4
doi:10.1016/j.ajic.2011.09.015. [15]
A.N. Healey, N. Sevdalis, C.A. Vincent, Measuring intra-operative interference from
RI PT
5 6
distraction and interruption observed in the operating theatre, Ergonomics. 49 (2006)
7
589–604. doi:10.1080/00140130600568899. [16]
10
Trans., 1993: pp. 223–229. [17]
11 12
American Soc. Heat. Refrig. Airconditioning Eng. 36 (1994) 36–40. [18]
13 14
D.T. Hitchings, Laboratory Space Pressurization Control Systems, ASHRAE Journal-
SC
9
O. Ahmed, J.W. Mitchell, S.A. Klein, Dynamics of laboratory pressurization, in: ASHRAE
D.E. Kiel, D.L. Wilson, Combining door swing pumping with density driven flow, in:
M AN U
8
ASHRAE Trans., 1989: pp. 590–599. [19]
C. Chen, B. Zhao, X. Yang, Y. Li, Role of two-way airflow owing to temperature difference
15
in severe acute respiratory syndrome transmission: revisiting the largest nosocomial
16
severe acute respiratory syndrome outbreak in Hong Kong., J. R. Soc. Interface. 8 (2011)
17
699–710. doi:10.1098/rsif.2010.0486.
18
[20]
S.C. Mears, R. Blanding, S.M. Belkoff, Door Opening Affects Operating Room Pressure During Joint Arthroplasty, Orthopedics. 38 (2015) e991–e994. doi:10.3928/01477447-
20
20151020-07.
21
[21]
TE D
19
E.B. Smith, I.J. Raphael, M.G. Maltenfort, S. Honsawek, K. Dolan, E.A. Younkins, The effect of laminar air flow and door openings on operating room contamination, J.
23
Arthroplasty. 28 (2013) 1482–1485. doi:10.1016/j.arth.2013.06.012. [22]
25 26
CHALMERS UNIVERSITY OF TECHNOLOGY Göteborg, 2010. doi:D. [23]
27
J. Infect. Control. 39 (2011) 91–97. doi:10.1016/j.ajic.2010.05.025.
[24]
30
A. Hathway, I. Papakonstantis, A. Bruce-Konuah, W. Brevis, Experimental and modelling
investigations of air exchange and infection transfer due to hinged-door motion in office
31 32
N.J. Adams, D.L. Johnson, R.A. Lynch, The effect of pressure differential and care provider movement on airborne infectious isolation room containment effectiveness, Am.
28 29
Gustavsson N., Dispersion of small particles into operating rooms due to openings,
AC C
24
EP
22
and hospital settings, Int. J. Vent. (2015). [25]
A. Joseph, S. Bayramzadeh, Z. Zamani, B. Rostenberg, Safety, Performance, and
33
Satisfaction Outcomes in the Operating Room: A Literature Review, (n.d.).
34
doi:10.1177/1937586717705107.
18
ACCEPTED MANUSCRIPT
1
[26]
Y. Tao, K. Inthavong, J. Tu, A numerical investigation of wind environment around a
2
walking human body, J. Wind Eng. Ind. Aerodyn. 168 (2017) 9–19.
3
doi:10.1016/j.jweia.2017.05.003.
4
[27]
A.L. Hewlett, S.E. Whitney, S.G. Gibbs, P.W. Smith, H.J. Viljoen, Mathematical modeling of pathogen trajectory in a patient care environment., Infect. Control Hosp. Epidemiol. 34
6
(2013) 1181–8. doi:10.1086/673451.
7
[28]
RI PT
5
J.M. Villafruela, J.F. San José, F. Castro, A. Zarzuelo, Airflow patterns through a sliding
8
door during opening and foot traffic in operating rooms, Build. Environ. 109 (2016) 190–
9
198. doi:10.1016/j.buildenv.2016.09.025. [29]
E.S. Mousavi, K.R. Grosskopf, Airflow patterns due to door motion and pressurization in
SC
10
hospital isolation rooms, Sci. Technol. Built Environ. 22 (2016) 379–384.
12
doi:10.1080/23744731.2016.1155959.
13
[30]
M AN U
11
J. Teter, I. Guajardo, T. Al-Rammah, G. Rosson, T.M. Perl, M. Manahan, Assessment of
14
operating room airflow using air particle counts and direct observation of door openings,
15
Am. J. Infect. Control. 45 (2017) 477–482. doi:10.1016/j.ajic.2016.12.018.
16
[31]
B. Rostenberg, P.R. Barach, Design of cardiovascular operating rooms for tomorrow’s
17
technology and clinical practice - Part 2, Prog. Pediatr. Cardiol. 33 (2012) 57–65.
