Title: The Impact of Operating Room (OR) Traffic on Infection Risk: Reducing Movement to Improve Patient Safety

A group of surgeons in the operating room with surgery equipment. The doctor is looking at the screen.

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When seeking ways to reduce surgical site infections (SSIs), we typically focus on several key elements, including but not limited to sterile technique, antibiotic administration, and the cleanliness of instruments used during a procedure. However, other factors can contribute to the risk of infection during surgery that might be overlooked, which include personal protective equipment (PPE) use, cleanliness of the suite, temperature, humidity, hand hygiene, interruptions to workflow, number of staff, and in and out traffic to the suite. 

The failure to adhere to the different modes of transmission (direct and indirect contact, airborne, droplet, and or fomite transmission) can result in various means of contamination. In this article, we will focus on the potential impacts of traffic, interruptions, and education within the operating room (OR) environment, as these factors may increase the risk of SSIs.

Debulking the Risks

In the surgical world, staff are trained to minimize traffic during surgical interventions. However, several obstacles can impede us from meeting that expectation. Some modifiable risks to traffic flow in the OR suite include impacts on pressure changes, PPE, and hand hygiene within workflow processes. OR suites are designed to ensure optimal air pressure, allowing air to flow from clean to less clean areas (pushing air out of the room). This design shields the surgical site from infections by preventing contaminants from entering and maintains comfort measures.

Therefore, each time the door opens into the OR suite, there is a temporary disruption to the air pressure relationship, increasing the risk of bringing outside particles into the suite. A study by Lansing et al highlights that traffic interruptions into an OR suite result in a 29 times higher particle count compared to a controlled room.¹ This information provides strong evidence that frequent entry into the OR during surgery can allow particles to enter the room, thereby increasing the risk of the patient contracting an infection.

Avoidable pressure changes are not the only cause of increased particle counts. What we bring into the room can also impact particulate counts. A key consideration for maintaining an optimal operating room (OR) environment is evaluating the condition of our surgical attire.

For example, did we dress in clean surgical attire in the hospital? Or did we dress at home, subsequently and inadvertently introducing possible fomites into the OR suite? Did we take the time to ensure the entirety of our hair was tucked and completely covered by our single-use disposable head covering? Do we have facial hair, that requires us to don an appropriate beard covering? Did we enter an OR suite without donning a procedure mask?

The use of PPE while in the OR is important not only for the specialists within the sterile field but also for whomever enters the suite and the patient. Additionally, we can sometimes be carriers of certain airborne or droplet illnesses, remain asymptomatic, and cause avoidable harm to our patients inadvertently when not wearing appropriate PPE.

Another modifiable risk is the lack of hand hygiene and the transportation of contaminated items into the OR suite. If hands are not cleaned before handling supplies or equipment in the OR suite, we become the mode of transportation or vehicle for particles into designated sterile areas.

Similarly to hand hygiene, the cleanliness of equipment is also essential. Before the procedure, we prefer that all equipment be in the OR suite. However, unforeseen circumstances may also arise and hinder this. Transporting equipment into an OR suite when the sterile field is in place and surgery is active, and without knowing if and how the equipment was cleaned and disinfected, can also increase the risk to our patients. Thus, everything must be staged and ready for surgery to decrease unnecessary interruptions to the workflow.

Corresponding to the risk of door openings and particle counts within surgical cases, the potential risks associated with avoidable traffic disruptions within the suite can also increase the risk of errors, which could be costly. It is recommended by The Joint Commission to consider a systematic approach by facilitating the intentional reduction in noise pollution, interruption, and distraction, as these can impede not only concentration but also communication.^2,3Any of these may negatively affect patient outcomes, as well as patient and staff safety. Common reasons why staff frequently enter the OR suite are due to obtaining additional supplies, equipment, or communication.

Another consideration that should be reviewed is the frequency of visits to the OR suite due to a provider’s preference.⁴ This could indicate that the preference log should be revised with the provider for completeness.⁴ The risks associated with infrequent updates to provider preference cards include, but are not limited to, surgical case delays, an increase in avoidable foot traffic, and an increase in the demand for reprocessing unnecessary sterile instruments that were opened for a case.⁴

Another opportunity is the risk of utilizing Immediate-use steam sterilization (IUSS), formerly Flash sterilization, due to poor planning.⁵ An exception to this process is that implants should never undergo IUSS for immediate use.⁵ A significant risk associated with increasing surgical site infections is the use of implants. Implants should be handled with sizable care and consideration. An opportunity that may exist within some surgical centers or health care systems is the lack of utilization awareness for best practices for using implants within surgical cases. Frequent visits to the suite can distract the surgeon and staff, increasing the risk of errors. These errors can cause infection, accidental nicks or in worse may result in death.

Other considerations that should be mentioned, as many can be drawn from the above-noted concerns, include, but are not limited to, failing to update policies and procedures promptly, staff turnover, and the necessity of comprehensive foundational education and training. Staff attrition is an ever-present and significant concern within the health care realm that is not specific to perioperative services, whereas high rates of staff turnover can negatively impact processes that should be hard-wired to support patient safety and reduce harm. The potential lack of sound education, training, and competency, which is both necessary and time-consuming to maintain high proficiency, further concerns the sensitivity of the patient care environment.

References

• Lansing SS, Moley JP, McGrath MS, Stoodley P, Chaudhari AMW, Quatman CE. High number of door openings increases the bacterial load of the operating room. Surg Infect (Larchmt). 2021;22(7):684-689. doi:10.1089/sur.2020.361
• The Joint Commission. Quick Safety 35: Minimizing noise and distractions in the OR and procedural units. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-35-minimizing-noise-and-distractions-in-the-or-and-procedural-units/. Accessed January 25, 2025.
• AORN Staff. 6 design elements of a safe OR. Association of periOperative Registered Nurses. 2019. https://www.aorn.org/about-aorn/aorn-newsroom/periop-today-newsletter/2021/2021-articles/6-design-elements-of-a-safe-or. Accessed January 25, 2025.
• Decreasing operating room (OR) traffic to improve patient safety in an academic medical center. Am J Infect Control. https://www.ajicjournal.org/article/S0196-6553(19)30538-5/fulltext. Accessed January 25, 2025.
• Eberhardt GL, et al. Multidisciplinary approach to optimizing immediate use steam sterilization (IUSS) workflows between the operating room and sterile processing departments: A case report. Perioper Care Oper Room Manag. 2024;35:100408. doi:10.1016/j.pcorm.2024.100408.