Previous Article in Journal
Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults?
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Surgeries
Volume 6
Issue 3
10.3390/surgeries6030061
surgeries-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

The Impact of Intraoperative Traffic and Door Openings on Surgical Site Infections: An Umbrella Review

by
Jessica Drago
1,†,
Sarah Scollo
1,†,
Simone Cosmai
1,
Daniela Cattani
1,2,
Gloria Modena
1,2,
Stefano Mancin
1,2,*,
Sara Morales Palomares
3,
Fabio Petrelli
4,
Francesca Marfella
5,
Giovanni Cangelosi
4,*,
Diego Lopane
1,2,‡ and
Beatrice Mazzoleni
1,‡
1
Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
2
IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
3
Department of Pharmacy, Health and Nutritional Sciences (DFSSN), University of Calabria, 87036 Rende, Italy
4
Experimental Medicine and “Stefania Scuri” Public Health Department, School of Pharmacy, University of Camerino, 62032 Camerino, Italy
5
Italian Coordination of Volunteer Nurses of Hemergencies Association (Cives), 00192 Rome, Italy
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
‡
These authors also contributed equally to this work.
Surgeries 2025, 6(3), 61; https://doi.org/10.3390/surgeries6030061
Submission received: 29 May 2025 / Revised: 30 June 2025 / Accepted: 15 July 2025 / Published: 21 July 2025
Browse Figures
Versions Notes

Abstract

Background: Surgical site infections (SSIs) are among the most common postoperative complications. Environmental factors, including intraoperative traffic and door openings in the operating room (OR), have been identified as critical contributors to microbial air contamination. Nurses play a pivotal role in managing these factors, directly influencing infection control practices. Methods: An integrative review was conducted to synthesize current evidence on the association between intraoperative traffic, door openings, and SSIs. A structured methodology was employed to identify, assess, and analyze the existing literature, with a specific focus on the nursing role in infection prevention. Results: Findings from a single-center prospective cohort study indicate that ORs with more than 10 personnel present exhibit a threefold increase in SSI risk [Relative Risk (RR) = 3.12; 95% Confidence Interval (CI): 0.71–13.66] compared to ORs with fewer personnel. Additionally, every five door openings per procedure were associated with a significant increase in SSI incidence [Hazard Ratio (HR) = 2.00; 95% CI: 1.24–3.20, p = 0.005]. Conclusions: These findings underscore the importance of strict protocols to limit intraoperative traffic and unnecessary OR access. A multidisciplinary approach plays a crucial role in ensuring surgical safety and preventing SSIs by regulating OR access and adhering to infection control best practices.

1. Introduction

Surgical site infections (SSIs) represent one of the most common postoperative complications and are defined as localized infectious processes occurring at specific anatomical sites following surgical interventions [1,2]. Preventing SSIs remains a significant challenge in modern medicine due to their high incidence and substantial impact on global healthcare systems [3,4]. In Europe, SSIs are the second most common type of healthcare-associated infection, with an estimated incidence ranging between 1% and 2% of all surgical procedures [4,5]. These infections lead to prolonged hospital stays, increased antibiotic use, hospital readmissions, and, in severe cases, additional surgical interventions such as revision surgery or debridement [4,5].
In addition to prolonging recovery times, SSIs significantly impact patients’ quality of life, causing substantial physical and psychological distress [6]. Furthermore, they are associated with a markedly increased mortality risk, with recent studies reporting SSI-related mortality rates ranging from 33% to 77% [7,8].
Numerous risk factors for the development of SSIs have been identified, categorized into intrinsic factors related to patient conditions and extrinsic factors associated with the surgical procedure and operating environment. Modifiable intrinsic factors include glycemic control, obesity, and serum albumin levels, while non-modifiable factors include advanced age and a history of radiotherapy. Extrinsic factors encompass surgical complexity, inadequate ventilation, high intraoperative traffic, and the presence of non-sterile surfaces [9,10].
Environmental conditions play a crucial role in microbial air contamination within the operating room (OR). Air contamination is closely linked to intraoperative traffic and personnel movements. Observational studies have demonstrated that frequent door openings and a high number of individuals present in the OR increase contamination through the dispersion of airborne particles, facilitating the entry of microorganisms from the external environment or originating from patients [11].
International guidelines, such as those issued by the Healthcare Infection Society (HIS) and the World Health Organization (WHO) in recent documents, emphasize the importance of maintaining low levels of microbial contamination in OR air [12,13]. These guidelines recommend a maximum of 180 colony-forming units per cubic meter (CFU/m3) during surgical procedures and 35 CFU/m3 in the absence of surgical activity [12,13].
Nurses, as integral members of the surgical team, play a pivotal role in managing these environmental factors. Their responsibilities extend beyond direct patient care and include maintaining sterility, enforcing infection control protocols, and regulating intraoperative movement. Several studies have highlighted that frequent door openings, often necessary for retrieving materials or responding to procedural demands, can increase airborne contamination, disrupt the sterile field, and compromise patient safety [11,14].
However, the real-world implementation of these recommendations largely depends on perioperative nurses’ awareness and practices. Understanding how nursing actions influence intraoperative contamination is essential for designing effective interventions aimed at SSI prevention [15].
The primary objective of this integrative review is to examine the association between intraoperative traffic, OR door openings, and the incidence of SSIs. This study aims to identify the direct impact of these environmental factors on microbial air contamination and postoperative infection risk, providing evidence to enhance infection prevention practices. The secondary objective is to explore the role of nurses in managing intraoperative traffic and infection control within the OR. This review seeks to evaluate existing strategies for reducing door openings and limiting personnel presence in the OR, identifying best practices to minimize microbial contamination and improve patient safety.

2. Materials and Methods

2.1. Study Design

An integrative literature review was conducted following a well-established methodological framework to provide a comprehensive and up-to-date synthesis of the available evidence on SSIs and intraoperative traffic. Given the heterogeneity of study designs included in this review, an approach similar to that proposed by Whittemore and Knafl [16] for integrative review methodology was adopted. This framework allows the synthesis of findings from diverse research designs while maintaining methodological rigor. By employing this strategy, studies with different designs could be evaluated comparatively without aggregating incompatible data, preserving methodological robustness and facilitating meaningful conclusions. For transparency and reproducibility, the study was registered on the Open Science Framework (OSF) database (https://doi.org/10.17605/OSF.IO/H4JWZ).

