Citation
Effect of Time of Day on Door Opening Rates in Neurosurgical Operating Rooms

Material Information

Title:
Effect of Time of Day on Door Opening Rates in Neurosurgical Operating Rooms
Creator:
Almond, Crystal R
Publisher:
University of Florida
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Epidemiology
Committee Chair:
PRINS,CINDY A
Committee Co-Chair:
YAGHJYAN,LUSINE
Committee Members:
SIMONNE,AMARAT

Subjects

Subjects / Keywords:
door
neurosurgical
ssi

Notes

General Note:
Surgical site infections (SSIs) present both physical and financial problems for patients and hospitals, alike. One well-known risk factor of SSIs is the frequency of which a door is opened during a surgical procedure. This is due to a disturbance in airflow and a compromise of the positive pressure environment. Twenty-four different procedures were observed in this observational study and categorized under three different times of day, Morning (N=10), Mid-day (N=10), and Afternoon (N=4). The procedures were further stratified into pre-incision and post-incision periods. The effect of time of day was analyzed as an independent variable on door opening frequencies by seven categories of professionals, six reasons for door openings, and three types of doors in the operating room. Mean rates of door openings per hour appeared to decrease as the day progressed among the pre-incision and post-incision periods and although the difference was not statistically significant, the trend approaches significance during the pre-incision period.

Record Information

Source Institution:
UFRGP
Rights Management:
All applicable rights reserved by the source institution and holding location.
Embargo Date:
5/31/2019

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1 EFFECT OF TIME OF DAY ON DOOR OPENING RATES IN NEUROSURGICAL OPERATING ROOMS By CRYSTAL ROSE ALMOND A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2018

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2 2018 Crystal R. Almond

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3 ACKNOWLEDGMENTS I thank the staff in the department of Infection Control at UF Health Shands, especially Deena Schuman, for making this study possible. I thank the staff in the operating rooms for allowing me to proceed with my observations and the members of the UF Libraries for their assistance. I thank my chair, Dr. Cindy Prins, and the members of my supervisory committee, Dr. Lusine Yaghjyan and Dr. Ama rat Simonne, for their mentoring. Lastly, I thank my parents for their constant support and encouragement throughout the duration of my enrollment in this program.

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4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ...... 3 LIST OF TABLES ................................ ................................ ................................ ................ 5 LIST OF FIGURES ................................ ................................ ................................ .............. 6 ABSTRACT ................................ ................................ ................................ .......................... 8 CHAPTER 1 INTRODUCTI ON ................................ ................................ ................................ .......... 9 2 METHODS ................................ ................................ ................................ .................. 11 Analysis ................................ ................................ ................................ ....................... 11 Variables ................................ ................................ ................................ ..................... 11 Overall Methodology ................................ ................................ ................................ ... 12 3 RESULTS ................................ ................................ ................................ .................... 15 4 DISCUSSION ................................ ................................ ................................ .............. 21 5 SUMMARY and CONCLUSION ................................ ................................ ................. 24 REFE RENCE LIST ................................ ................................ ................................ ............ 25 BIOGRAPHICAL SKETCH ................................ ................................ ................................ 27

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5 LIST OF TABLES Table page 3 1 Mean Rate of Door Openings per Hour by Time of Day and Incision .................. 16 3 2 Mean Rate of Door Openings per Hour by Time of Day and Professional .......... 18 3 3 Mean Rate of Door Openings per Hour by Time of Day and Reason .................. 19 3 4 Frequency of Door Use during Incision Periods for Room A ................................ 19 3 5 Frequency of Door Use by Professionals for Room A ................................ .......... 19 3 6 Frequency of Door Use during Incisio n Periods for Room B ................................ 19 3 7 Frequency of Door Use by Professionals for Room B ................................ .......... 20

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6 LIST OF FIGURES Figure page 2 1 This is a diagram of the layout of Neurosurgical Operating Rooms A, B, and C. ................................ ................................ ................................ ............................. 14 3 1 These box plots represent the rates of door openings per hour by time of day (morning, midday, and afternoon) during the p re incision periods. ...................... 17 3 2 These box plots represent the rates of door openings per hour by time of day (morning, midday, and aft ernoon) during the post incision periods. ..................... 18 3 3 Total Door Openings and Total Duration of Procedure ................................ ......... 20

