Original Paper
Urologia Internationalis
Received: July 24, 2013 Accepted after revision: September 10, 2013 Published online: February 18, 2014
Urol Int 2014;93:38–42 DOI: 10.1159/000355572
Multifunctional Use of an Operating Theatre: Is Floor Drainage Posing an Increased Risk of Infection? Hendrik Borgmann a Florian Wagenlehner b Stefan Borgmann c Walter Thon d a Department of Urology, University Hospital Frankfurt, Frankfurt, b Department of Urology, Paediatric Urology and Andrology, Justus Liebig University, Giessen, c Department of Infectious Diseases and Infection Control, Klinikum Ingolstadt, Ingolstadt, and d Department of Urology, Klinikum Siloah, Hannover, Germany
Key Words Wound infection · Surgical site infection · Floor drainage · Prostatectomy · Nephrectomy
skin incision surgery does not increase SSI rates. Thus, multifunctional use of theatres with floor drainage might lead to a gain in flexibility in the use of operating theatre capacity. © 2014 S. Karger AG, Basel
Abstract Introduction: For transurethral urologic surgery floor drainage is necessary for disposal of large amounts of fluid; for skin incision surgery floor drainage is unnecessary. The presence of floor drainage in an operating theatre may have a negative impact on the surgical site infection (SSI) rate after skin incision surgery due to aerosol contamination. We examined whether multifunctional use of an operating theatre would increase the SSI rate after skin incision surgery. Patients and Methods: Patients undergoing skin incision surgery on the kidney or prostate were prospectively divided into two groups with regard to operating theatre equipment. 272 patients were operated on in a theatre with floor drainage and 755 patients were operated on in a theatre without floor drainage. SSIs were categorized using the CDC classification and SSI rates in the two different theatres were determined. Results: No statistically significant difference (p = 0.86) in SSI rates after kidney and prostate surgery was found for operations in theatres with (2.6%) and without floor drainage (2.8%). Conclusions: Multifunctional use of an operating theatre with floor drainage for transurethral and
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0038$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Surgical site infections (SSIs) are among the most commonly reported types of healthcare-associated infections in patients undergoing surgery [1]. Infections increase the morbidity and mortality of patients and are a huge burden to national healthcare systems [2]. The costs for a patient with SSI are, on average, doubled compared to the costs for a patient without SSI [3]. Therefore, SSIs are a key target for nosocomial infection control programs, resulting in relative reductions of 25–38% in the SSI rate [4, 5]. Flexibility is a key demand directed to all participants in the healthcare sector in order to save human and financial resources. Pressure for cost effectiveness is steadily increasing, especially in developed countries. The operating theatre has been found to account for up to 40% of total hospital costs [6]. Various procedures, e.g. parallel induction of anaesthesia [7] and introduction of standard operating procedures [8], have improved operating theatre organization Dr. med. Hendrik Borgmann Klinik für Urologie und Kinderurologie Universitätsklinikum Frankfurt Theodor-Stern-Kai 7, DE–60590 Frankfurt (Germany) E-Mail hendrik.borgmann @ kgu.de
and efficiency, leading to reduced cost of surgery. However, research to optimize operating theatre efficiency is still increasing [9]. Any gain in flexibility will be a potential optimizing factor for efficient use of operating theatre capacity. Urologic surgery comprises a wide variety of operations requiring special equipment in the operating theatre. Two major groups of urologic surgery are transurethral surgery and skin incision surgery. Transurethral surgery requires large amounts of irrigation fluid and therefore floor drainage is necessary for adequate disposal of the irrigation fluid. Transurethral surgery is associated with a high percentage of urinary tract infections (up to 9.1%) [10]. In contrast, urologic skin incision surgery usually results in low postoperative infection rates (up to 3.2%) [11]. In contrast to transurethral surgery, floor drainage is not necessary in urologic skin incision surgery. Moreover, the presence of floor drainage might facilitate the formation of bacteria-containing aerosols, leading to an increased bacterial burden eventually resulting in additional SSI rates. Consequently, it seems desirable to perform skin incision surgery in operating theatres without floor drainage. The standards and requirements for operating theatre equipment