18
doi:10.1016/j.ppedcard.2011.12.010. [32]
S. Sadrizadeh, A. Tammelin, P. Ekolind, S. Holmberg, Particuology Influence of staff
TE D
19 20
number and internal constellation on surgical site infection in an operating room,
21
Particuology. 13 (2014) 42–51. doi:10.1016/j.partic.2013.10.006.
24
K. Grosskopf, E. Mousavi, Bioaerosols in health-care environments, ASHRAE J. 56 (2014) 22–31.
EP
23
[33]
AC C
22
19
ACCEPTED MANUSCRIPT
Highlights:
EP
TE D
M AN U
SC
RI PT
Doors are operated in the same manner regardless of door type, location, and user. OR door is frequently operated by personnel who are not a member of surgical team. The Automatic button resulted in lengthier and unnecessary door openings. Surgical table is the immediate destination in 25% of entries into the OR.
AC C
• • • •
S0360-1323(18)30526-2
DOI:
10.1016/j.buildenv.2018.08.052
Reference:
BAE 5665
To appear in:
Building and Environment
Received Date: 21 May 2018 Revised Date:
27 July 2018
Accepted Date: 24 August 2018
Please cite this article as: Mousavi ES, Jafarifiroozabadi R, Bayramzadeh S, Joseph A, San D, An observational study of door motion in operating rooms, Building and Environment (2018), doi: 10.1016/ j.buildenv.2018.08.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
An Observational Study of Door Motion in Operating Rooms
2
Ehsan S. Mousavi, Ph.D. 1, Roxana Jafarifiroozabadi, M.Sc. 2, Sara Bayramzadeh, Ph.D.,
3
M.Arch. 2, Anjali Joseph, Ph.D., EDAC 2, 3, and Dee San, MBA, BSH, BSN, RN, CSSBB 4
4
1
5
USA, 29634
6
2
School of Architecture, Clemson University, Clemson, SC, USA, 29634
7
3
Department of Public Health Sciences, Clemson University, Clemson, SC, USA, 29634
8
4
Perioperative Quality & Safety, Medical University of South Carolina, Charleston, SC, USA,
9
29625
M AN U
SC
RI PT
Department of Construction Science and Management, Clemson University, Clemson, SC,
Corresponding Author:
11
Ehsan S. Mousavi, Ph.D., Department of Construction Science and Management, 2-132 Lee
12
Hall, Clemson University, Clemson, SC, USA, 29634, [email protected], +1864-656-7473
13
Fax:+1864-656-0204
EP
15 16 17 18 19 20 21 22 23 24
AC C
14
TE D
10
25 26
1
ACCEPTED MANUSCRIPT
ABSTRACTS
2
Door openings have been shown to increase bacterial counts in the operating room (OR) as a
3
result of air exchange between the OR and adjacent spaces, potentially increasing risks for
4
Surgical Site Infections (SSIs). A deeper understanding of door opening behavior and patterns
5
is necessary to develop interventions that will have sustained impacts. Twenty-eight surgical
6
procedures were recorded and closely watched. Accordingly, duration, intent, and destination of
7
people involved in all door openings were identified and analyzed with respect to operation
8
phase (i.e., pre-incision, incision-to-closure, and post-closure phases). Results suggest that the
9
distribution of door opening duration in the incision-to-closure phase is independent of surgery
M AN U
SC
RI PT
1
type and room layout. The door was opened by someone other than the core surgical staff
11
around 23% of the time. There seems to be a need for improvement in communication and
12
design efficiency to manage traffic through the OR door.
13
Keywords
14
operating room, door opening, surgical site infection, foot traffic
15
TE D
10
1. INTRODUCTION
Airflow in the Operating Room (OR) must be carefully designed to move contaminants away
17
from the surgical site to the less sterile parts of the room along the edges. Studies have
18
confirmed that 80% to 90% of bacterial contaminants in the OR come from the ambient air [1,2]
19
specifically via bacterial shedding by OR occupants [3] and unsterile equipment [4]. ORs are
20
maintained at a positive pressure with adjoining spaces to impede external contaminants from
21
entry [5–7]. However, disturbance in airflow can lead to increased contamination rates [8–10].
22
Frequent door openings and moving bodies in the OR may interrupt the positive pressure inside
23
the room, reducing the effectiveness of the ventilation system and pressurization scheme [8,11].
AC C
EP
16
2
ACCEPTED MANUSCRIPT
The number of OR door openings during surgical procedures can be as high as 37 [12] to 40
2
[13] or even 56 [8] openings per hour with the peak occurring during pre-incision phase [12].
3
Although the frequency of door openings can significantly differ based on the type of surgery
4
[12,13], the factors contributing to the openings remain consistent across surgery types. Several
5
studies have shown that obtaining supplies, information issues (e.g., paperwork),
6
communication (e.g., consulting with other surgical team members), staff breaks, shift changes
7
[12–14] are common reasons for OR door openings. Further, door openings are also known to
8
influence patient safety indirectly via increased chance of distraction [15]. For example, door
9
openings can lead to surgical flow disruptions, which are events with different levels of severity
M AN U
SC
RI PT
1
interrupting staff work flow or the surgical procedure.
