A prospective observational study of operating room traffic during shunt surgery: who comes in and why?

Shunt infections are costly and stressful for families, patients, and providers. Many institutions use shunt checklists in an effort to reduce the risk of infection following shunt surgery. Such protocols often aim to limit operating room (OR) foot traffic, but there is little evidence that supports the theory that greater OR traffic increases the risk of acquiring a shunt infection through contamination of the air. The purpose of this study was to quantify foot traffic during shunt surgery at a children's hospital during a time period when a shunt checklist was used.

Starting in 2019, a premedical student was tasked with covertly collecting data on 50 shunt operations. Data were recorded in real time and documented in a prospectively updated database. Recording foot traffic through the OR door began at onset of skin prep; data points included patient and surgical details, operative length, and who entered the room and why. Each operation was followed for a minimum of 180 days for infection. The primary outcome was "door event," defined as any time a door to the OR was opened-fully or partially-with or without someone breaking the plane of the door (i.e., entering or exiting).

Fifty operations were observed with no primary shunt infection (mean follow-up 29.8 months, range 6.5-63.3 months). One patient experienced a late secondary infection due to systemic post-COVID-19 inflammatory syndrome causing gastrointestinal bacterial translocation. The average operative time-from applying sterile skin prep until surgery stop time-was 69.8 minutes. Overall, there were 1012 door openings with 1088 personnel entering or exiting. The average number of door openings per operation was 20.24. OR personnel (42.7%) and neurosurgery staff (31.6%) were responsible for the largest number of door events, followed by the anesthesiology service (18.9%). The most cited reasons for door events were for supplies (31.2%) and scrubbing in (26.5%).

This study represents the first detailed analysis of OR traffic during pediatric shunt surgery. No patient developed a primary shunt infection. While minimizing OR traffic makes intuitive sense, it remains unknown whether a causal relationship exists. Further investigation is needed.