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7 LIST OF ABBREVIATIONS CDC Centers for Disease Control and Prevention CFU Colony Forming Units HAI Healthcare Associated Infections MRI Magnetic Resonance Imaging OR Operating Room SAS Statistical Analysis Software SSI Surgical Site Infection UF University of Florida

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8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science EFFECT OF TIME OF DAY ON DOOR OPENING RATE S IN NEUROSURGICAL OPERATING ROOMS By Crystal Rose Almond May 2018 Chair: Cindy A. Prins Major: Epidemiol ogy Surgical site infections (SSIs) present both physical and financial problems for patients and hospitals alike. The frequency of which a door is opened during a surgical procedure One well known risk factor of SSIs is. Door openings cause a disturbance in airflow and a compromise of the positive press ure environment. Twenty four different procedures were observed in this study and were categorized under three different times of day, Morning (N=10), Midday (N=10), and Afternoon (N=4). The procedures were further stratified into pre incision and post inc ision periods. The effect of time of day was analyzed as an independent variable on door opening frequencies by seven categories of professionals, six reasons for door openings, and three types of doors in the operating room. Mean rates of door openings p er hour appeared to decrease as the day progressed among the pre incision and post incision periods and although the difference was not statistically significant, the trend approaches significance during the pre incision period.

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9 CHAPTER 1 INTRODUCTION Su rgical site infections (SSI) are among the most common healthcare associated infections (HAI) in the United States. In one prevalence survey, more than 21% of HAIs were attributed to SSIs. 1 SSIs have been shown to consistently result in longer hospital sta ys and readmission, and are known to contribute to mortality rates. 2 Heavy financial burdens of SSIs can be observed for both the patient and the hospital. One study carried out in an English hospital found very high critical care costs for SSI events. 3 Ot her increasing costs included running an operating room and the length of stay. 3 SSIs can occur when bacterial contamination of the operating room (OR) suite takes place. Patients are at an increased risk of developing an SSI if they are obese, smoke, have diabetes mellitus, or have microorganism colonization. 4 Perioperative contaminations may be introduced to the OR environment through door openings during procedures. Researchers have found positive correlations between the number of door openings and the number of colony forming units (CFU) found in an operating room (OR). 5,6 The negative effect of door openings on airflow in the OR has also been well established. 7,8,12,13 One way the quality of air in operating rooms has been improved is by the installati on of laminar ventilation. 9 Even still, Door openings are known to result in temperature changes, therefore jeopardizing positive pressure environments. 5 The importance of assessing the frequency of door openings in an OR is further enhanced when a particu lar room has more than one door in use. 8 This is the case when there is an additional door, which can lead to a sterile or sub sterile room, apart from the main entrance. The positive pressure state present in an OR is compromised if both doors are opened at the same time, even if just for a few seconds. 8

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10 There is reason to hypothesize that behaviors regarding preparedness in the OR change as the day progresses. Wrong site surgeries have occurred due to distractions or certain situations that must be addres sed as they occur throughout the day 10 A study published in 2014 found a significant difference in risk of a surgical site infection in patients who were first on the operating schedule as opposed to those who were last. 11 The authors observed a nearly dou bled rate of SSIs among patients who were last on the list when compared to those who were first. One study released in 2009 observed door openings over the duration of 2 neurosurgical procedures, among other specialties, and found that door opening freque ncy was highest during the pre incision period and rose around noon, presumably when staff went on break. 12 To our knowledge, no study has ever observed the effect that time of day has as an independent predictor of door opening frequency in neurosurgical procedures in a sample as large as this (N=24). Our study aims to elucidate whether precautionary behaviors and preparedness change throughout the day by assessing reasons staff enter or exit the OR during an operation. If significant differences in OR be haviors are observed as the day progresses, addressing these problems can help reduce the risk of SSIs.