2.2. Problem Identification

The research question formulated for this study is: “In patients undergoing surgical procedures, what is the impact of intraoperative traffic and door openings on the risk of developing SSIs compared to a controlled operating room environment with restricted movement?” To systematically structure the research process, the following PICO [17] framework was developed: (P): Patients undergoing surgical procedures, (I): Increased intraoperative traffic and frequent door openings in the OR, (C): A controlled OR environment with restricted movement and minimized door openings, and (O): Incidence of SSIs.

2.3. Inclusion and Exclusion Criteria

Studies were included if they explored the relationship between SSIs and intraoperative environmental variables, specifically OR traffic and the frequency of door openings. Eligible articles had to be peer-reviewed and present original research employing quantitative, qualitative, or mixed-method designs. Only studies published in English or Italian were considered, ensuring linguistic consistency and broad accessibility to the relevant literature, and no temporal limit was adopted for the research.
Particular attention was given to studies reporting measurable outcomes, such as microbial contamination levels and postoperative infection rates in relation to intraoperative movement. Theoretical models or simulation-based studies without direct clinical implications for SSIs were excluded. Editorials, commentaries, letters to the editor, conference abstracts, and non-peer-reviewed articles were also excluded.

2.4. Literature Search

The literature search was conducted between March and April 2024 across four major scientific databases: PubMed, Scopus, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library. To ensure comprehensive coverage and precise alignment with the study objectives, additional sources were preliminarily consulted, such as guidelines from the WHO and HIS [12,13], along with key articles identified through PubMed. The search strategy involved developing search strings based on Medical Subject Headings (MeSH) terms and specific keywords combined using Boolean operators (“AND,” “OR”) (Appendix A for search strategy). The selected keywords included “surgical site infection,” “surgical wound infection,” “operating room traffic,” “operating room foot traffic,” and “door openings.” Studies were included if they examined SSIs, analyzed the correlation between OR traffic and SSIs, evaluated the relationship between door openings and SSI incidence, and were clinical studies published in Italian or English. Conversely, studies were excluded if they focused on traffic models not directly related to SSIs, investigated only preoperative precautions aimed at reducing postoperative infections, compared various interventions to reduce OR traffic without directly evaluating SSI incidence, were editorial-type articles (e.g., letters to the editor), or were not written in Italian or English. These inclusion and exclusion criteria ensured methodological rigor and linguistic consistency for a comprehensive evaluation of the existing literature.

2.5. Data Extraction and Synthesis

Data extraction and synthesis followed a systematic and rigorous methodological approach to ensure the robustness and relevance of the findings. Initially, all records retrieved from database searches underwent preliminary screening based on titles and abstracts to identify potentially relevant studies. Two authors (G.D. and S.S.) independently selected the data in a blinded manner, and a third researcher (D.L.) was consulted to make the final decision in cases of disagreement. Subsequently, a comprehensive full-text review was performed to determine final eligibility according to the predefined criteria, using the same method described in the first stage.
Key study characteristics systematically recorded included the first author’s name, year of publication, study design, objectives, study population, principal findings, and qualitative insights. Extracted data were organized into a synthesis matrix to facilitate a comparative assessment across included studies (Table 1).
Additionally, a focused analytical synthesis was conducted to explore the relationship between intraoperative factors—specifically staff traffic, frequency of door openings, and airborne microbial contamination—and the incidence of SSIs. Quantitative metrics such as relative risk (RR), hazard ratios (HR), confidence intervals (CI), and p-values were extracted when available. The synthesis identified consistent trends and statistically significant outcomes across selected studies, providing valuable insights into the impact of modifiable intraoperative conditions on infection risk. These findings offer important implications for refining infection control protocols within operating room settings (Table 2).

