There is a growing body of evidence to support the theory that unnecessary staff movement can lead to environmental contamination in the operating theatre and increase the risk of surgical site infection (SSI). SSIs are among the most commonly occurring healthcare-associated infections and remain a significant cause of morbidity and mortality in the postoperative period (Lynch et al, 2009).
Brief literature searches demonstrated that traffic flow and door movement into and out of the operating theatre are important modifiable risk factors associated with SSIs owing to an increase in air and wound contamination (Lynch et al, 2009; Young et al, 2010; Birgand et al, 2014; Simons et al, 2014). Interestingly, unnecessary operating theatre traffic has also been described as a contributor to surgical error (Young et al, 2010) because of the interruption to the surgeon's concentration and an increase in noise levels within the environment.
Operating theatres are isolated, positive-pressure environments designed to recirculate air through filtered ventilation ducts. Frequent opening of theatre doors disrupts this airflow system and therefore may limit the effectiveness of measures for the prevention of SSIs (Lynch et al, 2009). A small study by Andersson et al (2012) investigated the air quality during orthopaedic trauma surgery and explored how traffic flow and the number of persons present in the operating theatre affected the air contamination rate in the vicinity of surgical wounds. The findings demonstrated that opening the operating room door disrupted the filtered atmosphere and increased contamination above the wound, which has the potential to increase the risk of SSI. They concluded that traffic flow has a strong negative impact on the theatre environment and supported interventions to reduce SSIs by reducing traffic flow within the theatre.
An observational study by Lynch et al (2009) collected data on the number of door openings, the roles of the staff members and the reasons for the events. The traffic varied from 19 to 50 door openings per hour across all surgical specialties and they identified a high rate of traffic compromising the sterile environment of the operating room.
A cross-sectional study by Young et al (2010) described the pattern of theatre traffic in a UK cardiac centre using an electronic door counter to calculate frequencies and rates of door openings during operations. The authors found that, during 46 surgical cases, the average number of door openings per case was 92.9, with 19.2 door openings per hour. This amounted to theatre doors being open for 10.7% of every hour. Therefore, in the course of a 5-hour procedure the theatre doors would be open for about 32 minutes. With door movement directly correlating with an elevated level of airborne bacteria-carrying particles in the operating theatre (Lynch et al, 2009), there is undoubtedly a negative impact on patient safety in an environment with a high rate of traffic and air-flow disruption.
The literature suggests three main reasons why staff open operating theatre doors or enter the theatre. These were theatre team members' unfamiliarity with hospital policy on entering and leaving the operating theatre during surgery, notices about unauthorised access not being visible enough, and unavailability of the telephone number on which staff within each operating theatre could be contacted. The latter resulted in the theatre door being opened for communication and information (Simons et al, 2014). Another common reason was to borrow equipment or access equipment in another operating theatre due to lack of storage within the department.
Of course there are also valid reasons for theatre door openings, which include staff breaks and shift changes (Lynch et al, 2009).
In the majority of operating theatres, the surgeon is held responsible for the outcome of surgery, which includes SSIs, and therefore the surgeon should primarily be responsible for the reduction of door movement during surgery (Simons et al, 2014). However, in reality, surgeons are often concentrating on the surgical procedure and responsibility should be determined by the nurse or operating department practitioner in charge of the theatre on the day. Defining clear rules and responsibilities could be considered the major factor in achieving a sustainable reduction in door movements during surgery (Simons et al, 2014) and the subsequent prevention of SSIs.
The literature discussed supports an observational study, previously carried out as part of a local infection prevention project at the author's trust to reduce the rate of SSIs using a bundle approach. This found that current levels of theatre traffic are unacceptably high and represent a modifiable risk factor for SSIs and error. Controlling the operating theatre environment with an appropriate ventilation system and staff discipline, with minimal movements, is therefore critical for SSI prevention.