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11 CHAPTER 2 METHODS Analysis Twenty four observations were recorded on Excel spreadsheets over a period of 10 days. The counts of door openings were an alyzed using the statistical analysis software, SAS 9.4. A one way analysis of variance (ANOVA) was utilized to determine if statistical differences existed among the mean rates of door openings per hour. Frequencies of door use were assessed and recorded in counts and percentages. =0.05) was used to analyze the relationship between the frequency of door openings and the duration of the procedure. Variables The time of day was categorized into three groups: Morning (betwe en 7:30 A.M. and 11:00 A.M.), Mid day (between 11:01 A.M. and 2:00 P.M.), and Afternoon (occurring after 2:00 P.M.). These time frames were logistically determined by taking lunch breaks, shift start and end times, and typical surgical scheduling into consi deration. The duration of pre incision and post incision periods were recorded. The pre incision period began at the time the sterile field was opened and ended at the time of incision. The post incision period began at the time of incision and ended at th e time the suturing process was completed. Professionals were categorized into one of 7 groups: Surgeon, Anesthesia, Surgical Nurse, Scrub Technician, Specialty, Research Team, and Other. Each of the seven groups included residents, attending physicians, n urses, and technicians working in their given field. For example, the Anesthesia category included residents and their attending physicians, nurse anesthetists, and anesthesia technicians. The Specialty

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12 group included doctors from the department of neurolo gy and the department of radiology. Reasons for door openings were categorized into one of six groups: Work Related Conversation, Non Work Related Conversation, Equipment/Medication Retrieval, Break/Relief/Scrub In, Status Update/Future Procedure Discussio n, or Other/Unknown. The fourth group identified as Break/Relief/Scrub In was created to include surgeons who do not typically go on break in the middle of a procedure but do scrub in, unlike many of the other professionals. Reasons for door openings were not quantified during the pre incision period. A series of variables for the duration of each procedure, the counts of door openings, and the time each procedure occurred were imported into SAS 9.4. Variables were created in SAS for rates of door openings per hour (frequency of door openings divided by the duration of the procedure, in minutes, times 60) during the pre incision and post incision periods of each typ e of door. The means in Tables 3 1 3 2 and 3 3 were calculated in SAS using the values of th ese new variables. Overall Methodology This was an observational study that took place in the new medical tower at UF Health Shands Hospital. This academic hospital houses nearly 1,000 licensed beds in Gainesville, Florida and has been ranked as one of the Neurology and Neurosurgery. 13 Observations occurred in three different operating rooms designated for neurosurgical procedures. Pre incision periods were documented after the first observation. In one observation, the post incision period was not recorded as the surgery was postponed. Twenty three pre incision periods were recorded and lasted anywhere from 14 to 100 minutes with one outlier of 137 minutes. Twenty three post

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13 incision periods were recorded and lasted anywhere from five to one hundred and ninety four minutes in length. While all procedures performed are classified under conventional techniques (non robotic), rooms varied in the type of procedure that typically took place in them and in the different types of do ors that were part of their design. It is for this reason that frequency of door use was assesse d by room, as seen in Tables 3 4, 3 5 3 6, and 3 7 Room A (Figure 2 ) allows for access to a highly controlled, positive pressurized environment where only ste rile equipment is stored and Room B allows for access to a sub sterile storage area. The doors leading to these particular rooms were labeled as Door Z and Door Y, respectively. Rooms A, B, and C are laminar ventilated rooms. All three rooms have the stand ard hallway door for patient entry, labeled Door X. In addition to the standard do uble doors in room B (Figure 2 ) and room C (Figure 1 3), these rooms also have access to a magnetic resonance imaging (MRI) room. All observations were made by the principal investigator and the study was approved under the institutional review board at the University of Florida. All procedures were elective surgeries and none took place in an emergency situation. Only procedures tha t required the setup of an open sterile field were included in the analysis.

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14 Figure 2 1 This is a diagram of the layout o f Neurosurgical Operating Rooms A, B, and C Sterile Field Nurse Station Sterile Zone (Z) Anesthesia N on Sterile Zone (X) Room A A Sterile Field Patient Bed Nurse Station Anesthesia M RI R oom N on S terile Z one (X) S ub Sterile Z one (Y) Room B B Sterile Field Patient Bed N urse St ation Anesthesia M RI R oom N on S terile Door (X) Room C C