3. Results

This integrative review initially identified a total of 318 records through a comprehensive screening process, as outlined in the flowchart. The search was conducted across multiple scientific databases, including CINAHL, Cochrane, PubMed, and Scopus, each contributing a specific number of studies to the initial pool (CINAHL: n = 47; Cochrane: n = 12; PubMed: n = 183; and Scopus: n = 76). These records were then systematically reviewed and filtered based on predefined inclusion and exclusion criteria to ensure the relevance and quality of the final selection. After removing 169 duplicates, an initial screening of titles and abstracts was conducted using predefined inclusion and exclusion criteria. As a result, 32 studies were selected for full-text assessment. Among these, 2 studies could not be retrieved and 20 did not meet the eligibility criteria. Ultimately, 10 studies were included in the final synthesis [18,19,20,21,22,23,24,25,26,27], ensuring a methodologically rigorous and evidence-based evaluation of the relationship between intraoperative traffic and SSIs (Summary Figure 1). All data findings are summarized in Table 1 and Table 2.
Table 1. Synthesis included studies.
Table 1. Synthesis included studies.
Author (Year) CountryStudy DesignObjectivePopulationMain ResultsQuantitative Data
Lynch et al. [20] (2009). USAQuantitative–Descriptive StudyDetermines the number of door openings in the OR and the role of nursing staff28 surgical procedures observedNursing staff responsible for 37–52% of door openingsDoor openings: 52% nurses, 24% surgeons, 18% anesthesiologists
Parikh et al. [19] (2010), USAQuantitative–Descriptive StudyDetermines the number of door openings in the OR and the role of nursing staff30 pediatric proceduresHigh number of door openings correlated with infection riskAverage door openings per procedure: 79, Infection risk >100 openings: 2.49×
Bohl et al. [24] (2010), USARandomized Controlled TrialEvaluates the impact of intraoperative traffic on surgical site infection rates1116 neurosurgical casesInfection rate paradoxically higher in the reduced traffic groupInfection rate in reduced traffic group: 3.8%, normal group: 2.1%
Kurmann et al. [27] (2011), SwitzerlandObservational StudyEvaluates the impact of noise in the OR on the risk of surgical site infectionsPatients undergoing surgerySignificant increase in infections with high intraoperative noise levelsIncreased infection risk: +20%, Noise level: >80 dB
Andersson et al. [21] (2012), SwedenDescriptive Observational StudyAnalyzes air quality and the number of people present in the OR30 orthopedic surgical proceduresStrong correlation between microbial air contamination and the number of people presentOR traffic: 18 door openings/hour, Air contamination: +15%
Mathijssen et al. [23] (2016), NetherlandsQuantitative–Descriptive StudyExamines the correlation between door openings and microbial air contaminationHip revision surgeryDoor openings associated with a significant increase in microbial contaminationCFU increase after >100 door openings: +26.6%
Wanta et al. [22] (2016), USACase–Control StudyEvaluates the impact of intraoperative traffic on the risk of superficial surgical site infectionsAdult patients (>18 years) undergoing clean surgical proceduresNo significant correlation after risk adjustment analysisAverage traffic: 35 events, no significant association
Stauning et al. [26] (2018), Ghana/DenmarkObservational StudyEvaluates microbial air contamination in relation to intraoperative traffic124 general surgery patients2.5% increase in microbial contamination for each additional person in the roomContamination increase per person in the room: +2.5%
Roth et al. [25] (2019), SwitzerlandProspective Observational StudyDetermines the effect of door openings in cardiac surgery on surgical site infections688 patients undergoing cardiac surgeryInternal door openings were significantly correlated with infection riskDoor openings in cardiac surgery: 68% correlated with infections
Bediako-Bowan et al. [18] (2020), GhanaProspective Cohort StudyAnalyzes risk factors associated with surgical site infections in abdominal surgery358 patients undergoing abdominal surgeryTripled risk of infections when more than 10 people are in the roomInfection risk: +3.1×, People in the room: >10
Legend. OR: Operating Room; CFU: colony-forming units.
Table 2. Quantifying the influence of intraoperative traffic and environmental contaminants on SSI risk.
Table 2. Quantifying the influence of intraoperative traffic and environmental contaminants on SSI risk.
Macro-AreaAnalyzed VariablesReference ArticlesMain Results
Intraoperative TrafficEffect of Traffic Reduction on SSIWanta et al. [22], Bohl et al. [24], Roth et al. [25] Traffic reduction showed a variable effect on SSI: not statistically significant (p = 0.06, p = 0.75, p = 0.83)
Operating Room Traffic MonitoringParikh et al. [19]High number of door openings and traffic significantly correlated with infections (statistically significant, p < 0.05)
Intraoperative Traffic as a Modifiable Risk FactorWanta et al. [22]Intraoperative traffic identified as a modifiable risk factor for SSI (statistically significant, p = 0.006)
Total Number of Traffic Events and SSIWanta et al. [22]Total number of traffic events was significantly higher in SSI cases compared to non-SSI cases (statistically significant, p = 0.006)
Effect of Operating Room Traffic on InfectionsBohl et al. [24]BRITE trial: association between traffic and infections, but not statistically significant (p > 0.05)
Door OpeningsNumber of Door Openings per Procedure and SSIParikh et al. [19]More than 100 door openings per procedure were associated with an SSI incidence of 26.6% (95% CI: 19.1–35.3), with an RR of 2.49 (95% CI: 1.48–4.18)
Number of Door Openings and SSI RiskMathijssen et al. [23]>100 door openings per procedure significantly increased microbial contamination (statistically significant, p < 0.001)
Impact of Door Openings on Microbial ContaminationMathijssen et al. [23]Every 100 door openings increased microbial contamination by 26.6% (statistically significant, p < 0.001)
Impact of Door Openings in Abdominal SurgeriesBediako-Bowan et al. [18]Door openings during abdominal surgery tripled SSI risk (statistically significant, p < 0.01)
Frequent Door Openings and SSI Risk in Cardiac SurgeryRoth et al. [25]Frequent door openings in cardiac surgery increased SSI risk by 68% (statistically significant, p < 0.05)
Microbial ContaminationTraffic Flow and Air ContaminationAndersson et al. [21]High traffic in orthopedic surgery correlated with increased air contamination in the OR (statistically significant, p = 0.001)
Number of People in the Operating Room and Microbial ContaminationStauning et al. [26]Each additional person in the OR increased microbial contamination by 2.5% (statistically significant, p < 0.001)
Intraoperative Factors and Microbial ContaminationStauning et al. [26]Intraoperative factors like general anesthesia and incision time significantly influenced microbial contamination (statistically significant, p < 0.001)
Operating Room Traffic Flow and Air QualityStauning et al. [26]High traffic flow in surgical wards in Ghana correlated with airborne contamination (statistically significant, p = 0.001 for number of persons and CFU/m3)
Microbial Contamination and Intraoperative NoiseKurmann et al. [27]High intraoperative noise levels were significantly associated with increased SSI risk (statistically significant, p < 0.05)
Pedestrian Traffic Measurement and Infection Control ImplicationsLynch et al. [20]Greater pedestrian traffic in the OR linked to increased SSI risk (statistical significance not reported)
Legend. SSI—Surgical Site Infection, OR—Operating Room, BRITE—Barrow Randomized Operating Room Traffic Evaluation, CI—Confidence Interval, RR—Relative Risk, CFU—Colony-Forming Units, p—p-value (statistical significance indicator).

3.1. Intraoperative Traffic

Several studies have explored the potential impact of intraoperative traffic on SSI incidence. Findings from a single-center prospective cohort study indicated that the presence of more than ten individuals in the OR was associated with a threefold increase in SSI risk (RR = 3.12; 95% CI: 0.71–13.66) compared to settings with fewer than five individuals [18]. Conversely, Parikh et al. [19] identified a positive correlation between the number of personnel and SSIs, although this association lost statistical significance after adjusting for confounding variables, underscoring the multifactorial nature of infection risk.
Additional qualitative insights from multiple studies emphasized how intraoperative traffic may disrupt sterile fields and impair staff concentration, potentially contributing indirectly to contamination and increased infection risk. These findings support the notion that, beyond numerical thresholds alone, the behavior and patterns of personnel movements significantly influence asepsis maintenance [19].
Lynch et al. [20] further analyzed OR traffic and identified nursing staff as responsible for 37–52% of door openings, highlighting the pivotal role nurses play in managing intraoperative traffic. Anderson et al. [21] observed a strong correlation between microbial air contamination and the number of individuals present, documenting an average of 18 door openings per hour, which resulted in a 15% increase in air contamination. Moreover, an analysis of OR movement patterns revealed that frequent entries and exits were associated with elevated contamination levels, reinforcing the need to minimize unnecessary movements to optimize patient safety and infection control [22].

