Ever count the number of times the OR doors open during a case? You'd be amazed and alarmed. It could be as many as 40 door openings per hour. In and out, in and out, all case long. Why so much foot traffic during a sterile procedure? When I asked my colleagues, I got all kinds of answers.

Not surprisingly, the most common reason for door openings was to speak to someone in the room (I was guilty of that!) — to ask questions, to check on cases or to process paperwork. Some said they enter and leave for breaks or to relieve someone, while others said they left and came back to retrieve and deliver supplies during a case. Some even used the OR as a shortcut, passing through the room to get to another place in the building or to exit.

We all know that foot traffic in the OR is an infection risk. Door openings disturb the room's airflow, which can increase contamination above the incision. It can take the door as long as 20 seconds to fully close, ample time for bacteria to rush in from areas outside the OR. Here are a few simple steps to reduce foot traffic in and out of the OR — and possibly lower your infection rate.

1Let your fingers do the walking.
You just popped in the OR to ask someone a quick question or to see if they need any help, but those pop-ins aren't always necessary. We now realize that, in many cases, we don't need to talk to someone face-to-face during surgery. We now communicate with them via the phone. The phone is right outside the OR so that the person on it is visible to the OR team through a window. We've posted a list of phone numbers at every phone station, so no one has a reason to give up on using the phone because they don't have the right number. A seemingly obvious step, but one that people don't do because they're focusing more on the amount of time they're in the room rather than the fact that they opened the door to get in there and get out ("I was only in there a few minutes!"). I was guilty of this. Sometimes I'd go into the room to check on the staff or the progress of the case. Now I just pick up the phone and ask if they need anything or any help. It's kind of like Facetiming through the OR window.

2If there are implants, give them a sign.
During any type of implant surgery, you want to limit foot traffic as much as possible. We post a sign outside the room for orthopedic or breast implant procedures: "Do not come in! Implants being implanted." The sign keeps people from entering the OR, but it's also important that the OR team remains in the room until the implants have been implanted. We wait until after that critical point of surgery to relieve anyone in the room, even if, for example, it is their scheduled lunch break.

3Clear the room of unneeded equipment.
Before surgery, determine the equipment that you'll need and park the rest at a temporary spot in a hallway outside the OR. Not only does that free up space in the OR, but it keeps people from having to leave the room to get equipment that should have been there from the start. Likewise, those who would have been coming in the room in search of equipment now have easy access to it in the hallway.

4Have all supplies in the room.
Just as you should have the equipment you'll need for the case in the room before they wheel the patient in, so, too, should you have all the supplies in the room. Studies show that peak rates for OR traffic are at the beginning of the case, in the pre-incision period, when you're prepping the patient and the room and staff are arriving in the room. Researchers found that up to 20% of door openings are for supplies or equipment, and that the circulator and staff from the sterile core are responsible for up to 50% of all traffic. While some degree of flexibility is necessary to allow for intraoperative decisions or findings, most supplies should be on hand based on surgeons' pick lists. You don't want a surgeon turning to you while a patient is on the table and saying, "I need a local." Know before surgery the supplies and equipment that a surgeon likes to use so you don't have to run out and get anything. We've gotten more vigilant with the use of preference cards and the need to update them. We can pull them up on the computer before a surgery and find out the specific needs of a specific surgeon. If a doctor submits a change to his list, we make sure to make that change on the card. Updated cards are essential when assisting surgeons want to use them as reference, too.

5If they don't remember, remind them.

We already knew the consequences of opening and closing the door too much, but you'll have to remind each other to use the OR door as little as possible. Get the message out there during a quick gathering and stress the importance of minimizing foot traffic from an infection prevention standpoint.

Open-and-shut case

There are any number of ways to lower your rate of surgical site infections. All I can say is that our rate has dwindled ever since we made a conscientious effort to reduce the number of times we open and close the OR doors during surgery. Coincidence? No, I'd say it's been the key to our success. OSM