11
Similar studies have been conducted in other settings such as clean rooms [16–19]. Although
12
increasing the pressure differential across the door can somewhat mitigate the effect of door
13
swing, traffic transition still allows contamination transport to a positively pressurized room. The
14
positive pressure control method has shown little effectiveness for keeping contaminants out of
15
the room [20–22].
16
There is ample evidence indicating a relationship between increased bacterial level and higher
17
SSI risk in the OR and door motion attributes, such as frequency and duration of door openings
18
and traffic flow upon entering the OR [14,23,24]. However, attributes of the door opening itself
19
and factors associated with it are not closely investigated [25]. This study aims to characterize
20
door motion attributes and traffic patterns in the OR to understand the factors that contribute to
21
door openings from an organizational perspective (i.e., role and behavior of personnel) and an
22
environmental perspective (i.e., location and type of doors). Such understanding can help in
23
reducing unnecessary door openings in the OR, and therefore decreasing bacterial level and
24
SSI risks. Worthy to note that characterizing these risks and their impacts on patient outcome is
25
beyond the scope of this paper.
AC C
EP
TE D
10
3
ACCEPTED MANUSCRIPT
1
2. METHODS
2
2.1.
Design and Setting
An observational method was adopted to study the OR door openings. A convenience sample
4
of 28 surgeries from a major hospital in the South-East region of the United States was
5
collected. The sample included 10 pediatric, three orthopedic surgeries, as well as 15 general
6
adult procedures performed in three different ORs. While all the ORs were equipped with a
7
laminar airflow ventilation system, they differed in their size and overall configuration, which
8
allowed a greater assessment of door openings across different environments. In each of the
9
three ORs under study, there were two doors, one connecting the OR to the corridor (Corridor
M AN U
SC
RI PT
3
Door) and the other connecting the OR to the clean core (Clean Door) (Figure 1).
11
Since door opening events are ephemeral and yet each includes many details such as number
12
and role of personnel who pass through the door, a videography observational method was
13
selected. The videography approach also allowed for playback of the scenes to ensure all the
14
necessary information is captured. All 28 surgeries were simultaneously video recorded using
15
the Observer® XT (version 12.5), an observational analysis software. To maximize visibility to
16
all parts of the OR, four cameras were placed in each corner of the OR. Door openings were
17
observed only inside the ORs and were not extended beyond the boundaries of the room. The
18
surgeries were recorded from the point of patient entry to the OR to exit. Approval for this study
19
was obtained from the institutional review boards of the healthcare system under study as well
20
as the researchers’ institution.
AC C
EP
TE D
10
4
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Figure 1 Operating room layout and position of sterile and corridor doors
1
2.2.
Definitions
Using The Observer® XT (version 12.5), a team coded each door opening event and variables
3
of interest associated with each door opening including duration, type of the door (corridor door
4
or clean door), number of agents passed through the door, and the role of the subjects crossing
5
the door. The subject roles included surgeons, anesthesia personnel, surgical residents,
6
circulating nurses, scrub nurses, and external personnel. External personnel referred to those
7
individuals in the OR that were not a core member of the OR team. External personnel’s
8
behaviors were categorized based on the observations and are presented in Table 2.
9
Additional information such as phase of the surgery was also coded. Phases of surgery included
AC C
EP
TE D
2
10
(1) pre-incision: the time between patient entering the OR and incision to start the surgery, (2)
11
incision-to-closure: the time between the starting incision to when the area under surgery is
12
closed, and (3) post-closure: the time between the closure of the patient’s body and when the
13
patient is wheeled out of the OR.
14
Next, these event-based data were converted into a time-based dataset to determine the status
15
of every agent, as well as the door, in one-second intervals for the duration of the surgery. The 5
ACCEPTED MANUSCRIPT
time-based dataset identified an opening event, duration of the opening, and the user(s) of the
2
door for both corridor and clean doors. Three graduate students were trained to use The
3
Observer® XT software and the coding scheme. The training involved follow-up discussions to
4
calibrate inconsistencies with coding.