3.2. Door Openings

Several studies have investigated the impact of door openings on SSI risk, frequently reporting a positive correlation between the number of door openings and the incidence of SSIs, thus emphasizing the importance of controlling environmental factors in infection prevention [19,23]. However, some studies did not find a significant association, suggesting that other variables might influence this relationship [23].
A two-phase randomized controlled trial examining intraoperative traffic’s effect on SSIs found no significant difference between infected and non-infected cases during the observational phase (p = 0.78). Paradoxically, higher main door traffic was recorded in non-infected cases. Moreover, reducing door traffic in the randomized phase did not result in statistically significant differences in infection rates (p > 0.05), highlighting the need for further investigation into these dynamics [24].
Mathijssen et al. [23] examined the effect of door openings specifically during hip revision surgeries and found that increased door openings significantly elevated colony-forming units (CFUs) in the air, suggesting a direct pathway leading to increased SSI risk. Similarly, Parikh et al. [19] reported that more than 100 door openings per procedure were associated with a twofold increase in SSI risk (RR = 2.49; 95% CI: 1.48–4.18), with each additional five door openings increasing SSI risk by 2% (HR = 2.00; 95% CI: 1.24–3.20; p = 0.005). Roth et al. [25] also observed a significant correlation between internal door openings during cardiac surgery and an increased risk of infection, further underscoring the importance of stringent door management policies to prevent SSIs. Taken together, these findings highlight the critical need for rigorous control of door traffic within surgical environments to effectively reduce infection risks.

3.3. Microbial Air Contamination

Microbial air contamination in the OR is a critical factor influencing the incidence of SSIs. Several observational studies have documented a clear correlation between the number of personnel present, the frequency of door openings, and the microbial load in the air. Mathijssen et al. [23] reported significant relationships between microbial contamination and both the number of personnel present (r = 0.79; p = 0.01) and the frequency of door openings (r = 0.74; p = 0.001). Similarly, Stauning et al. [26] found that each additional person in the OR increased microbial contamination by approximately 2.5%, while each door opening incrementally raised contamination levels by 0.2%. Moreover, environmental noise has also been investigated as an indirect indicator of intraoperative disturbances linked to microbial contamination. Kurmann et al. [27] observed that higher intraoperative noise levels were associated with increased bacterial counts, potentially elevating the risk of SSIs. Collectively, these findings emphasize the critical importance of implementing evidence-based strategies aimed at reducing intraoperative traffic, limiting door openings, and mitigating environmental noise to effectively decrease microbial contamination, thereby enhancing patient safety and surgical outcomes (Table 2).

4. Discussion

SSIs remain a persistent and complex challenge for healthcare systems, with implications that extend far beyond the immediate postoperative period. These infections contribute to prolonged hospitalizations, increased antibiotic use, elevated morbidity, and heightened healthcare costs. While conventional strategies such as antiseptic skin preparation, antimicrobial prophylaxis, and sterile technique have long served as pillars of SSI prevention, emerging literature increasingly recognizes the role of intraoperative environmental dynamics, particularly personnel traffic and door openings, as critical yet underappreciated contributors to infection risk [4].
This integrative review confirms that frequent door openings and elevated intraoperative traffic correlate significantly with increased microbial air contamination and higher SSI incidence, particularly in procedures involving more than 10 individuals in the OR [18,21]. These findings align with those from Lansing et al. [28], who demonstrated that increased door movements proportionally raised airborne bacterial concentrations, reinforcing a mechanistic pathway between environmental disturbances and microbial transmission.
Nonetheless, findings across the literature are not entirely consistent. Bohl et al. [24] and Wanta et al. [22], for example, reported no statistically significant reduction in SSIs despite efforts to decrease OR traffic. These discrepancies may reflect methodological differences, such as variability in the definition and recording of traffic events and the influence of confounding factors like ventilation systems, surgical duration, and staff behavior. As Schafer et al. [29] noted, the integration of automated traffic monitoring technologies may enhance study reliability by minimizing subjective bias and improving data granularity.
Importantly, the literature collectively frames intraoperative traffic as a modifiable risk factor. Anderson et al. [30] emphasize the value of pattern sequencing and structured entry protocols as practical solutions to limit unnecessary staff movements without disrupting workflow. Practical interventions such as structured staff training, implementation of visual reminders at OR doors, and the adoption of hands-free communication tools have shown promising results in minimizing unnecessary movement and enhancing team coordination during surgical procedures [30,31]. These localized interventions align well with broader, evidence-based infection prevention bundles, which have been shown to reduce SSIs across various surgical contexts [32,33].
The importance of multidisciplinary team coordination also emerges as a recurrent theme. A substantial proportion of intraoperative door openings has been attributed to clinical team members’ legitimate needs during surgery [20]. Qualitative evidence indicates that perioperative staff, including nurses, play an important role in maintaining asepsis and managing environmental factors. For instance, Qvistgaard et al. [34] found that OR nurses often see themselves as actively contributing to SSI prevention, although structural and cultural barriers may limit their ability to regulate intraoperative conditions. While many of these actions are necessary, these findings underscore the need to optimize workflows and storage systems to reduce unnecessary movements. Educational interventions targeting the entire perioperative team have been shown to promote sustainable behavioral changes and improve infection-related outcomes [31,35].
Interestingly, some studies propose that monitoring and feedback mechanisms play a central role in improving adherence to infection control protocols. Borer et al. [36] demonstrated that real-time feedback on staff compliance was associated with lower deep sternal infection rates in cardiac surgery, suggesting a potential model for broader OR-based infection prevention strategies. Another reflection pertains to organizational culture and technology. While staff education is essential, structural interventions, such as automated supply delivery systems, hands-free communication tools, and dedicated OR coordinators, may be equally crucial in reducing reliance on door access during procedures. These innovations not only reduce microbial contamination but also improve efficiency and team coordination.
From a systems-level perspective, the cumulative evidence suggests that SSIs are the product of multifactorial dynamics. Integrating environmental controls—such as door traffic monitoring—into existing SSI prevention bundles may enhance their overall efficacy. Crucially, this integration must be supported by institutional leadership, infection prevention committees, and operating room design considerations. As demonstrated by several studies [32,33], comprehensive care bundles that combine environmental control with staff training and behavioral auditing can significantly reduce postoperative infection rates across diverse surgical settings.
In this context, the OR should no longer be viewed merely as a procedural space but rather as a complex ecosystem where physical, behavioral, and architectural variables coalesce to shape patient outcomes. A deeper understanding of this ecosystem and a commitment to interdisciplinary collaboration are key to transforming surgical safety paradigms. Developing a culture of shared responsibility, where all team members are accountable for minimizing contamination risk, may ultimately prove as impactful as any technological innovation.