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15 CHAPTER 3 RESULTS Although all observations were carried out on neurosurgical procedures, the length, and therefore frequency, of door openings varied by the type of procedure and its complexity. Twenty four observatio ns were made over the course of ten days. Ten of the 24 observations were categorized as occurring in the morning, ten were categorized as midday, and four were categorized as afternoon. Procedures ranged in length from 19 minutes to 318 minutes, including the sterile field setup (the pre incision period). Rates of the number of door openings per hour were determined for both the pre incision and post incision periods. A decreasing trend is apparent in the pre incision period where the mean rate of door ope nings per hour was 42.40 and the mean rate in the latter part of the day was observed to be 32.4 8 openings per hour (Table 3 1 ). However, this was not statistically significant (Pr>F = 0.0782). Furthermore, a decreasing trend can be seen in the mean rates of door openings per hour during the post incision period, although this difference also lacks statistical significance (Pr>F = 0.3445). Further analyses do not show a statistically significant difference in door opening tendencies throughout the day among professionals in their given categories (Table 3 2 ): Surgeons (Pr>F = 0.6418), Anesthesia (Pr>F = 0.58196), Surgical Nurses (Pr>F = 0.6974), Scrub Technicians (Pr>F = 0.5897), Specialty (Pr>F = 0.2863), Research Team (Pr>F = 0.1218), or among the professi 0.9956). Differences among reasons for door openings were not statistically significant throughout the day either (Table 3 3): Work Related Conversation (Pr>F = 0.6033), Non Work Related Conversation (Pr>F = 0.1427), Equipment/Medication Retrieval

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16 (Pr>F = 0.5959), Break/Relief/Scrub In (Pr>F = 0.0810), Status Update/Future Procedure Discussion (Pr>F = 0.5093), or Other/Unknown (Pr>F = 0.5026). A significant positive correlation (0.93141) was observed between the freque ncy of door openings and the duration of the procedure with a p value of < 0. 0001, as can be seen in Figure 3 3 the scatter plot. Specific tendencies for the use of the different types of doors were assessed. Since the layo ut of each room varied (Figure 2 ), door use was assessed by room. During the pre incision and post incision periods in Room A, Door X was used approximately 67.2 and 69.4 percent of t he time, respectively (Table 3 4 ). Door X was used more frequently by the groups: surgeons (100%), scrub technician (67.4%), specialty (96.2%), research team (100), and ot her (81.3%) in Room A (Table 3 5 .). During the pre incision and post incision periods in Room B, Door X was used approximately 86.3 and 80.8 percent of t he time, respectively (Table 3 6 ). Do or X was used more frequently by all categories of professionals: surgeons (82.6%), anesthesia (85%), surgical nurse (79.6%), scrub technician (94.9%), specialty (100%), research team (60%), and ot her (82.4%) in Room B (Table 3 7 .). Because Room C did not have a door leading to a sub sterile or sterile area, all door openings occurred via Door X. The doors leading to the MRI room were not used in Room C and used only once in Room B over the course of these observations. Table 3 1 Mean Rate of Door Openings per Hour by Time of Day and Incision Incision Morning Midday Afternoon p value Pre incision 42.40 36.79 32.48 0.0782 Post incision 20.69 17.06 14.19 0.3445

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17 Figure 3 1 These box plots represent the rates of door openings per hour by time of day (morning, midday, and afternoon) during the pre incision periods.

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18 Figure 3 2 These box plots represent the rates of door openings per hour by time of day (morning, midday, and afternoon) during the post incision periods. Table 3 2 Mean Rate of Door Openings per Hour by Time of Day and Professional Professional Morning Midday Afternoon p value Surgeon 13.56 12.70 9.00 0.6418 Anesthesia 11.89 9.90 8.25 0.5896 Nurse 14.44 18.00 13.75 0.6974 Scrub Technician 9.22 10.30 6.40 0.5897 Specialty 4.67 5.10 0.00 0.2863 Research 1.70 0.50 0.00 0.1218 Other 9.44 9.10 9.50 0.9956