5
Table 1. Purpose of door opening by external personnel
RI PT
1
Description of activity
Taking out an instrument, equipment, or other items
Exited the room while taking out an instrument or equipment that was brought in during the surgery (e.g., C-arm)
Bringing in an instrument, equipment, or other items
Entered the room while bringing in an instrument or equipment that was to be used in that particular surgery (e.g., C-arm, IV bag)
Shortcut
Entered the OR from one door and exited the OR from another door without engaging in any other activity
Patient transport/transfer
Entered the room while transporting patient in or out of the OR
M AN U
SC
Type of activity
TE D
Entered the room to help transferring the patient bed to bed
Shift change
Entered and exited the room due to end of start of their working shift
Observing
AC C
Whiteboard activity
Entered the room and made conversations with the personnel working in the OR
EP
Talking
Entered the room and passively observed the procedure or personnel
Entered the room and wrote on the whiteboard
Holding the door open
Opened the door and held it open
Borrowing an item
Entered the room and took an item with no identifiable purpose
Computer activity
Entered the room and worked with a computer
Hand in
Handed in an item without passing the door
6 7
6
ACCEPTED MANUSCRIPT
As a result of a transition from event-based to time-based data, erroneous data points were
2
generated with extremely long opening durations (>50s). The coding team revisited the original
3
videos and manually corrected these data points.MS Excel and IBM SPSS were used to draw
4
descriptive summaries and conduct statistical analyses from the aforementioned dataset. Since
5
the data were not normal, A Kruskal–Wallis test was used to conduct analysis on group
6
comparisons. An α value of 0.05, equivalent to 95% confidence interval, assumed statistical
7
significance. Further, a computer code was developed to delineate the immediate destination of
8
surgical staff upon entry to the OR.
SC
3. RESULTS
M AN U
9
RI PT
1
A total of 28 surgeries with a total time of 65.5 hours were observed and analyzed. Across all
11
surgeries, 1,532 door openings (23 door openings per hour) occurred, among which 361
12
(23.5%) instances were attributed to external personnel. The duration of door openings has a bi-
13
modal distribution with 5s and 27s peaks. The latter was due to the use of automatic button.
14
Sub-distributions for different types of surgeries were statistically similar (p = 0.52), meaning
15
that the door opening duration was independent of the type of surgery. However, the number of
16
door openings per hour varied among surgery type. The time spent for the users to walk through
17
the door was also calculated and compared with the corresponding duration of the door
18
opening. On average, the door was open for four seconds (SD = 3.98) after cleared, roughly
19
40% of an average opening, indicating a considerable amount of time the door was open
20
without being used. Further, results of a Chi-squared analysis showed that the traffic entering
21
the OR had a similar distribution, regardless of the operating room (p = 0.07).
EP
AC C
22
TE D
10
23
7
ACCEPTED MANUSCRIPT
Surgery Type
Surgery Number [count]
Total Duration (SD) [hour]
Ave. Duration [hour]
Number of Openings [count]
Door openings [count/hour]
Ave. Opening Duration (SD) [s]
General
15
36.8 (0.9)
2.45
863
23.5
10.5 (8.3)
Orthopedic
3
11.7 (1.3)
3.92
186
15.8
9.5 (7.3)
Pediatric
10
17.0 (1.4)
1.70
483
28.4
10.1 (7.0)
3.1.
Door opening by phase of surgery
RI PT
2
Table 2 Descriptive Statistics of Door Openings
SC
1
The average duration of door openings varied across the three phases of surgery. For corridor
4
door, the average (M) duration of door openings was highest in the post-closure phase (M =
5
15.83s), 95% CI [13.48, 18.18], followed by pre-incision (M = 11.89), 95% CI [10.83, 12.95] and
6
incision-to-closure phases (M = 10.24s), 95% CI [8.95, 11.52]. The average duration of door
7
openings for clean door across all three phases was (M = 9.01s), 95% CI [8.31, 9.72] for
8
incision-to-closure; (M = 8.93s), 95% CI [8.47, 9.39] for pre-incision and (M = 9.02s), 95% CI
9
[7.93, 10.12] post-closure phases.
TE D
M AN U
3
Corridor door opened 24.7 times per hour in the pre-incision phase, 17 times in post-closure,
11
and six times in incision-to-closure. In contrast, clean door accounted for 15.3 openings per
12
hour in the incision-to-closure phase. The number of clean door openings was similar with 20.3
13
openings per hour in post-closure and 20.2 openings per hour in pre-incision phases. Results of
14
the Kruskal–Wallis analysis showed that distribution of corridor door opening duration is
15
statistically different across three phases (p <0.001). Unlike the corridor door, the clean door did
16
not show any significant differences in the duration of door openings across three phases (p =
17
0.70) (Table 3).
AC C
EP
10
18
8
ACCEPTED MANUSCRIPT
Table 3 Comparison of door opening duration between corridor and clean doors across surgery phases Pre-incision
incision-to-closure
Post-closure
Total
11.89
10.24
15.83
12.28
(10.83~12.95)
(8.95~11.52)
(13.48~18.18)
(11.45~13.11)
9.01
8.93
9.02
9.03
(8.31~9.72)
(8.47~9.39)
(7.93~10.12)
(8.64~9.42)
< 4.0E-5
< 1.2E-3
Corridor door Mean /range 95% CI
/range 95% CI p-value
3
3.2.