4.1. Limitations

While this review offers valuable insights into the relationship between intraoperative traffic, door openings, and SSIs, certain limitations must be acknowledged. As an integrative review, it does not allow for structured data comparison or quantitative synthesis, as would be feasible in a systematic review or meta-analysis. Nonetheless, it provides a comprehensive overview of current evidence and identifies key areas for further exploration. The heterogeneity in study designs, sample sizes, study types (only one RCT included), and measurement methods among the included studies may limit the generalizability of the findings. However, the consistent trends observed across multiple investigations reinforce the association between intraoperative movement and infection risk.
Moreover, due to the predominantly observational nature of most included studies, a direct causal relationship between OR traffic and SSIs cannot be conclusively established. Still, the available data strongly support the hypothesis that intraoperative movement management is a crucial component of infection prevention strategies.
It should be noted that the definition of surgical site infection varied or was not always clearly reported across the included studies. While some authors explicitly described clinically documented SSIs, others focused primarily on microbiological contamination or did not specify the diagnostic criteria used. This heterogeneity may influence comparability and limits the generalizability of pooled findings. Future research should adopt standardized SSI definitions, ideally following internationally recognized criteria (e.g., CDC guidelines), to strengthen the consistency and interpretability of results.
Another element to consider is possible comorbidities of patients that represent a potential bias in data synthesis. Future research should prioritize controlled trials to evaluate the effectiveness of targeted interventions aimed at minimizing unnecessary OR traffic. Expanding these investigations to include various healthcare settings, particularly resource-limited environments, would further enhance the relevance and applicability of the findings.

4.2. Implications for Clinical Practice

A multidisciplinary team plays a crucial role in the prevention of SSIs, particularly through the management of intraoperative movement and adherence to infection control protocols. This review underscores the potential benefits of raising awareness among healthcare staff regarding the impact of door openings and unnecessary traffic in operating rooms on microbial contamination, with particular emphasis on the key role of nurses in this process [37]. Training programs and workplace policies that promote more efficient communication and movement management within the operating room could help reduce these risks without compromising operational workflow efficiency [38,39,40,41]. Another aspect, well-established in chronic disease management from various perspectives [42,43,44,45,46], could be the investment in increasingly advanced technologies that might support both managerial and care-related improvements, enhancing overall patient care during such a critical phase as the surgical procedure and potentially reducing emissions in healthcare, which represents an increasingly important topic in healthcare management [47]. Adapting such strategies to a variety of healthcare settings, particularly resource-limited environments, will be key to maximizing their impact. Through improved intraoperative traffic management and stronger interdisciplinary collaboration, healthcare professionals can work together to enhance patient safety and significantly reduce the risk of preventable SSIs (Figure 2).

5. Conclusions

In conclusion, a multidisciplinary approach is essential to minimize the risk of SSIs, focusing on managing intraoperative movement and adhering to infection control protocols. Raising awareness among healthcare staff about the impact of environmental factors, such as door openings and unnecessary traffic, is key to reducing microbial contamination. The implementation of structured training programs and institutional policies aimed at improving intraoperative communication and movement management can help mitigate these risks. Furthermore, adapting these strategies to different healthcare environments, especially resource-constrained settings, will be vital to ensuring their efficacy. By optimizing intraoperative traffic and fostering a culture of collaboration and accountability, healthcare professionals can meaningfully improve patient safety and contribute to a sustained reduction in preventable SSIs. To support the implementation of these measures, surgical teams are encouraged to appoint designated staff responsible for monitoring intraoperative traffic and ensuring adherence to sterile protocols in real practice. Healthcare managers should be encouraged to integrate environmental monitoring and behavioral audits into routine quality improvement processes. This dual approach can enhance operational efficiency, foster continuous education, and embed infection prevention as a core institutional value.

Author Contributions

Conceptualization, J.D. and S.S.; methodology, S.C. and D.C.; software, G.M.; validation, S.M.P., S.M., G.M., F.P., G.C., D.L., F.M. and B.M.; formal analysis, S.M.; investigation, G.C. and J.D.; data curation, S.S.; writing—original draft preparation, G.C., G.M., D.C., S.M.P., S.M. and F.P.; writing—review and editing, G.C., S.M., S.M.P., F.M. and D.L.; visualization, B.M., F.M. and S.M.P.; supervision, G.C., S.M., D.L., B.M. and F.P.; project administration, S.C. and F.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data Availability Statement

The data presented in this study are available on request from the corresponding author due to confidentiality agreements with participants or third parties.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.