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19 Table 3 3 Mean Rate of Door Openings per Hour by Time of Day and Reason Reason for Door Opening Morning Midday Afternoon p value Work Conversation 1.90 1.10 1.00 0.6033 Non work Conversation 1.00 0.20 0.00 0.1427 Equipment/Medication 5.80 3.20 4.00 0.5959 Break/Relief/Scrub in 3.20 5.60 0.25 0.0810 Status Update 2.90 2.20 4.00 0.5093 Other/Unknown 13.10 15.70 5.50 0.5026 Table 3 4 Frequency of Door Use during Incision Periods for Room A Room A Door X (Non Sterile) % Door Z (Sterile) % Total % Pre incision (N = 5) 123 67.2 60 32.8 183 100 Post incision (N = 6) 184 69.4 81 30.6 265 100 Table 3 5 Frequency of Door Use by Professionals for Room A Room A Door X (Non Sterile) % Door Z (Sterile) % Total % Surgeon 63 100 0 0 63 100 Anesthesia 19 39.6 29 60.4 48 100 Nurse 72 47.1 81 52.9 153 100 Scrub Technician 29 67.4 14 32.6 43 100 Specialty 51 96.2 2 3.8 53 100 Research Team 5 100 0 0 5 100 Other 68 81.9 15 18.1 80 100 Table 3 6 Frequency of Door Use during Incision Periods for Room B Room B Door X (Non Sterile) % Door Y (Sub Sterile) % Total % Pre incision (N = 6) 302 86.3 48 13.7 350 100 Post incision (N = 5) 160 80.8 38 19.2 198 100

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20 Table 3 7 Frequency of Door Use by Professionals for Room B Room B Door X (Non Sterile) % Door Y (Sub Sterile) % Total % Surgeon 99 83.2 20 16.8 119 100 Anesthesia 84 85.7 14 14.3 98 100 Nurse 97 77.6 28 22.4 125 100 Scrub Technician 83 90.2 9 9.8 92 100 Specialty 10 90.9 1 9.1 11 100 Research Team 7 77.8 2 22.2 9 100 Other 82 87.2 12 12.8 94 100 Figure 3 3 Total Door Openings and Total Duration of Procedure

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21 CHAPTER 4 DISCUSSION The aim of this observational study was to determine if the frequency of door openings change as the day progresses in neurosurgical operating rooms. Twenty four conventional neurosurgical procedures were observed. These procedures were made up of cranioto mies, spinal fusions, deep brain stimulations (parts 1 & 2), burr holes, and biopsies. The pre incision period was not recorded for one of the surgeries and the post incision period was not observed for a separate procedure, bring the total pre incision an d post incision periods recorded to twenty three each. The mean rate of door openings per hour was higher during pre incision period (38.23) when compared to the mean rate of door openings during the post incision period (18.26) (data not shown). This is perhaps due to a lower perception of risk by the staff because the patient is no longer in the room. Lynch et al. observed a mean rate of 42 door openings per hour, with approximately 30% of events occurring during the pre incision period. 12 A one way anal ysis of variance was utilized to assess a difference in means between the three different times of day, Morning: Mid day, and Afternoon. The results from this study, although not statistically significant (Pr>F = 0.0782), approach significance and imply th at time of day may be associated with the rate of door openings per hour. A significant value may be seen with a larger sample size. The high rate of door openings per hour in the morning, prior to the time of the incision may be due to OR staff arriving f or shift or the retrieval of supplies needed to start the day. Although not statistically significant (Pr>F = 0.3445), a decreasing trend in the rate of door openings was also observed to occur during the post incision period.

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22 There appeared to be a differ ence between the mean rates of door openings per hour for Break/Relief/Scrub In, although not statistically so (Pr>F = 0.0810). This slight increase in door openings could be due to the midday lunch break. The increase in door opening rates by nurses and s crub technicians arou nd Midday can be seen in Table 3 2 The majority of door openings occurred by the surgical nurses. Teter et al. also found the majority of door openings occurred by the nursing staff. 14 (Pr>F = 0.5959). Equipment and medication may have been prepared and retrieved during the pre incision period, where specific reasons for door openings were not quantified. Teter et al. concluded that the main reason personne l opened the door was to retrieve equipment for the case. 14 This is similar to results obtained through these observations, as equipment/medication retrieval was the reason with the highest n). It is worth noting that a large rate of door openings occurred for a reason not obvious to the 3 Perhaps this is where staff could cut down on the frequency for which the door opens if the reason did not correctly fall under any of the necessary categories such as those for lunch breaks and equipment retrievals. The positive correlation coefficient provided for the relationship between duration of the surgery and the number of door openings has been sh own in numerous studies to date. 7, 12. To our knowledge, no other study has observed time of day as an independent factor for the frequency of which a door is opened. Since there is evidence that having more than one door open in the operating room at the same time

