What? Could sound level in the operating room be an infection culprit?
"Yes it can," say researchers from the Berne University Hospital in Switzerland, reporting in a recent issue of the British Journal of Surgery.
Over the years, researchers have considered many possible causes for increases for these troublesome nosocomials, and some have been shown to be influential, including: the number of people in the operating room, the length of the surgical procedure, increased body mass index, degree of existing disease in the patient, loss of blood, the amount of tissue exposed, and so on
They've also considered the type of scrubs worn, the pre-operative scrubbing techniques, sanitization, tools and devices used during the procedure and the list goes on.
But of all the areas on that long list, rarely has noise level been considered.
At the Department of Visceral Surgery and Medicine, Guidi Beldi, MD, and colleagues measured decibel levels during 35 major elective open abdominal procedures.
In 2009, Beldi enrolled 1,032 surgical patients in a study to determine whether extensive antiseptic measures, compared with standard measures, could reduce surgical site infections. They didn't. But what was revealed was that changing team members during surgery, visitors in the O.R., hectic movements, and loud noise are associated with higher rates of SSIs.
But measuring hectic movement and loud noise are subjective. So Beldi tried another study, this one fine-tuning an objective measurement of noise in the O.R.
Beldi and his colleagues measured decibel levels of sound during 35 elective open abdominal procedures in decibels every second of the operation. (Yes, the number was extremely small and perhaps statistically insignificant. But Beldi might just be on to something.) The researchers also counted surgical site infections within 30 days of each patient's surgery.
Not only did they find a correlation, they also found that discussions involving non-surgery related topics raised the volume considerably, and thus the number of infections. Apparently team members spoke louder when they weren't talking about the surgery, and therefore, they were distracted from the surgery.
Six of the 35 patients, or 17%, developed surgical site infections within 30 days, a result that Beldi attributed to the sound level in the operating room, "in particular talking about non-surgery related topics."
"The median sound level and the median level above baseline were significantly higher for patients who developed a surgical site infection," the researchers wrote.
In addition to noise, other variables were examined, such as: the number of team members replaced during the procedure, whether 10 or more people were in the operating room, whether there was unfocused conversation by the anesthesiologists and, of course, adherence to standard antiseptic protocols before and during surgery.
Beldi speculated that talking about topics that did not involve the surgery "may represent a lack of concentration by the surgical team."
Contacted by e-mail in Berne, Beldi explained that noise is "the only factor that can be assessed objectively. Noise is not just speaking about casual things, but also (includes people) giving strict instructions that might be associated with increased noise."
"We rather think that noise is a surrogate for a difficult operation and therefore is associated with complications," he wrote in his e-mail response.
Of course, it may be that some higher noise levels in the surgeries with resulting surgical site infections were related to machinery, surgical instruments, monitors, alarms, and background noise associated with a more difficult procedure. That "could explain the association between volume and SSI," the researchers said in their published report.
Reducing surgical site infections is important in the U.S. for a number of reasons. They increase length of stay by weeks, increase cost of care, and in the near future will lead to reduced reimbursement when they occur in Medicare beneficiaries, according to provisions in the Patient Protection and Affordable Care Act. So, any hints about how to reduce them shouldn't be ignored.
The Berne study is already making its rounds via the Internet, in particular on medical malpractice lawyers' websites. It has also prompted commentary in the British Journal of Surgery from Ara Darzi, MD, of the Division of Surgery at the Imperial College of London.
Darzi notes that much of the research so far on noise, operating room performance and surgical outcomes has been done "in simulated environments, and real clinical implications have been demonstrated infrequently.
"[This study] investigates a stressor that all surgeons face, that of noise in the operating theatre. Whether this be in the form of a pertinent and welcome discussion, a perhaps unnecessary conversation, or a purely extraneous distraction, it stands to reason that noisy surgical environments distract the surgeon from what is a complex task."
It should be noted that Beldi's research came because he was not afraid to ask a simple question. And it didn't cost a lot of money to explore his hypothesis.
A lot of quality initiatives require money and resources, but here's one strategy that doesn't. How about giving it a try in your operating rooms just to see if it might make a difference in your surgical site infection rate, and perhaps other medical mishaps as well.
What harm could it do?
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