Orthopedic implants and using the substerile door

[coffeebythelake]

"Don't go through the external OR door", "Limit OR traffic".
As far as I'm aware, no real evidence for this preventing infection vs substerile door.
Seems theoretical with disruption of positive pressure and particulate contamination,
Tried to do a search on this topic but haven't found much. I don't think it actually translates to higher infection rates.
Thoughts? Anyone with references that say otherwise?

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[nimbus]

In my experience the surgeons who get a lot of infections take a long time and have a lot of reps in the room.

 

[coffeebythelake]

In my experience the surgeons who get a lot of infections take a long time and have a lot of reps in the room.

Yes exactly!

 

[Urzuz]

More BS invented by nurses who haven't taken care of a patient in decades, similar to the bouffant vs skull cap fiasco from a few years back.

 

[dhb]

I go in and out of the room all the time by the main door without any problem.

 

[abolt18]

I remember reading in Barash that there was found to be a direct correlation between the number of people entering the room and the incidence of SSI. I do not know the level of evidence behind that statement. I did not comment on which door was used.

 

[GassYous]

I never listened to their stupid bouffant only rules and I go through whichever door I want. Infection rates are associated with hypothermia, length of procedure, number of people going in and out. I try to limit my movement when the joint is going in.

Everything else is irrelevant including which door you use, laminar flow vs otherwise, ortho hoods vs just face mask, how attractive the reps are, etc

Anecdotally there was a push when I was in training to not use premade setups, including cardiac. They wanted everything fresh for right before the patient rolled into the room. Patently absurd. I've inadvertently used an iv setup in residency that was 5 days old in a cardiac case with no problems.

 

[Arch Guillotti]

I remember reading in Barash that there was found to be a direct correlation between the number of people entering the room and the incidence of SSI. I do not know the level of evidence behind that statement. I did not comment on which door was used.

And the ones going in and out the most are the reps.

 

[fakin' the funk]

I go in and out of the room all the time by the main door without any problem.

I would argue that your observation is not statistically powered to find a difference

 

[fakin' the funk]

I never listened to their stupid bouffant only rules and I go through whichever door I want. Infection rates are associated with hypothermia, length of procedure, number of people going in and out. I try to limit my movement when the joint is going in.

Everything else is irrelevant including which door you use, laminar flow vs otherwise, ortho hoods vs just face mask, how attractive the reps are, etc

Anecdotally there was a push when I was in training to not use premade setups, including cardiac. They wanted everything fresh for right before the patient rolled into the room. Patently absurd. I've inadvertently used an iv setup in residency that was 5 days old in a cardiac case with no problems.

What...what sort of problem WOULD you have with a 5 day old IV setup? This is a dumb claim.

 

[Southpaw]

I’ve never looked at the evidence but my orthos have said the only things that matter, with regard to infection, are patient weight and length of surgery. Maybe DMII also? Regardless, my place throws a hissy fit also if we enter/exit through the non-sterile corridor door. Schaudenfreud!

 

[GassYous]

What...what sort of problem WOULD you have with a 5 day old IV setup? This is a dumb claim.

They think if you don't replace iv sets every day you increase infection risk. They also change the pressure bags daily if unused. We have them set up every day in case there is a takeback or emergency.

I used the same bags for nitro and neo for a week. New syringes and needles every time. Infection rate was zero on my cardiac month.

 

[dhb]

I would argue that your observation is not statistically powered to find a difference

Oh but you like to argue.
I'm 100% sure that if you bang a TKA in 30min in a tent on the parking lot with street clothes under your gown you'll do better infection wise than a 2h procedure with laminar flow and space suits.

 

[Urzuz]

Everything else is irrelevant including...how attractive the reps are

Now I don't want to start another argument with you, but...

 

[DrOwnage]

This one time I had a redline Crani coming up to the OR, and I rushed in to setup knowing nothing about the patient. Opened up an A line kit and threw some sterile stuff in (because I set it up a certain way) and the nurse was like "you have to throw that away now, have to wait until the patient is here." I was a resident back then, now I would be like go $%^$ yourself.

 

[pgg]

Oh but you like to argue.
I'm 100% sure that if you bang a TKA in 30min in a tent on the parking lot with street clothes under your gown you'll do better infection wise than a 2h procedure with laminar flow and space suits.

I see where you're going with that, faster surgeons = better surgeons and time = complications, but nope. That's basically how they did total joints at a developing-world hospital where I worked for a few months, and the infection rate was well over 20%. But hey, an explant and a redo were two more procedures they could bill the patients for, and as far as the patients knew, thems was the risks, so it was all cool.

 

[GassYous]

This one time I had a redline Crani coming up to the OR, and I rushed in to setup knowing nothing about the patient. Opened up an A line kit and threw some sterile stuff in (because I set it up a certain way) and the nurse was like "you have to throw that away now, have to wait until the patient is here." I was a resident back then, now I would be like go $%^$ yourself.