< 5.2E-7
< 10.0E-10
M AN U
Clean door Mean
RI PT
Door location
SC
1 2
Door opening by personnel role
Different cluster of users (e.g., anesthesia personnel, circulating nurse) used the door in a
5
similar manner. In fact, no statistical difference was found between the duration of door opening
6
when operated by different groups for the corridor door (p = 0.082). The null hypothesis was not
7
rejected for the clean door (p = 0.053) indicating the relative similarity between the distributions
8
of door opening with respect to door operator.
9
The number of staff simultaneously passing through the door was also analyzed. The duration
10
of corridor door did not change with respect to the number of agents passed through the sterile
11
door (p = 0.225). In fact, regardless of the number of staff passing through the door, the
12
distributions of door opening durations were not statistically different. This was not true for the
13
clean door where the average duration of door opening significantly increased with the number
14
of staff passing through the door (p < 0.001). A closer look revealed that there was no difference
15
between the corridor and clean door opening distributions when only one person passed
16
through the door (p = 0.234) while the difference was significant for higher traffic rates (p <
17
0.001) (Figure 2).
AC C
EP
TE D
4
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
1 2
Figure 2. Corridor and clean door opening distributions
10
ACCEPTED MANUSCRIPT
In addition to the core surgical team members, the external personnel were studied to get an
2
insight into their behaviors. A total of 361 door openings were associated with external
3
personnel. No identity was recognized for nearly one-third of the external agents that used the
4
corridor (41%) and clean (33%) doors throughout the surgery. External personnel who entered
5
the OR through the corridor door mainly observed the OR without direct interactions with
6
surgical staff (44%, n = 158). They were also engaged in talking to surgical staff (23%, n = 78),
7
followed by transferring items such as c-arm (20%, n = 71), borrowing items (7%, n = 24), and
8
patient transfer (5%, n = 17). External personnel opened the door manually 288 times across
9
all surgeries and used the automatic button to open this door 39 times.
SC
3.3.
M AN U
10
RI PT
1
Door opening by Destination
Team members had different sets of destinations, as their responsibilities entailed to follow a
12
particular movement pattern. Such movement patterns are important to study as they affect
13
airflow. The destination was selected solely based on the effect of human body motion on the
14
airflow. Since, wakes created by human movement, diminish after approximately 10 seconds
15
[26], a destination for an agent was defined as the first zone the agent occupied and spent more
16
than 10 seconds after entering the OR. Results showed that upon entering the OR, most
17
common destination for anesthesia personnel (41%) and circulating nurse (30%) was their own
18
workstations. Data also showed that nearly one of every five immediate destination was the
19
surgical table. Anesthesia personnel (28%) and surgical residents (15%) walked to the surgical
20
table immediately after they entered the OR with higher frequencies, compared to surgeons
21
(10%) and nurses (7%). Ultra clean space around the surgical table, transitional zone between
22
the door and the surgical table, and the circulating nurse’s workstation were the most frequent
23
destinations of the surgical staff upon entry (Figure 3).
AC C
EP
TE D
11
11
SC
RI PT
ACCEPTED MANUSCRIPT
M AN U
1
Figure 3. Destination of different agents after entry
3 4
A significant fraction of surgical staff walked towards the surgical table immediately after entry
5
(Figure 4). For example, anesthesia personnel frequently visited the areas around the surgical
6
table upon entry to the OR. This phenomenon could directly perturb the laminar airflow in the
7
ultra-clean zone and potentially increase the risks of airborne migration of pathogens to the
8
vicinity of an open wound.
AC C
EP
TE D
2
12
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
2 3
TE D
1
Figure 4. Heat map of the immediate destination after entry into the operating room
4. DISCUSSION
The aim of this study was to explore functionality of the door openings in the OR due to their
5
influential role on airflow [21,27] and movement patterns of staff and equipment [12]. Excessive
6
door openings can compromise patient safety by distracting staff [15] and disturbing airflow,
7
which increases the risk of contamination [28–30]. The location of doors can be a critical factor
8
in guiding the staff circulation flow in surgical rooms and can be positioned to separate the
9
sterile and circulation zones [31]. The nature of door openings differs between corridor door and
AC C
EP
4
10
clean door. This can be due to various reasons including the accessibility of staff to each of
11
these doors and the type of equipment and supplies provided through each of these doors. For
12
example, corridor door is used for entering patient gurney and larger equipment. Results
13
ACCEPTED MANUSCRIPT
showed that orthopedic surgeries had the highest average duration of openings compared to
2
other surgeries, which can be explained by the type of equipment (e.g., C-arm) necessary for
3
this type of surgery requiring the corridor door to remain open for a longer period [32].