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23 jeopardizes the integrity of a positive pressure room, OR staff should be cautious when entering and exiting the room. A strength of this study was the lack of variation in the recording of data since there was only one individual making all of the observations. The observer sat in a low traffic area of the operating room and did not ask the staff for the reason of each door opening to limit the alteration of behavior by the staff (Hawthorne effect). To our knowledge, this is the largest sample o f neurosurgical procedures for which door opening procedures were assessed. One weakness in this study was the inequality in sample sizes between the times of day. Another weakness was that reason for door opening was subject to misclassification bias sinc e the reason was not asked of the professional opening the door. Although all procedures observed were classified as neurosurgeries, there are several types of neurosurgeries that vary in length according to their complexity and this was not controlled for

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24 CHAPTER 5 SUMMARY and CONCLUSION Although decreasing trends were observed in the mean rates of door openings during both pre incision and post incision periods, these differences were not statistically significant. Since a high rate of door openings was observed during the pre incision period, future studies should investigate the added risk this rate has on the sterility of the open field. Active settle plates should be considered as a method for assessing influence of door openings on the sterile fi eld as a significant positive association was found between door openings and microbial counts in a previous study. 15

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25 REFERENCE LIST 1. Pr evalence Survey of Health Care New England Journal of Medicine vol. 370, no. 13, 2014, pp. 1198 1208., doi:10.1056/nejmoa1306801. 2. Badia, J.M Journal of Hospital In fection vol. 96, no. 1, 8 Mar. 2017, pp. 1 15., doi:10.1016/j.jhin.2017.03.004. 3. Jenks, P.J and Predicted Financial Consequences of Elimination of SSI from an English Journ al of Hospital Infection vol. 86, no. 1, 16 Oct. 2013, pp. 24 33., doi:10.1016/j.jhin.2013.09.012. 4. Halyard Health. 5. Mathijssen, Nina M.C Colony Forming Units in the Operating Room during Hip Revision Surgical Infections vol. 17, no. 5, 5 Nov. 2016, pp. 535 540., doi:10.1089/sur.2015.174. 6. Andersson, Annette Erichsen, et Explorative and Descriptive Study on Air Quality during Orthopedic Trauma American Journal of Infection Control vol. 40, no. 8, 2012, pp. 750 755., doi:10.1016/j.ajic.2011.09.015. 7. Mears, Simo Orthopedics vol. 38, no. 11, Nov. 2015, pp. e991 e994., doi:10.3928/01477447 20151020 07. 8. Weiser, Mitchell C, et al. nd Journal of American Academic Orthopedic Surgery vol. 26, no. 5, 1 Mar. 2018, doi:10.5435/JAAOS D 16 00891. 9. Andersson, Annette Erichsen, et al. Airflow Systems in Operating Rooms and th e Influence of Human Factors: American Journal of Infection Control Elsevier Inc., 2014. 10. 2010: A 65 Year Old Woman with an Incorrect New England J ournal of Medicine vol. 363, no. 20, 2010, pp. 1950 1957., doi:10.1056/nejmcpc1007085.

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26 11. Turkish Journal Of Medical Sciences vol. 44, 27 May 2014, pp. 674 680., doi:10.3906/sag 1305 47. 12. Lynch, Raymond J, et al. American College of Medical Quality vol. 24, no. 1, 2009, do i:10.1177/1062860608326419. 13. U.S. News & World Report 2018. https://health.usnews.com/best hospitals/rankings/neurology and neurosurgery 14. American Journal of Infection Control vol. 45, no. 5, 2017, pp. 477 482., doi:10.1016/j.ajic.2016.12.018. 15. Scaltriti, S., et al. Journal of Hospital Infection 25 July 2007, doi:doi:10.1016/j.jhin.2007.05.019.

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27 B IOGRAPHICAL SKETCH Crystal Rose Almond graduated with a Bachelor of Science in b iology from Florida International University in the spring of 2016. Here, she was involved in leadership positions for various healthcare related organizations. She began a ma degree at the University of Florida after graduating from FIU and defended her thesis in March of 2018. She g raduated with an M.S. from the D epartment of Epidemiology at UF in the spring of 2018.