LOL even as a resident you can say that

 

[dhb]

I see where you're going with that, faster surgeons = better surgeons and time = complications, but nope. That's basically how they did total joints at a developing-world hospital where I worked for a few months, and the infection rate was well over 20%. But hey, an explant and a redo were two more procedures they could bill the patients for, and as far as the patients knew, thems was the risks, so it was all cool.

What was the cause for it in your opinion?
If the site is preped, the surgeon has clean gloves and doesn't pick his nose or spit in the wound you can't do much harm in 30min.
Was it not due to deficient post op care?

 

[coffeebythelake]

What was the cause for it in your opinion?
If the site is preped, the surgeon has clean gloves and doesn't pick his nose or spit in the wound you can't do much harm in 30min.
Was it not due to deficient post op care?

Or lack of antibiotics. Or no patient warming. Lots of things that muddy the water here.

 

[coffeebythelake]

What was the cause for it in your opinion?
If the site is preped, the surgeon has clean gloves and doesn't pick his nose or spit in the wound you can't do much harm in 30min.
Was it not due to deficient post op care?

I agree with you. WHO recommends sterile gloves and gown. CDC recommends sterile gloves. British guidelines suggest "maybe double glove?"

There isn't much real evidence for OR attire other than that. Even mask vs no mask = probably no difference.. Bouffant vs skull cap = no difference, or bouffant might be even worse!. Don't talk, cough, sneeze, snort into the surgical field. Everything else is precautionary based on no real evidence. Some of you have read about the "Naked Surgeon" commentary in the Journal of Clinical Infectious Diseases.

 

[Status Sciaticus]

This one time I had a redline Crani coming up to the OR, and I rushed in to setup knowing nothing about the patient. Opened up an A line kit and threw some sterile stuff in (because I set it up a certain way) and the nurse was like "you have to throw that away now, have to wait until the patient is here." I was a resident back then, now I would be like go $%^$ yourself.

LOL, I do that now as a resident. Bring me proof, or STFU. If they're going to complain, let them. Unless it a professionalism issue, IDGAF.

 

[okayplayer]

A lot of blustering and hot air on this thread. I hope in real life most of you in private practice groups just politely do the job asked of you and follow the silly rules set out (don't go in and out of this door, wear this hat/don't wear that hat) if they don't impact patient care. It's incredibly bad PR for the group to have people make a fuss over stupid stuff. Speaking personally, I'm looking for partners who get along well with others and don't make waves if it doesn't directly impact patient care.

My 2 cents.

 

[coffeebythelake]

A lot of blustering and hot air on this thread. I hope in real life most of you in private practice groups just politely do the job asked of you and follow the silly rules set out (don't go in and out of this door, wear this hat/don't wear that hat) if they don't impact patient care. It's incredibly bad PR for the group to have people make a fuss over stupid stuff. Speaking personally, I'm looking for partners who get along well with others and don't make waves if it doesn't directly impact patient care.

My 2 cents.

There are people who don't make a fuss and do whatever the policy js, while recognizing a lot of the measures being asked probably does nothing to prevent infection. They are not mutually exclusive. And more importantly if there is no evidence of harm from adopting such measures.

Obviously group dynamic is important, jf a surgeon or colleague likes things done a certain way and I don't see harm to patient from doing it I'm fine with obliging.

But we are physicians. We are supposed to approach things rationally and understand why we do things a certain way and the facts that back it up. Then form an opinion and a basis of practice.

You must concede that not all things are evidence based, nor do they always need to be.

 

[Status Sciaticus]

A lot of blustering and hot air on this thread. I hope in real life most of you in private practice groups just politely do the job asked of you and follow the silly rules set out (don't go in and out of this door, wear this hat/don't wear that hat) if they don't impact patient care. It's incredibly bad PR for the group to have people make a fuss over stupid stuff. Speaking personally, I'm looking for partners who get along well with others and don't make waves if it doesn't directly impact patient care.

My 2 cents.

I hope in private practice, the physicians arent being bossed around by clipboards, and the physicians acquiescing to their non-evidence based claims. Im wearing my scrub caps. they can wear what they want.

Sounds like by "dont make waves", you just want people who keep their head down and dont speak up. Precisely the attitude reinforcement that leads to the passive nature of the profession and people encroaching on us.

 

[okayplayer]

I hope in private practice, the physicians arent being bossed around by clipboards, and the physicians acquiescing to their non-evidence based claims. Im wearing my scrub caps. they can wear what they want.

Sounds like by "dont make waves", you just want people who keep their head down and dont speak up. Precisely the attitude reinforcement that leads to the passive nature of the profession and people encroaching on us.

Good luck.

 

[Status Sciaticus]

Good luck.

So you are being bossed around by clipboards? Good luck with that as well.

 

[ChiDO]

OR traffic has been shown to increase infection rate in arthroplasty cases.

Operating Room Traffic is a Major Concern During Total Joint Arthroplasty - PMC

Periprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty (TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, and may lead to increased rates of infection. Our purposes ...

www.ncbi.nlm.nih.gov

But, I agree with the statements above. Patient comorbidities and surgical time are definitely a higher concern than if the door opens. All of our anesthesiologists use the sterile core when they switch.