vary among different countries. In Germany, for example, it is advised not to use a floor drainage inside an operating theatre [12]. On the other hand, from an economic perspective, it is beneficial to perform transurethral and skin incision surgeries in the same operating theatre to maximize logistic flexibility. Since floor drainage is essential for transurethral operations, both groups of operations, transurethral and skin incision surgery, should be performed in theatres exhibiting floor drainage. The aim of the present study was to examine whether the presence of floor drainage in the operating theatre causes an increased SSI rate. For this purpose, skin incision surgery was performed in operating theatres with or without floor drainage and the corresponding SSI rates were compared. Patients and Methods From 2007 until 2012, data were collected from 1,027 patients who underwent the indicator operations open radical prostatectomy, open (partial) nephrectomy and laparoscopic (partial) nephrectomy at our institution. The standard data collection protocol comprised information on the operation and on the patient. Data concerning the operation included type of operation, operation time, operating surgeon and presence of floor drainage in the operating theatre. Data concerning the patient included age, gender, BMI, ASA class, presence of diabetes mellitus, length of hospital stay, presence of SSI, CDC class of SSI, bacterial pathogen
Multifunctional Operating Theatre Use
Table 1. Characteristics of patients operated on in theatres with and without floor drainage Parameter
Open nephrectomy Open partial nephrectomy Laparoscopic nephrectomy Laparoscopic partial nephrectomy Open prostatectomy Age, years Male Female BMI ASA class Diabetes mellitus Hospital stay, days
Patients operated on in theatre with floor drainage (n = 272)
Patients operated on in theatre without floor drainage (n = 755)
14 (5%) 29 (11%) 48 (18%)
40 (5%) 77 (10%) 145 (19%)
49 (18%) 132 (49%) 68±6.9 219 (81%) 53 (19%) 24±4.2 2±1 24 (9%) 8±2.3
139 (18%) 354 (47%) 66±5.3 596 (79%) 159 (21%) 25±3.8 2±1 60 (8%) 8±2.1
For age, BMI, ASA class and hospital stay, median values and ranges are listed.
causing SSI, necessity for operative revision and cause of operative revision. SSIs were classified according to the CDC classification into superficial, deep incisional and organ/space infections [13]. For documentation of data Microsoft Excel version 2003 was used. Patients were operated on in two same-sized operating theatres, of which one was equipped with a floor drainage used for transurethral surgery (e.g. transurethral resection of the prostate or bladder). The floor drainage was permanently installed in the operating theatre and connected to the fluid-collecting system of the transurethral resection set via a closed tube system. The decision as to whether a patient undergoing prostatectomy or (partial) nephrectomy was scheduled in the operating theatre with or without floor drainage depended only on organisational reasons for operating theatre planning. Before surgery the theatres were cleaned according to the same standard protocol. No special cleaning of the floor drainage was performed. All patients received the same standard antibiotic prophylaxis of a single shot of 2 g cefazolin 30 min before incision. After radical prostatectomy antibiotic prophylaxis was switched to oral (cephalexin) and continued for 4 days. After (partial) nephrectomy no further antibiotics were given. Operations were performed using a standardized technique by three experienced surgeons. Surgeries were done on an elective basis with the exception of two emergency nephrectomies, of which one was in the theatre with and one in the theatre without floor drainage. Smears were taken from the floor drainage every 3 months during the study period. Bacterial species of smears from the floor drainage were compared with the bacterial species that were found in SSIs on species level. There was no comparison done for genetic analogy of the proven bacterial species from these two origins. Both groups were analysed with regard to age, gender, BMI, ASA class, presence of diabetes and length of hospital stay (table 1). Qualitative parameters were calculated by χ2 test and
Urol Int 2014;93:38–42 DOI: 10.1159/000355572
39
quantitative parameters by t test to assess differences between the groups. Statistical calculations were performed using the Statistical Package for the Social Sciences 15.0 software (SPSS Inc., Chicago, Ill., USA). The hypothesis that overall SSIs and deep organ/space infections are more frequent after operations in a theatre with floor drainage compared to operations in a theatre without floor drainage was examined using the χ2 test. A p value
