The impact of operating room door openings on surgical site infections (SSIs) has long been a topic of debate. Minimizing door openings – or implementing a strict zero door opening policy for certain surgical procedures - is a common recommendation in SSI prevention bundles and clinical guidelines. This recommendation is based on associations between door openings and surrogates of SSI, such as increased microbial air contamination or wound contamination. However, direct clinical evidence of an increase in SSI rates has been lacking.
Our systematic review and individual patient data meta-analysis (IPDMA) of eight observational studies including 4,412 procedures provides the first cumulative clinical data assessing the effect of the number of door openings in the operating room on SSIs across all surgical types1. Very low certainty of evidence suggested a marginal increase in SSI risk with each additional door opening per hour, patients at a higher baseline risk being more affected (Figure 1). Given the minimal observed effect on clinical outcomes and the very low certainty of the evidence, our results do not support enforcing a strict zero-door-opening policy solely for the purpose of SSI prevention.
We found it particularly relevant to examine the potential impact of door openings in clean surgeries and implant procedures, where strict zero-door-opening policies are often most rigorously enforced to minimize contamination risks. Although exogenous sources of contamination other than the patient’s own microflora are believed to play a role in infection after clean and long-duration surgery, this is primarily based on studies showing associations with surrogates such as colony forming units in wounds or operating rooms, rather than a direct effect on higher SSI rates2-4. In implant surgeries, the serious consequences of prosthetic infections, especially those linked to biofilm formation on implant surfaces, further support the rationale for stricter door-opening policies5. However, our findings suggest that the relationship between the number of door openings per hour and clinical SSI outcomes remains comparable across different wound contamination levels and implant statuses.
Although our study did not investigate non-infectious outcomes related to frequent door openings, prior research suggests that these disruptions may lead to distractions and lapses in operating room discipline, factors that could indirectly contribute to SSIs5-7. Therefore, reducing unnecessary door movements may still be beneficial in maintaining operating room focus and discipline, potentially offering indirect benefits for patient safety and infection control. However, our data suggest that strict rigorous zero-door-opening policies to reduce SSIs are not necessary. The very low certainty of evidence of our findings due to the observational nature of all included studies highlights the need for stronger evidence, which presents significant challenges.
References
1. Groenen H, Jalalzadeh H, Bontekoning N, Bediako-Bowan AAA, Buis DR, Dreissen YEM et al. Effect of the number of door openings in the operating room on surgical site infections: individual-patient data meta-analysis. BJS Open 2025;9, doi: 10.1093/bjsopen/zraf044
2.Perez P, Holloway J, Ehrenfeld L, et al. Door openings in the operating room are associated with increased environmental contamination. Am J Infect Control. Aug 2018;46(8):954-956. doi:10.1016/j.ajic.2018.03.005
3.Birgand G, Azevedo C, Rukly S, et al. Motion-capture system to assess intraoperative staff movements and door openings: Impact on surrogates of the infectious risk in surgery. Infect Control Hosp Epidemiol. May 2019;40(5):566-573. doi:10.1017/ice.2019.35
4.Birgand G, Saliou P, Lucet JC. Influence of staff behavior on infectious risk in operating rooms: what is the evidence? Infect Control Hosp Epidemiol. 2015;36(1):93-106. doi:10.1017/ice.2014.9
5.Roberts ER, Hider PN, Wells JM, Beasley SW. The frequency and effects of distractions in operating theatres. Anz J Surg. May 2021;91(5):841-846. doi:10.1111/ans.16799
6.Beldi G, Bisch-Knaden S, Banz V, Muhlemann K, Candinas D. Impact of intraoperative behavior on surgical site infections. Am J Surg. Aug 2009;198(2):157-62. doi:10.1016/j.amjsurg.2008.09.023
7.Wheelock A, Suliman A, Wharton R, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Ann Surg. Jun 2015;261(6):1079-84. doi:10.1097/SLA.0000000000001051
Effect of door openings on SSI rate
The plot shows the effect of the number of door openings per hour on SSI rate from a one-step meta-analysis of individual participant data using a random-effects framework, and corrected for confounders. The light blue lines show the absolute increase in SSI risk for every extra door opening per hour (OR 1·012 (95%CI 1·005 – 1·019)) for every possible scenario in the model. In darker blue, the absolute increase in SSI risk for three different baseline SSI risks is highlighted: 1% (line A) versus 10% (line B) versus 30% (line C). Variables included in the model: age, sex, BMI, smoking, diabetes, the use of appropriate systemic antibiotic prophylaxis, ASA score, the level of wound contamination according to the CDC criteria, emergency surgery, procedure duration, income level of the country where the study was conducted, implantation of a foreign body, and study as a random effect. Vertical line at x = 10 represents the commonly recommended threshold of 10 door openings per hour, as often suggested in guidelines.1-3
ASA, American Society of Anaesthesiologists; BMI, body mass index; CDC, Centers for Disease Control and Prevention criteria; CI, confidence interval; OR, odds ratio; SSI, surgical site infection
1. Excellence National Institute for Health Care. Surgical site infections: prevention and treatment of surgical site infection. 2019. htps://www.nice.org.uk/guidance/NG125 (accessed 2024, January 10).
2. Humphreys H, Bak A, Ridgway E, et al. Rituals and behaviours in the operating theatre - joint guidelines of the Healthcare Infection Society and the European Society of Clinical Microbiology and Infectious Diseases. J Hosp Infect. 2023;140:165 e1- e28.
3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Commitee. Am J Infect Control. 1999;27:97-132.
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