 

[coffeebythelake]

I remember reading in Barash that there was found to be a direct correlation between the number of people entering the room and the incidence of SSI. I do not know the level of evidence behind that statement. I did not comment on which door was used.

I haven't flipped open Barash but I haven't yet seen a study saying actual increased ssi rate

OR traffic has been shown to increase infection rate in arthroplasty cases.

Operating Room Traffic is a Major Concern During Total Joint Arthroplasty - PMC

Periprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty (TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, and may lead to increased rates of infection. Our purposes ...

www.ncbi.nlm.nih.gov

But, I agree with the statements above. Patient comorbidities and surgical time are definitely a higher concern than if the door opens. All of our anesthesiologists use the sterile core when they switch.

Article says increased contamination. Does that actually translate to higher infection?

 

[abolt18]

I haven't flipped open Barash but I haven't yet seen a study saying actual increased ssi rate



Article says increased contamination. Does that actually translate to higher infection?

Page 188: "A recent Israeli study of risk factors for surgical infection after total knee replacement demonstrated a trend toward increased infection rates with increased number of orthopedic surgeons or anesthetists present in the OR. This study reconfirmed a prior study showing a trend toward increased incidence of SSI as the number of people in the operating suite increases."

Babkin Y, Raveh D, Lifschitz M, Itzchaki M, Wiener-Well Y, Kopuit P, Jerassy Z, Yinnon AM. Incidence and risk factors for surgical infection after total knee replacement. Scand J Infect Dis. 2007;39(10):890-5. doi: 10.1080/00365540701387056. PMID: 17852911.
- looking this source over, it's questionable that they made such a statement in Barash based on this.

Pryor F, Messmer PR. The effect of traffic patterns in the OR on surgical site infections. AORN J. 1998 Oct;68(4):649-60. doi: 10.1016/s0001-2092(06)62570-2. PMID: 9795720.
- this also lacked "statistical significance" but noted a trend.

 

[Status Sciaticus]

Pryor F, Messmer PR. The effect of traffic patterns in the OR on surgical site infections. AORN J. 1998 Oct;68(4):649-60. doi: 10.1016/s0001-2092(06)62570-2. PMID: 9795720.

AORN study. I find their 'studies' usually lacking proper design or merit. They wouldnt accept the fact that scrub caps were better or atleast equivalent to bouffants... TJC had to step in 2019 and issue a statement about it.

 

[Iso4ane]

Didn’t read the studies, but are they standardized for length of surgery?

 

[jwk]

OR traffic has been shown to increase infection rate in arthroplasty cases.

Operating Room Traffic is a Major Concern During Total Joint Arthroplasty - PMC

Periprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty (TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, and may lead to increased rates of infection. Our purposes ...

www.ncbi.nlm.nih.gov

But, I agree with the statements above. Patient comorbidities and surgical time are definitely a higher concern than if the door opens. All of our anesthesiologists use the sterile core when they switch.

This is a study about how many times the door is opened during a total joint case. Unless that is somehow correlated with actual infection rates, it only shows what all of us already know - we're not the problem.

 

[coffeebythelake]

Didn’t read the studies, but are they standardized for length of surgery?

Length of surgery is clearly one of the biggest risk factors for SSI. I imagine any study will correct for that.

 

[Drangue]

LOL, I do that now as a resident. Bring me proof, or STFU. If they're going to complain, let them. Unless it a professionalism issue, IDGAF.

I wish we could do that...

 

[coffeebythelake]

I wish we could do that...

It's mostly surgeon b.s. based on minimal evidence. Lots of things we do to prevent SSI are based on theoretical benefit which later has been shown to be dubious outcome benefit. I've looked into this topic more. This has been studied quite a bit. Theoretical risk yes. Actual evidence for more SSI no.

 

[ChiDO]

Hospital nursing admin rules are dumb. One of the hospitals I work at requires 5 mins of drying time for chloroprep before you are allowed to drape. Timer starts once the nurse finished the last stick. Apparently there is a 1 in million risk in fire.

Anyways, at the last ortho meeting there was a paper that debunked the drying time and showed once its visibly dry there is no difference in fumes, temp, or combustion. (ie. About 30secs)

I showed hospital admin and they could care less.

 

[coffeebythelake]

Hospital nursing admin rules are dumb. One of the hospitals I work at requires 5 mins of drying time for chloroprep before you are allowed to drape. Timer starts once the nurse finished the last stick. Apparently there is a 1 in million risk in fire.

Anyways, at the last ortho meeting there was a paper that debunked the drying time and showed once its visibly dry there is no difference in fumes, temp, or combustion. (ie. About 30secs)

I showed hospital admin and they could care less.

5 min? My place does 3 min. It's fjne... not a ridiculous wait. Gives us time to make sure that ancef goes in before incision (not much evidence for this metric either)

 

[Neopolymath]

My money is on the reps.