4
The traffic entering the OR had a similar distribution, regardless of the operating room. This
5
could be due to similarities in procedure of activities, dictated by standard protocols, regardless
6
of the OR. Although the number of people crossing the door did not change the duration of
7
openings significantly, surgery phases did change the duration of the door opening. Door
8
opening durations were shorter during the incision-to-closure phase with the patient cut open
9
suggesting that the surgical staff recognized the importance of asepsis during this phase. The
M AN U
SC
RI PT
1
use of automatic button lengthened the total hold-open time of the door, and this button was
11
used more frequently during the pre- and post-closure phases. Although the surgery type was
12
not a significant factor influencing door opening pattern, the lower number of door openings in
13
the Orthopedic surgeries might be due to a different set of protocols in regards with such
14
surgeries. For example, the corridor door is often locked when a transplant is in brought in the
15
OR in a case of orthopedic surgery.
16
There were differences in the patterns of door opening between the clean and corridor doors.
17
Given that the clean door is primarily used to retrieve supplies or materials not present in the
18
OR, the frequent clean core door opening and the exchange of items between external
19
personnel and core surgical team members can be due to lack of storage in the OR or
20
preference card issues [12]. Also, quantity and quality of conversation could be improved by
21
interventions that reduce the need for door openings [12,30]. These behaviors can have
22
implications for organizational factors regarding scheduling and cultural elements of the
23
healthcare systems. From the physical environment perspective, some of the door openings
24
related to the use of OR as a shortcut can be further investigated to find design solutions that
25
accommodate more efficient circulation in the operating suite, and as a result, prevent the need
26
for using the OR as a shortcut.
AC C
EP
TE D
10
14
ACCEPTED MANUSCRIPT
1
5. LIMITATIONS Agents were defined based on their role in the surgery and included anesthesia personnel,
3
scrub nurse, circulating nurse, surgical residents, and surgeons. However, the role and number
4
of agents passed through the door were missing for 361 door opening instances. Only those
5
particular door openings were double coded to address the missing information. In the second
6
observation, additional variables including the unknown external personnel, type or door
7
(Automatic vs. Manual), and the activity of the agent were collected. This information was not
8
collected for all openings. Moreover, the role and purpose of door opening remained unclear for
9
126 cases even after the second observation. As stated earlier, only three orthopedic surgeries
10
were observed in this study. This number may be small to make a strong conclusion. However,
11
the number of door opening incidents (186) in orthopedic procedures is sufficiently large to
12
exhibit clear trends for different surgical procedures
SC
M AN U
6. CONCLUSIONS
TE D
13
RI PT
2
Door openings are complex phenomena with an interdependency on both design and
15
organizational factors. Surgery type and room type did not change the number and duration of
16
door openings. Thus, door motion behaviors could be modeled with a potential of generalizing
17
the results for a typical OR, regardless of the room design and surgical procedure. However,
18
door openings significantly differ across surgery phases where the incision-to-closure phase has
19
the fewest openings. Further, the location of the door (i.e., corridor or clean room) was found to
20
alter the frequency and duration of door openings [33]. Future research should focus on how
21
the location of the door relative to internal areas can influence traffic circulation flow and
22
disruptions within the OR. Although this study does not investigate the increased risk of
23
contamination, it can serve as a foundation for further research on the relationship between
24
airborne contaminants and door openings.
AC C
EP
14
15
ACCEPTED MANUSCRIPT
1
Three main aspects of this study could impact the building environment as well as the human-
2
building interactions: •
3
Doors were commonly used by personnel who were not a member of the surgical team to provide supplies or having conversations related or unrelated to the surgery. Providing
5
and improving communication technologies, storage in the OR, preference cards,
6
efficient circulation outside the OR are some of the strategies that can help reducing the
7
door openings.
SC
•
8
RI PT
4
There was a significant gap between the hold-open duration, and the time spent for the user to pass through the door. Excess durations could be minimized by using smart
10
doors where the automatic button communicates with a sensor and closes the door
11
readily after it is cleared. •
12
M AN U
9
The surgical table was an immediate destination for numerous door opening events. Thus, staff could be advised to spend some time in the OR periphery before walking
14
towards the surgical table. Further research is needed to investigate the potential
15
consequences of this phenomenon and strategies to control them.
TE D
13
Acknowledgement
17
The authors would like to thank the RIPCHD.OR Study Group for their contribution to the work
18
supporting the effort in this study. This work was supported by the Agency for Healthcare
19
Research and Quality [grant number P30HS0O24380, 2015].
20
REFERENCES
21
[1]
22 23
F.H. Howorth, Prevention of airborne infection in operating rooms, J. Med. Eng. Technol.
11 (1987) 263–266. [2]
24 25
AC C
EP
16
J.A. Wagner, K.J. Schreiber, R. Cohen, Improving operating room contamination control, ASHRAE J. 56 (2014) 18–27.
[3]
B. Zhao, C. Yang, C. Chen, C. Feng, X. Yang, L. Sun, W. Gong, L. Yu, How Many
16
ACCEPTED MANUSCRIPT
1
Airborne Particles Emitted from a Nurse will Reach the Breathing Zone/Body Surface of
2
the Patient in ISO Class-5 Single-Bed Hospital Protective Environments?—A Numerical
3
Analysis, Aerosol Sci. Technol. 43 (2009) 990–1005. doi:10.1080/02786820903107925.