Urologia Internationalis
Received: July 24, 2013 Accepted after revision: September 10, 2013 Published online: February 18, 2014
Urol Int 2014;93:38–42 DOI: 10.1159/000355572
Multifunctional Use of an Operating Theatre: Is Floor Drainage Posing an Increased Risk of Infection? Hendrik Borgmann a Florian Wagenlehner b Stefan Borgmann c Walter Thon d a Department of Urology, University Hospital Frankfurt, Frankfurt, b Department of Urology, Paediatric Urology and Andrology, Justus Liebig University, Giessen, c Department of Infectious Diseases and Infection Control, Klinikum Ingolstadt, Ingolstadt, and d Department of Urology, Klinikum Siloah, Hannover, Germany
Key Words Wound infection · Surgical site infection · Floor drainage · Prostatectomy · Nephrectomy
skin incision surgery does not increase SSI rates. Thus, multifunctional use of theatres with floor drainage might lead to a gain in flexibility in the use of operating theatre capacity. © 2014 S. Karger AG, Basel
Abstract Introduction: For transurethral urologic surgery floor drainage is necessary for disposal of large amounts of fluid; for skin incision surgery floor drainage is unnecessary. The presence of floor drainage in an operating theatre may have a negative impact on the surgical site infection (SSI) rate after skin incision surgery due to aerosol contamination. We examined whether multifunctional use of an operating theatre would increase the SSI rate after skin incision surgery. Patients and Methods: Patients undergoing skin incision surgery on the kidney or prostate were prospectively divided into two groups with regard to operating theatre equipment. 272 patients were operated on in a theatre with floor drainage and 755 patients were operated on in a theatre without floor drainage. SSIs were categorized using the CDC classification and SSI rates in the two different theatres were determined. Results: No statistically significant difference (p = 0.86) in SSI rates after kidney and prostate surgery was found for operations in theatres with (2.6%) and without floor drainage (2.8%). Conclusions: Multifunctional use of an operating theatre with floor drainage for transurethral and
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0038$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Surgical site infections (SSIs) are among the most commonly reported types of healthcare-associated infections in patients undergoing surgery [1]. Infections increase the morbidity and mortality of patients and are a huge burden to national healthcare systems [2]. The costs for a patient with SSI are, on average, doubled compared to the costs for a patient without SSI [3]. Therefore, SSIs are a key target for nosocomial infection control programs, resulting in relative reductions of 25–38% in the SSI rate [4, 5]. Flexibility is a key demand directed to all participants in the healthcare sector in order to save human and financial resources. Pressure for cost effectiveness is steadily increasing, especially in developed countries. The operating theatre has been found to account for up to 40% of total hospital costs [6]. Various procedures, e.g. parallel induction of anaesthesia [7] and introduction of standard operating procedures [8], have improved operating theatre organization Dr. med. Hendrik Borgmann Klinik für Urologie und Kinderurologie Universitätsklinikum Frankfurt Theodor-Stern-Kai 7, DE–60590 Frankfurt (Germany) E-Mail hendrik.borgmann @ kgu.de
and efficiency, leading to reduced cost of surgery. However, research to optimize operating theatre efficiency is still increasing [9]. Any gain in flexibility will be a potential optimizing factor for efficient use of operating theatre capacity. Urologic surgery comprises a wide variety of operations requiring special equipment in the operating theatre. Two major groups of urologic surgery are transurethral surgery and skin incision surgery. Transurethral surgery requires large amounts of irrigation fluid and therefore floor drainage is necessary for adequate disposal of the irrigation fluid. Transurethral surgery is associated with a high percentage of urinary tract infections (up to 9.1%) [10]. In contrast, urologic skin incision surgery usually results in low postoperative infection rates (up to 3.2%) [11]. In contrast to transurethral surgery, floor drainage is not necessary in urologic skin incision surgery. Moreover, the presence of floor drainage might facilitate the formation of bacteria-containing aerosols, leading to an increased bacterial burden eventually resulting in additional SSI rates. Consequently, it seems desirable to perform skin incision surgery in operating theatres without floor drainage. The standards and requirements for operating theatre equipment vary