Appendix A. Search Strategy

DatabaseSearch Queries
Cinahl(“Surgical Wound Infection*” OR “surgical site infection*”) AND (“operating room traffic” OR “door openings”)
Cochrane(“Surgical Wound infection (MeSH)” OR “Surgical Site Infection” OR “Surgical Site Infections” OR “Surgical Wound Infection” OR “Surgical Wound Infections”) AND (“Operating room traffic” OR “door openings”)
(“Surgical Wound Infection” OR “surgical site infections”) AND (“operating room traffic” OR “door openings”)
“Surgical Wound Infection” AND “operating room traffic”
“surgical site infections” AND “operating room traffic”
“Surgical Wound Infection”[Mesh]) AND “door openings”
“surgical site infections” AND “door openings”
PubMed“surgical site infections” AND “operating room foot traffic”
(“Surgical Wound Infection”[Mesh]) AND “operating room foot traffic”
(“Surgical Wound Infection”[Mesh] OR “surgical site infections”) AND (“operating room traffic” OR “door openings”)
“Surgical Wound Infection”[Mesh]) AND “operating room traffic”
“surgical site infections” AND “operating room traffic”
“Surgical Wound Infection”[Mesh]) AND “door openings”
“surgical site infections” AND “door openings”
(“Surgical Wound Infection”[Mesh] OR “surgical site infection*”) AND (“operating room traffic” OR “door openings”)
Scopus(“Surgical Wound Infection*” OR “surgical site infection*”) AND (“operating room traffic” OR “door openings”)

