Infectious complications, particularly surgical site infections (SSIs), are well documented to increase costs, morbidity, mortality, and length of stay (LOS). Surgical operative duration has long been suggested as a risk factor for infectious complications (ICs).
The causes for this association may be multifactorial. For example, prolonged tissue exposure to the air can desiccate the wound, increasing tissue death and worsening tissue healing. Increased operative duration has also been associated with increased tissue trauma, which raises the metabolic demand on the body to heal these wounds. Lastly, greater operative duration has been shown in previous research to increase the risk of blood loss, periods of hypothermia during surgery, and the need to re-dose antibiotics perioperatively.
Determinants of operative duration can include any of the following:
1. The proficiency of the surgeon.
2. The presence of surgical trainees.
3. Communication among operative professionals.
4. Emergency operation.
5. Operating room (OR) staffing.
7. Process efficiency.
New Study Data
In a study published in the January 2010 Journal of the American College of Surgery, my colleagues and I sought to gain a better understanding of the link between operative duration and outcomes, particularly ICs and LOS. Considering that all ICs are significant after surgery, our investigation included some of the most important infections that can impact postoperative surgical patient care, including SSIs, sepsis, urinary tract infections, intravascular catheter-related infections, and pneumonia.
“Strategies that reduce operative duration as well as improve IC rates and LOS need to be identified.”
After analyzing nearly 300,000 general surgery operations performed at 173 hospitals with the National Surgical Quality Improvement Program (NSQIP) database, we found that the risk of infectious complications appeared to depend on the type of operation. For example, major intra-abdominal, vascular, and large soft tissue operations had the largest rate of ICs. Even after adjusting for operative and patient risk variables, operative duration was still shown to be an independent risk factor for ICs in the study. The odds ratios for ICs increased by about 0.32 per 30 minutes of operative duration. Procedure group, case complexity, wound class (eg, clean, clean contaminated, contaminated, or infected), and amount of intraoperative transfusion were also found to be major predictors of ICs.
An important finding of the study was that LOS increased as the operative duration increased. LOS increased by about 6% per every 30 minutes of operative duration. The 30-day rate of ICs rose by almost 2.5% for every 30 minutes of operative duration (start of incision to closure). That rate increased to 31.4% for cases that took more than 6 hours to complete.
Increase Efficiency to Gain Improvement
More research is needed to explore the potential barriers that may hinder efficiency during operations. Strategies that reduce operative duration as well as improve IC rates and LOS need to be identified. Several approaches may be feasible, including the use of preoperative checklists and debriefings that focus on efficiency, preparedness, and individualized care. It may also be beneficial to minimize operative staff and traffic in the OR and to establish a multidisciplinary plan that synergize efforts by surgeons, anesthesiologists, nurses, and other OR personnel. Mandating that OR teams be trained in certain case types so that they’re familiar with specific case flow and material requirements may also be of benefit. Ultimately, the goal should be to get all OR personnel more prepared to handle issues that may arise during unfamiliar situations as well as in complicated procedures.
Readings & Resources (click to view)
Procter LD, Davenport DL, Bernard AC, et al. General surgical operative duration is associated with increased risk-adjusted infectious complicate rates and length of hospital stay. J Am Coll Surg. 2010;210:60-65.
Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980.
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Eng J Med. 2009;360:491-499.
Vijayasekar C, Steele RJ. The World Health Organization’s surgical safety checklist. Surgeon. 2009;7:260-262.
Khuri SF, Henderson WG, Daley J, et al. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg. 2008;248:329-336.
Haridas M, Malangoni MA. Predictive factors for surgical site infection in general surgery. Surgery. 2008;144:496-501.