among different countries. In Germany, for example, it is advised not to use a floor drainage inside an operating theatre [12]. On the other hand, from an economic perspective, it is beneficial to perform transurethral and skin incision surgeries in the same operating theatre to maximize logistic flexibility. Since floor drainage is essential for transurethral operations, both groups of operations, transurethral and skin incision surgery, should be performed in theatres exhibiting floor drainage. The aim of the present study was to examine whether the presence of floor drainage in the operating theatre causes an increased SSI rate. For this purpose, skin incision surgery was performed in operating theatres with or without floor drainage and the corresponding SSI rates were compared. Patients and Methods From 2007 until 2012, data were collected from 1,027 patients who underwent the indicator operations open radical prostatectomy, open (partial) nephrectomy and laparoscopic (partial) nephrectomy at our institution. The standard data collection protocol comprised information on the operation and on the patient. Data concerning the operation included type of operation, operation time, operating surgeon and presence of floor drainage in the operating theatre. Data concerning the patient included age, gender, BMI, ASA class, presence of diabetes mellitus, length of hospital stay, presence of SSI, CDC class of SSI, bacterial pathogen
Multifunctional Operating Theatre Use
Table 1. Characteristics of patients operated on in theatres with and without floor drainage Parameter
Open nephrectomy Open partial nephrectomy Laparoscopic nephrectomy Laparoscopic partial nephrectomy Open prostatectomy Age, years Male Female BMI ASA class Diabetes mellitus Hospital stay, days
Patients operated on in theatre with floor drainage (n = 272)
Patients operated on in theatre without floor drainage (n = 755)
14 (5%) 29 (11%) 48 (18%)
40 (5%) 77 (10%) 145 (19%)
49 (18%) 132 (49%) 68±6.9 219 (81%) 53 (19%) 24±4.2 2±1 24 (9%) 8±2.3
139 (18%) 354 (47%) 66±5.3 596 (79%) 159 (21%) 25±3.8 2±1 60 (8%) 8±2.1
For age, BMI, ASA class and hospital stay, median values and ranges are listed.
causing SSI, necessity for operative revision and cause of operative revision. SSIs were classified according to the CDC classification into superficial, deep incisional and organ/space infections [13]. For documentation of data Microsoft Excel version 2003 was used. Patients were operated on in two same-sized operating theatres, of which one was equipped with a floor drainage used for transurethral surgery (e.g. transurethral resection of the prostate or bladder). The floor drainage was permanently installed in the operating theatre and connected to the fluid-collecting system of the transurethral resection set via a closed tube system. The decision as to whether a patient undergoing prostatectomy or (partial) nephrectomy was scheduled in the operating theatre with or without floor drainage depended only on organisational reasons for operating theatre planning. Before surgery the theatres were cleaned according to the same standard protocol. No special cleaning of the floor drainage was performed. All patients received the same standard antibiotic prophylaxis of a single shot of 2 g cefazolin 30 min before incision. After radical prostatectomy antibiotic prophylaxis was switched to oral (cephalexin) and continued for 4 days. After (partial) nephrectomy no further antibiotics were given. Operations were performed using a standardized technique by three experienced surgeons. Surgeries were done on an elective basis with the exception of two emergency nephrectomies, of which one was in the theatre with and one in the theatre without floor drainage. Smears were taken from the floor drainage every 3 months during the study period. Bacterial species of smears from the floor drainage were compared with the bacterial species that were found in SSIs on species level. There was no comparison done for genetic analogy of the proven bacterial species from these two origins. Both groups were analysed with regard to age, gender, BMI, ASA class, presence of diabetes and length of hospital stay (table 1). Qualitative parameters were calculated by χ2 test and
Urol Int 2014;93:38–42 DOI: 10.1159/000355572
39
quantitative parameters by t test to assess differences between the groups. Statistical calculations were performed using the Statistical Package for the Social Sciences 15.0 software (SPSS Inc., Chicago, Ill., USA). The hypothesis that overall SSIs and deep organ/space infections are more frequent after operations in a theatre with floor drainage compared to operations in a theatre without floor drainage was examined using the χ2 test. A p value
