In my experience, there are two kinds of people in the world. The first adheres to rules rigidly and spends much of their time maintaining the status quo, dotting the I's and crossing the T's. This kind of person feels most comfortable as a result of the rules. The other enjoys working more outside the bounds. This person feels the rules are more of a suggestion, and getting the job done is more important. Essentially, the ends justify the means. Although these two perspectives seem diametrically opposed, there may be a way for the two to meet, and that is through the use of logic and science.

I am one of those people that leans more towards the latter group. Now, don’t get me wrong; laws and rules are important or chaos will ensue. However, I am also a very task-oriented person and always want to get the job done. Sometimes, I come in direct opposition of those individuals who are in the first group, which can cause friction. Let me give you an example.

Perhaps a year and a half ago, I was about to start a surgical procedure with one of my residents and a third-year podiatry student. My resident and I had already scrubbed in, had the surgical field draped, and were about to make the incision when we noticed the student was nowhere to be found. I glanced up and saw the student near the scrub sink looking in through a window into the operating room. Annoyed, I waived the student into the room.

---

“The nurse in charge told me I couldn’t scrub because there were too many people in the room”

---

When I heard this, my blood pressure immediately elevated. Not to get overly territorial, but I am one of those surgeons who feels the operating room belongs to me during my time. I want maximal control over the environment to create an effective team and maintain good patient outcomes. Remember, it’s my medical license on the line, so I want some control.

With this running through my mind, I asked for the nurse to come into the room. I should mention here that this was not one of my operating room nurses but rather a midlevel nurse administrator. We proceeded to argue over having my student scrub in. Her argument was principally that there were too many people in the room, and it was not safe for the patient due to an increased infection risk. The fact was there were exactly six people in the operating room at the time, including the anesthesiologist, scrub tech, circulating nurse, one student, one resident, and me.

This is not an excessive number of people in the room, but the hospital had an informal policy about not having “too many people in the operating room.” There was no actual stated number indicating what “too many” meant. Then I realized that I was dealing with a robot who was incapable of understanding anything outside of the “rules.”

Keep in mind that we had not even started the procedure yet, and here I am getting angrier by the second. This is not a good situation for patient safety. Realizing this, I immediately ended the conversation, demanding the nurse leave and my student scrub in, which is exactly what happened.

The procedure went well and, of course there were no complications as a result of the six people in the room. Afterward, I spoke to the chief OR nurse to complain. I again became frustrated when the nurse told me it was “hospital policy.” Being a member of the surgery committee for the hospital, I knew there was no actual policy regarding the number of people in the operating room.

I asked for her to supply that research, and of course she couldn’t because it didn’t exist. The hospital had never done this kind of study and had created some kind of random rule based on no legitimate information. These two administrators lived in a world of rules with a complete lack of evidence.

---

“These two administrators lived in a world of rules with a complete lack of evidence. ”

---

Since this encounter, no one has challenged me on the number of people in my operating room. Score one for me.

Now, any of you who have read Practice Perfect for any period of time will know that I can’t just leave it at the narrative of what happened. I mentioned before that these two groups, the rule followers and the task completers, can meet in the middle. And that middle is the research evidence. Make rules based on scientific evidence, and any logical person will happily follow those rules.

The research is rather sparse. It turns out there are only a couple of clinical studies that directly examined operating room traffic and postoperative skin and skin structure infections (SSIs) – the only outcome that really matters in our discussion. Pryor and Messmer in 1995 did a retrospective review of 2,284 clean surgical procedures and resulting SSIs. They found a trend of increased infections with the increased number of people in the operating room, though the trend was not statistically significant.¹ This study had methodological problems including no control group and a poor statistical analysis with only descriptive statistics. Additionally, they did not isolate other potential causes of postop SSIs.

The second study is more recent and is of much higher research quality. Wanta and colleagues in 2016 did a retrospective, matched case-control study in patients undergoing clean surgery at the Mayo Clinic in Rochester, Minnesota. They had 474 patients and 803 control subjects. In a much more methodologically rigorous fashion, they looked at various operating room personnel including those who were scrubbed and not scrubbed as well as patient characteristics. They also performed a conditional logistic regression analysis that allowed them to look at specific characteristics individually.

Basically, after adjusting for the individual factors, they found the number of people in the operating room did not significantly affect the postoperative infection rate. Interestingly, they did find that specific patient characteristics such as diabetes as well as long operating room times did increase postop SSIs.²

---

“The highest quality study shows the number of people in the operating room did not significantly affect the postoperative infection rate. A large prospective randomized controlled trial is underway but yet to be published.”

---

Unfortunately, there is yet to be published a prospective randomized controlled trial to fully answer this question. But, for now it looks like I am right, and I don’t mind when that happens! For those of you in training institutions with a relatively greater number of people in the room, you can rest reasonably assured that your patients will be ok. And now you have the best available evidence to fight back with your administrations!