4
[4]
D.J. Dalstrom, I. Venkatarayappa, A.L. Manternach, M.S. Palcic, B.A. Heyse, M.J. Prayson, Time-Dependent Contamination of Opened Sterile Operating-Room Trays, J.
6
Bone Jt. Surgery-American Vol. 90 (2008) 1022–1025. doi:10.2106/JBJS.G.00689.
7
[5]
RI PT
5
S. Ridgeway, J. Wilson, A. Charlet, G. Kafatos, A. Pearson, R. Coello, Infection of the
8
surgical site after arthroplasty of the hip, J. Bone Jt. Surg. - Br. Vol. 87–B (2005) 844–
9
850. doi:10.1302/0301-620X.87B6.15121. [6]
L. Neumayer, P. Hosokawa, K. Itani, M. El-Tamer, W.G. Henderson, S.F. Khuri,
SC
10
Multivariable Predictors of Postoperative Surgical Site Infection after General and
12
Vascular Surgery: Results from the Patient Safety in Surgery Study, J. Am. Coll. Surg.
13
204 (2007) 1178–1187. doi:10.1016/j.jamcollsurg.2007.03.022.
14
[7]
M AN U
11
G. Birgand, G. Toupet, S. Rukly, G. Antoniotti, M.N. Deschamps, D. Lepelletier, C.
15
Pornet, J.B. Stern, Y.M. Vandamme, N. Van Der Mee-Marquet, J.F. Timsit, J.C. Lucet, Air
16
contamination for predicting wound contamination in clean surgery: A large multicenter
17
study, Am. J. Infect. Control. 43 (2015) 516–521. doi:10.1016/j.ajic.2015.01.026.
18
[8]
S. Scaltriti, S. Cencetti, S. Rovesti, I. Marchesi, A. Bargellini, P. Borella, Risk factors for particulate and microbial contamination of air in operating theatres, J. Hosp. Infect. 66
20
(2007) 320–326. doi:10.1016/j.jhin.2007.05.019. [9]
22 23
S. Dharan, D. Pittet, Environmental controls in operating theatres, J. Hosp. Infect. 51 (2002) 79–84. doi:10.1053/jhin.2002.1217.
[10]
R.S. Young, D.J. O’Regan, Cardiac surgical theatre traffic: time for traffic calming
EP
21
TE D
19
24
measures?, Interact. Cardiovasc. Thorac. Surg. 10 (2010) 526–529.
25
doi:10.1510/icvts.2009.227116. [11]
27
Yinnon, Incidence and risk factors for surgical infection after total knee replacement,
28 29
Scand. J. Infect. Dis. 39 (2007) 890–895. doi:10.1080/00365540701387056.
[12]
30
R.J. Lynch, M.J. Englesbe, L. Sturm, A. Bitar, K. Budhiraj, S. Kolla, Y. Polyachenko, M.G.
Duck, D.A. Campbell, Measurement of foot traffic in the operating room: implications for
31 32
Y. Babkin, D. Raveh, M. Lifschitz, M. Itzchaki, Y. Wiener-Well, P. Kopuit, Z. Jerassy, A.M.
AC C
26
infection control., Am. J. Med. Qual. 24 (2008) 45–52. doi:10.1177/1062860608326419. [13]
S.N. Parikh, S.S. Grice, B.M. Schnell, S.R. Salisbury, Operating Room Traffic: Is There
33
Any Role of Monitoring it?, J. Pediatr. Orthop. 30 (2010) 617–623.
34
doi:10.1097/BPO.0b013e3181e4f3be.
17
ACCEPTED MANUSCRIPT
1
[14]
A.E. Andersson, I. Bergh, J. Karlsson, B.I. Eriksson, K. Nilsson, Traffic flow in the
2
operating room: An explorative and descriptive study on air quality during orthopedic
3
trauma implant surgery, Am. J. Infect. Control. 40 (2012) 750–755.
4
doi:10.1016/j.ajic.2011.09.015. [15]
A.N. Healey, N. Sevdalis, C.A. Vincent, Measuring intra-operative interference from
RI PT
5 6
distraction and interruption observed in the operating theatre, Ergonomics. 49 (2006)
7
589–604. doi:10.1080/00140130600568899. [16]
10
Trans., 1993: pp. 223–229. [17]
11 12
American Soc. Heat. Refrig. Airconditioning Eng. 36 (1994) 36–40. [18]
13 14
D.T. Hitchings, Laboratory Space Pressurization Control Systems, ASHRAE Journal-
SC
9
O. Ahmed, J.W. Mitchell, S.A. Klein, Dynamics of laboratory pressurization, in: ASHRAE
D.E. Kiel, D.L. Wilson, Combining door swing pumping with density driven flow, in:
M AN U
8
ASHRAE Trans., 1989: pp. 590–599. [19]
C. Chen, B. Zhao, X. Yang, Y. Li, Role of two-way airflow owing to temperature difference
15
in severe acute respiratory syndrome transmission: revisiting the largest nosocomial
16
severe acute respiratory syndrome outbreak in Hong Kong., J. R. Soc. Interface. 8 (2011)
17
699–710. doi:10.1098/rsif.2010.0486.