References

  1. Borchardt, R.A.; Tzizik, D. Update on surgical site infections: The new CDC guidelines. JAAPA 2018, 31, 52–54. [Google Scholar] [CrossRef]
  2. Istituto Superiore di Sanità. Protocollo per la Sorveglianza delle Infezioni del Sito Chirurgico. EpiCentro. 2022. Available online: https://www.epicentro.iss.it/sorveglianza-ica/pdf/Protocollo%20Sito%20chirurgico%20VERS%20definitiva%2012%2010%2022-1.pdf (accessed on 28 March 2025).
  3. World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection, 2nd ed.; World Health Organization: Geneva, Switzerland, 2018; Available online: https://iris.who.int/handle/10665/277399 (accessed on 19 February 2024).
  4. Seidelman, J.L.; Mantyh, C.R.; Anderson, D.J. Surgical site infection prevention: A review. JAMA 2023, 329, 244–252. [Google Scholar] [CrossRef]
  5. Chauveaux, D. Preventing surgical-site infections: Measures other than antibiotics. Orthop. Traumatol. Surg. Res. 2015, 101 (Suppl. S1), S77–S83. [Google Scholar] [CrossRef]
  6. Avsar, P.; Patton, D.; Ousey, K.; Blackburn, J.; O’Connor, T.; Moore, Z. The impact of surgical site infection on health-related quality of life: A systematic review. Wound Manag. Prev. 2021, 67, 10–19. [Google Scholar] [CrossRef]
  7. Han, C.; Chen, W.; Ye, X.L.; Cheng, F.; Wang, X.Y.; Liu, A.B.; Mu, Z.H.; Jin, X.J.; Weng, Y.H. Risk factors analysis of surgical site infections in postoperative colorectal cancer: A nine-year retrospective study. BMC Surg. 2023, 23, 320. [Google Scholar] [CrossRef] [PubMed]
  8. Shambhu, S.; Gordon, A.S.; Liu, Y.; Pany, M.; Padula, W.V.; Pronovost, P.J.; Hsu, E. The burden of health care utilization, cost, and mortality associated with select surgical site infections. Jt. Comm. J. Qual. Patient Saf. 2024, 50, 857–866. [Google Scholar] [CrossRef] [PubMed]
  9. Anderson, D.J.; Podgorny, K.; Berríos-Torres, S.I.; Bratzler, D.W.; Dellinger, E.P.; Greene, L.; Nyquist, A.C.; Saiman, L.; Yokoe, D.S.; Maragakis, L.L.; et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect. Control Hosp. Epidemiol. 2014, 35, 605–627. [Google Scholar] [CrossRef] [PubMed]
  10. Neumayer, L.; Hosokawa, P.; Itani, K.; El-Tamer, M.; Henderson, W.G.; Khuri, S.F. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: Results from the Patient Safety in Surgery Study. J. Am. Coll. Surg. 2007, 204, 1178–1187. [Google Scholar] [CrossRef]
  11. Kanamori, H.; Rutala, W.A.; Gergen, M.F.; Weber, D.J. Perioperative bacterial contamination from patients on contact precaution in operating room environment. Open Forum Infect. Dis. 2020, 7, ofaa508. [Google Scholar] [CrossRef]
  12. Healthcare Infection Society (HIS). Guidelines to reduce ritualistic behavior in operating theatres without increasing surgical site infection risk. J. Hosp. Infect. 2023, 140, 165.e1–165.e28. [Google Scholar] [CrossRef]
  13. World Health Organization (WHO). WHO Guidelines for Indoor Air Quality: Selected Pollutants; WHO Regional Office for Europe: Geneva, Switzerland, 2010; Available online: https://www.who.int/publications/i/item/9789289002134 (accessed on 28 March 2025).
  14. Western Australia Department of Health. Microbiological Air Sampling of Operating Rooms; Western Australia Department of Health: East Perth, WA, Australia, 2021. Available online: https://www.health.wa.gov.au/~/media/Corp/Documents/Health-for/Communicable-Diseases/Guidelines/Guideline-Microbiological-Air-Sampling-of-ORs.pdf (accessed on 19 February 2025).
  15. Cristina, M.L.; Spagnolo, A.M.; Ottria, G.; Schinca, E.; Dupont, C.; Carbone, A.; Oliva, M.; Sartini, M. Microbial air monitoring in turbulent airflow operating theatres: Is it possible to calculate and hypothesize new benchmarks for microbial air load? Int. J. Environ. Res. Public Health 2021, 18, 10379. [Google Scholar] [CrossRef]
  16. Whittemore, R.; Knafl, K. The integrative review: Updated methodology. J. Adv. Nurs. 2005, 52, 546–553. [Google Scholar] [CrossRef]
  17. Brown, D. A review of the PubMed PICO tool: Using evidence-based practice in health education. Health Promot. Pract. 2020, 21, 496–498. [Google Scholar] [CrossRef]
  18. Bediako-Bowan, A.A.A.; Mølbak, K.; Kurtzhals, J.A.L.; Owusu, E.; Debrah, S.; Newman, M.J. Risk factors for surgical site infections in abdominal surgeries in Ghana: Emphasis on the impact of operating room door openings. Epidemiol. Infect. 2020, 148, e147. [Google Scholar] [CrossRef]
  19. Parikh, S.N.; Grice, S.S.; Schnell, B.M.; Salisbury, S.R. Operating room traffic: Is there any role of monitoring it? J. Pediatr. Orthop. 2010, 30, 617–623. [Google Scholar] [CrossRef] [PubMed]
  20. Lynch, R.J.; Englesbe, M.J.; Sturm, L.; Bitar, A.; Budhiraj, K.; Kolla, S.; Polyachenko, Y.; Duck, M.G.; Campbell, D.A., Jr. Measurement of foot traffic in the operating room: Implications for infection control. Am. J. Med. Qual. 2009, 24, 45–52. [Google Scholar] [CrossRef] [PubMed]
  21. Andersson, A.E.; Bergh, I.; Karlsson, J.; Eriksson, B.I.; Nilsson, K. Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am. J. Infect. Control 2012, 40, 750–755. [Google Scholar] [CrossRef] [PubMed]
  22. Wanta, B.T.; Glasgow, A.E.; Habermann, E.B.; Kor, D.J.; Cima, R.R.; Berbari, E.F.; Curry, T.B.; Brown, M.J.; Hyder, J.A. Operating room traffic as a modifiable risk factor for surgical site infection. Surg. Infect. 2016, 17, 755–760. [Google Scholar] [CrossRef]
  23. Mathijssen, N.M.; Hannink, G.; Sturm, P.D.; Pilot, P.; Bloem, R.M.; Buma, P.; Petit, P.L.; Schreurs, B.W. The effect of door openings on numbers of colony forming units in the operating room during hip revision surgery. Surg. Infect. 2016, 17, 535–540. [Google Scholar] [CrossRef]
  24. Bohl, M.A.; Clark, J.C.; Oppenlander, M.E.; Chapple, K.; Budde, A.; Lei, T.; Meeusen, A.J.; Porter, R.W.; Spetzler, R.F. The Barrow randomized operating room traffic (BRITE) trial: An observational study on the effect of operating room traffic on infection rates. Neurosurgery 2016, 63 (Suppl. S1), 91–95. [Google Scholar] [CrossRef]
  25. Roth, J.A.; Juchler, F.; Dangel, M.; Eckstein, F.S.; Battegay, M.; Widmer, A.F. Frequent door openings during cardiac surgery are associated with increased risk for surgical site infection: A prospective observational study. Clin. Infect. Dis. 2019, 69, 290–294. [Google Scholar] [CrossRef]
  26. Stauning, M.T.; Bediako-Bowan, A.; Andersen, L.P.; Opintan, J.A.; Labi, A.K.; Kurtzhals, J.A.L.; Bjerrum, S. Traffic flow and microbial air contamination in operating rooms at a major teaching hospital in Ghana. J. Hosp. Infect. 2018, 99, 263–270. [Google Scholar] [CrossRef] [PubMed]
  27. Kurmann, A.; Peter, M.; Tschan, F.; Mühlemann, K.; Candinas, D.; Beldi, G. Adverse effect of noise in the operating theatre on surgical-site infection. Br. J. Surg. 2011, 98, 1021–1025. [Google Scholar] [CrossRef]
  28. Lansing, S.S.; Moley, J.P.; McGrath, M.S.; Stoodley, P.; Chaudhari, A.M.W.; Quatman, C.E. High number of door openings increases the bacterial load of the operating room. Surg. Infect. 2021, 22, 684–689. [Google Scholar] [CrossRef] [PubMed]
  29. Schafer, M.; Dixon, H.; Palladino, K.; Baumann, S.; Martinson, J.; Bolland, M.; Lakdawala, M.; Yassin, M. Automated traffic monitoring of neurosurgical operating room. Am. J. Infect. Control 2024, 52, 630–634. [Google Scholar] [CrossRef] [PubMed]
  30. Anderson, R.L.; Lipps, J.A.; Pritchard, C.L.; Venkatachalam, A.M.; Olson, D.M. An operating room audit to examine for patterns of staff entry/exit: Pattern sequencing as a method of traffic reduction. J. Infect. Prev. 2021, 22, 69–74. [Google Scholar] [CrossRef]
  31. Parent, M. OR traffic and surgical site infections: A quality improvement project. AORN J. 2021, 113, 379–388. [Google Scholar] [CrossRef]
  32. Crolla, R.M.P.H.; van der Laan, L.; Veen, E.J.; Hendriks, Y.; van Schendel, C.; Kluytmans, J. Reduction of surgical site infections after implementation of a bundle of care. PLoS ONE 2012, 7, e44599. [Google Scholar] [CrossRef]
  33. van der Slegt, J.; van der Laan, L.; Veen, E.J.; Hendriks, Y.; Romme, J.; Kluytmans, J. Implementation of a bundle of care to reduce surgical site infections in patients undergoing vascular surgery. PLoS ONE 2013, 8, e71566. [Google Scholar] [CrossRef]
  34. Qvistgaard, M.; Lovebo, J.; Almerud-Österberg, S. Intraoperative prevention of surgical site infections as experienced by operating room nurses. Int. J. Qual. Stud. Health Well-Being 2019, 14, 1632109. [Google Scholar] [CrossRef]
  35. Wistrand, C.; Falk-Brynhildsen, K.; Nilsson, U. National Survey of Operating Room Nurses’ Aseptic Techniques and Interventions for Patient Preparation to Reduce Surgical Site Infections. Surg. Infect. 2018, 19, 438–445. [Google Scholar] [CrossRef] [PubMed]
  36. Borer, A.; Gilad, J.; Meydan, N.; Riesenberg, K.; Schlaeffer, F.; Alkan, M.; Schlaeffer, P. Impact of active monitoring of infection control practices on deep sternal infection after open-heart surgery. Ann. Thorac. Surg. 2001, 72, 515–520. [Google Scholar] [CrossRef] [PubMed]
  37. Esser, J.; Shrinski, K.; Cady, R.; Belew, J. Reducing OR traffic using education, policy development, and communication technology. AORN J. 2016, 103, 82–88. [Google Scholar] [CrossRef] [PubMed]
  38. Aktaş, F.; Damar, H.T. Determining operating room nurses’ knowledge and use of evidence-based recommendations on preventing surgical site infections. J. PeriAnesthesia Nurs. 2022, 37, 404–410. [Google Scholar] [CrossRef]
  39. Ferrara, G.; Cangelosi, G.; Morales Palomares, S.; Mancin, S.; Melina, M.; Diamanti, O.; Sguanci, M.; Amendola, A.; Petrelli, F. Optimizing Ultrasound Probe Disinfection for Healthcare-Associated Infection Control: A Comparative Analysis of Disinfectant Efficacy. Microorganisms 2024, 12, 2394. [Google Scholar] [CrossRef]
  40. Perez, P.; Holloway, J.; Ehrenfeld, L.; Cohen, S.; Cunningham, L.; Miley, G.B.; Hollenbeck, B.L. Door openings in the operating room are associated with increased environmental contamination. Am. J. Infect. Control 2018, 46, 954–956. [Google Scholar] [CrossRef]
  41. Assolari, F.; Mancin, S.; Lopane, D.; Dacomi, A.; Coldani, C.; Tomaiuolo, G.; Cattani, D.; Palomares, S.M.; Cangelosi, G.; Mazzoleni, B. Advanced practice nursing in surgery: A scoping review of roles, responsibilities, and educational programs. Int. Nurs. Rev. 2024. [Google Scholar] [CrossRef]
  42. Sguanci, M.; Mancin, S.; Gazzelloni, A.; Diamanti, O.; Ferrara, G.; Morales Palomares, S.; Parozzi, M.; Petrelli, F.; Cangelosi, G. The Internet of Things in the Nutritional Management of Patients with Chronic Neurological Cognitive Impairment: A Scoping Review. Healthcare 2024, 13, 23. [Google Scholar] [CrossRef]
  43. Mieronkoski, R.; Azimi, I.; Rahmani, A.M.; Aantaa, R.; Terävä, V.; Liljeberg, P.; Salanterä, S. The Internet of Things for basic nursing care-A scoping review. Int. J. Nurs. Stud. 2017, 69, 78–90. [Google Scholar] [CrossRef]
  44. Sguanci, M.; Palomares, S.M.; Cangelosi, G.; Petrelli, F.; Sandri, E.; Ferrara, G.; Mancin, S. Artificial Intelligence in the Management of Malnutrition in Cancer Patients: A Systematic Review. Adv. Nutr. 2025, 16, 100438. [Google Scholar] [CrossRef]
  45. Cangelosi, G.; Mancin, S.; Morales Palomares, S.; Pantanetti, P.; Quinzi, E.; Debernardi, G.; Petrelli, F. Impact of School Nurse on Managing Pediatric Type 1 Diabetes with Technological Devices Support: A Systematic Review. Diseases 2024, 12, 173. [Google Scholar] [CrossRef]
  46. Pantanetti, P.; Cangelosi, G.; Morales Palomares, S.; Ferrara, G.; Biondini, F.; Mancin, S.; Caggianelli, G.; Parozzi, M.; Sguanci, M.; Petrelli, F. Real-World Life Analysis of a Continuous Glucose Monitoring and Smart Insulin Pen System in Type 1 Diabetes: A Cohort Study. Diabetology 2025, 6, 7. [Google Scholar] [CrossRef]
  47. Mezzalira, E.; Orsini, L.P.; Leardini, C.; Veronesi, G. Towards zero emissions in healthcare. The Italian experience. In Routledge Handbook of Climate Change and Health System Sustainability; Routledge: London, UK, 2024. [Google Scholar]
Surgeries 06 00061 g001
Figure 1. Flowchart selection.
Figure 1. Flowchart selection.
Surgeries 06 00061 g001
Surgeries 06 00061 g002
Figure 2. Summary of the study’s key conclusions, highlighting the main problems contributing to surgical site infections (SSIs) and outlining the core resolution strategies, including multidisciplinary approaches, staff awareness, and adaptation to diverse healthcare settings.
Figure 2. Summary of the study’s key conclusions, highlighting the main problems contributing to surgical site infections (SSIs) and outlining the core resolution strategies, including multidisciplinary approaches, staff awareness, and adaptation to diverse healthcare settings.
Surgeries 06 00061 g002
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Drago, J.; Scollo, S.; Cosmai, S.; Cattani, D.; Modena, G.; Mancin, S.; Morales Palomares, S.; Petrelli, F.; Marfella, F.; Cangelosi, G.; et al. The Impact of Intraoperative Traffic and Door Openings on Surgical Site Infections: An Umbrella Review. Surgeries 2025, 6, 61. https://doi.org/10.3390/surgeries6030061

