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Patient Safety Tip of the Week
More on OR
Traffic and Surgical Site Infections
OR traffic, with frequent opening and
closing of doors leading to the OR, is a potential risk factor for SSI’s
(surgical site infections). Seidelman et al. (Seidelman
2023), in their review
of surgical site infection prevention,
discussed risk factors for SSI’s. Among the modifiable operation–related
factors associated with SSI’s, they noted that airborne
contamination (raising the amount of microorganisms in
the operating room environment) provides an additional opportunity for surgical
site infection. And they acknowledge that most of the airborne pathogens are generated
by persons in the operating room and their movements.
Kuehl and colleagues (Kuehl
2025) recently studies the
influence of OR traffic on airborne microbial counts during 2 types of
abdominal surgery that tend to have the highest SSI rates – colon surgery and
abdominal hysterectomy. They did microbial counts during those procedures in 16
OR’s in 4 facilities in an integrated healthcare
system in the Midwest.
Sterile agar “settle” plates were placed in
strategic sites. The set-up plate was positioned on the OR bed where a patient
would be positioned during the procedure. This plate was opened during setup,
closed when the patient was transported into the OR, and set aside until the
end of the procedure. Two wound zone plates were inserted into custom
surgical steel plate holders and clipped to the drape. To gather deposits on
the sterile back table, two back table zone plates were positioned on
opposite corners of the back table within the laminar airflow curtain.
The median total door-opening count was 74 per
procedure (range 42.0 to 168.0), with significantly more openings during colon
surgeries when compared to abdominal hysterectomies. The median door-opening rate
for all procedures was 20 per hour (0.33 per minute).
The microbial deposits for all locations and
operative phases were weakly correlated with the total door-opening counts and
increased personnel counts during procedures, suggesting that deposits increase
when the number of door openings and personnel increases. That relationship was
slightly stronger when evaluated for case phase only (as opposed to the setup
phase). There was only 1 SSI during the study, though the total number of cases
(n = 60) limited the statistical power to correlate OR traffic with actual SSI’s.
Perhaps the best takeaway from the Kuehl
article is the example of the tracking tool they used to monitor OR traffic
(Figure 1 in the Kuehl article). If you plan to track OR traffic in your
facility, you may want to use a tool like that. Supply management, staffing
changes, and communication were the most frequent reasons for door opening in
both the setup and operative phases. On average, nurses were responsible for
38% of door openings, with approximately one third of those openings occurring
during room setup. Scrub personnel contributed to 19% of door openings, and
anesthesia professionals were responsible for 15%. Those statistics are similar to those from most other studies that have measured
OR traffic.
Your OR staff probably significantly
underestimates how often those OR doors open and close. The first step is
getting an accurate estimate and identifying the common reasons for such.
Increasing awareness and understanding why it is important to reduce unnecessary
OR traffic is just a first step. You then need to tailor your interventions to
address the specific reasons at your facility.
Unless you have a good understanding of why
the OR door is opening, you are unlikely to have a successful intervention. The
method used by Kuehl et al. was good, but labor intensive (they had trained
observers collecting the data). In several of our columns we’ve advocated
keeping a log where staff are required to log in every time they leave and
enter the OR for each case. To counter your staff’s objections that this might
be time consuming, use a voice assistant like Amazon’s “Alexa” to simply add
each reason to a list. We’ve often mentioned that “black box” video monitoring
in the OR, which has multiple applications, can also provide estimates of OR
traffic.
Low-cost interventions like placing a
noticeable sign on the door prohibiting nonessential traffic, along with
retractable tape that creates a small barrier to opening the door, may increase
awareness. Perhaps the most effective intervention is ensuring
that necessary equipment and supplies are in the OR before the start of the
procedure. That requires proper planning and knowledge of needs for individual
surgeons and/or anesthesiology staff. That’s where pre-op huddles may be very
important. And post-op debriefings can identify supplies or equipment that can
be incorporated for future cases. Proper planning to schedule staff breaks
should also help reduce unnecessary door opening.
Alternative means of communication, such as
using phones or the intercom, has also been suggested as a way to reduce OR door opening. However, we would
caution that such audible means could also create distractions or interruptions
that could be detrimental. Perhaps more directed silent methods (like texting)
would be less likely to distract multiple members of the OR team. Keep in mind
we have also written frequently about the dangers of cell phones and texting in
the OR (see our June 2025 What's New in the Patient Safety World column “Cellphones
and the Surgical Timeout”).
Of course, OR traffic has another
potentially adverse effect: it increases distractions and interruptions that
can lead to errors. Several of our prior columns on OR traffic listed below
address that impact in addition to the impact of OR traffic on SSI’s.
Our
prior columns focusing on surgical OR foot traffic and door opening:
·
March
10, 2009 “Prolonged Surgical Duration and Time
Awareness”
·
January 2010 “Operative Duration and Infection”
·
August
26, 2014 “Surgeons’ Perception of Intraoperative Time”
·
December
30, 2014 “Data Accumulates on Impact of Long Surgical
Duration”
·
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
·
July 26,
2016 “Confirmed:
Keep Your OR Doors Closed”
·
December
2017 “A
Fix for OR Foot Traffic?”
·
April
23, 2019 “In and Out the Door and
Other OR Flow Disruptions”
·
June 8,
2021 “Cut OR Traffic to Cut
Surgical Site Infections”
·
January
11, 2022 “Documenting Distractions in
the OR”
·
October
4, 2022 “Successfully Reducing OR
Traffic”
·
August 20, 2024 “Air Traffic Control for the
OR?”
·
January 28, 2025 “Reducing Traffic in the OR”
References:
Seidelman JL, Mantyh
CR, Anderson DJ. Surgical site infection prevention: a review. JAMA 2023; 329(3):
244-252
https://jamanetwork.com/journals/jama/article-abstract/2800424
Kuehl M., Mitchell K., Crucero M., et al.
The Association Between OR Traffic and Airborne Microbial Counts During Two
Types of Abdominal Surgeries. AORN J 2025; 121(5): 344-360
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.14335
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