18
[20]
S.C. Mears, R. Blanding, S.M. Belkoff, Door Opening Affects Operating Room Pressure During Joint Arthroplasty, Orthopedics. 38 (2015) e991–e994. doi:10.3928/01477447-
20
20151020-07.
21
[21]
TE D
19
E.B. Smith, I.J. Raphael, M.G. Maltenfort, S. Honsawek, K. Dolan, E.A. Younkins, The effect of laminar air flow and door openings on operating room contamination, J.
23
Arthroplasty. 28 (2013) 1482–1485. doi:10.1016/j.arth.2013.06.012. [22]
25 26
CHALMERS UNIVERSITY OF TECHNOLOGY Göteborg, 2010. doi:D. [23]
27
J. Infect. Control. 39 (2011) 91–97. doi:10.1016/j.ajic.2010.05.025.
[24]
30
A. Hathway, I. Papakonstantis, A. Bruce-Konuah, W. Brevis, Experimental and modelling
investigations of air exchange and infection transfer due to hinged-door motion in office
31 32
N.J. Adams, D.L. Johnson, R.A. Lynch, The effect of pressure differential and care provider movement on airborne infectious isolation room containment effectiveness, Am.
28 29
Gustavsson N., Dispersion of small particles into operating rooms due to openings,
AC C
24
EP
22
and hospital settings, Int. J. Vent. (2015). [25]
A. Joseph, S. Bayramzadeh, Z. Zamani, B. Rostenberg, Safety, Performance, and
33
Satisfaction Outcomes in the Operating Room: A Literature Review, (n.d.).
34
doi:10.1177/1937586717705107.
18
ACCEPTED MANUSCRIPT
1
[26]
Y. Tao, K. Inthavong, J. Tu, A numerical investigation of wind environment around a
2
walking human body, J. Wind Eng. Ind. Aerodyn. 168 (2017) 9–19.
3
doi:10.1016/j.jweia.2017.05.003.
4
[27]
A.L. Hewlett, S.E. Whitney, S.G. Gibbs, P.W. Smith, H.J. Viljoen, Mathematical modeling of pathogen trajectory in a patient care environment., Infect. Control Hosp. Epidemiol. 34
6
(2013) 1181–8. doi:10.1086/673451.
7
[28]
RI PT
5
J.M. Villafruela, J.F. San José, F. Castro, A. Zarzuelo, Airflow patterns through a sliding
8
door during opening and foot traffic in operating rooms, Build. Environ. 109 (2016) 190–
9
198. doi:10.1016/j.buildenv.2016.09.025. [29]
E.S. Mousavi, K.R. Grosskopf, Airflow patterns due to door motion and pressurization in
SC
10
hospital isolation rooms, Sci. Technol. Built Environ. 22 (2016) 379–384.
12
doi:10.1080/23744731.2016.1155959.
13
[30]
M AN U
11
J. Teter, I. Guajardo, T. Al-Rammah, G. Rosson, T.M. Perl, M. Manahan, Assessment of
14
operating room airflow using air particle counts and direct observation of door openings,
15
Am. J. Infect. Control. 45 (2017) 477–482. doi:10.1016/j.ajic.2016.12.018.
16
[31]
B. Rostenberg, P.R. Barach, Design of cardiovascular operating rooms for tomorrow’s
17
technology and clinical practice - Part 2, Prog. Pediatr. Cardiol. 33 (2012) 57–65.
18
doi:10.1016/j.ppedcard.2011.12.010. [32]
S. Sadrizadeh, A. Tammelin, P. Ekolind, S. Holmberg, Particuology Influence of staff
TE D
19 20
number and internal constellation on surgical site infection in an operating room,
21
Particuology. 13 (2014) 42–51. doi:10.1016/j.partic.2013.10.006.
24
K. Grosskopf, E. Mousavi, Bioaerosols in health-care environments, ASHRAE J. 56 (2014) 22–31.
EP
23
[33]
AC C
22
19
ACCEPTED MANUSCRIPT
Highlights:
EP
TE D
M AN U
SC
RI PT
Doors are operated in the same manner regardless of door type, location, and user. OR door is frequently operated by personnel who are not a member of surgical team. The Automatic button resulted in lengthier and unnecessary door openings. Surgical table is the immediate destination in 25% of entries into the OR.
AC C
• • • •