AMA Style

Drago J, Scollo S, Cosmai S, Cattani D, Modena G, Mancin S, Morales Palomares S, Petrelli F, Marfella F, Cangelosi G, et al. The Impact of Intraoperative Traffic and Door Openings on Surgical Site Infections: An Umbrella Review. Surgeries. 2025; 6(3):61. https://doi.org/10.3390/surgeries6030061

Chicago/Turabian Style

Drago, Jessica, Sarah Scollo, Simone Cosmai, Daniela Cattani, Gloria Modena, Stefano Mancin, Sara Morales Palomares, Fabio Petrelli, Francesca Marfella, Giovanni Cangelosi, and et al. 2025. "The Impact of Intraoperative Traffic and Door Openings on Surgical Site Infections: An Umbrella Review" Surgeries 6, no. 3: 61. https://doi.org/10.3390/surgeries6030061

APA Style

Drago, J., Scollo, S., Cosmai, S., Cattani, D., Modena, G., Mancin, S., Morales Palomares, S., Petrelli, F., Marfella, F., Cangelosi, G., Lopane, D., & Mazzoleni, B. (2025). The Impact of Intraoperative Traffic and Door Openings on Surgical Site Infections: An Umbrella Review. Surgeries, 6(3), 61. https://doi.org/10.3390/surgeries6030061

Article Metrics

Back to TopTop