Monitoring Foot Traffic within the Operating Room Suite
Jennifer Cox
American Sentinel University
Monitoring Foot Traffic within the Operating Room Suite
The operating room is a mentally and physically challenging area that depends on the
knowledge and expertise of highly skilled perioperative nurses in ensuring optimal patient
outcomes. Preventing hospital acquired infections and ensuring patient safety is imperative in
achieving best patient outcomes. The operating room staff, behaviors, and environment can
influence a patient’s risk of developing or preventing infections. Decreasing foot traffic within
the operating room suite is a way to decrease the incidence of surgical site infections.
Surgical site infections (SSI) are one of the most common hospital acquired infections as
two to five percent of all patients who undergo an operation will develop a surgical site infection
which leads to significant causes of mortality and morbidity (Labrague, Arteche, Yboa, &
Pacolor, 2012). The Center for Disease and Prevention (CDC) estimates that 1.7 million people
contract a hospital acquired infection annually, and nearly 99,000 of them die (Klevens et al.,
2007). Hospital acquired infections in the United States cost hospitals an average of $28 billion
to $45 billion per year (Scott, 2009). Research has shown disruption of airflow by multiple door
openings with an increase in personnel thru the surgical suite increases contaminants in the air
predisposing a patient to infection. Health care organizations have the responsibility to
implement strategies for infection prevention; however, the operating room personnel,
environment, surgical technique, and practice standards influence the means of patients
developing a surgical site infection.
Statement of Purpose
Is there a correlation between operating room foot traffic during total joint replacement
surgery and the incidence of surgical site infections?
Explains the nursing problem
SSI’s after a total joint replacement can be devastating on a patients quality of life; and
accounts for prolonged hospitalizations and increased healthcare costs. The aim of this study is
to collect quantitative data to measure the amount of foot traffic during an operating room (OR)
case and find its correlation in patients developing surgical site infections (SSI). The study will
also record the reasons for this traffic in order to implement new strategies within the OR.
One of the suspected causes of SSI’s is increased foot traffic thru the operating room
suite. A SSI is an infection that develops within thirty days after an operation or within one year
if an implant was placed. OR foot traffic consists of personnel in and out of the OR suite and
door openings. Proper air handling is the single most important environmental factor in the
prevention of surgical site infections (Lindsay, Bigsby, & Bannister, 2011). OR suites are
maintained at positive pressure ventilation with 15 air exchanges per minute filtering fresh air so
that air flows from the cleanest area to the least clean area (Evans, 2011). When personnel open
doors connecting to the outside hallways, this unfiltered air mixes with the clean, filtered air
within the OR suite.
Personnel are a major source of contaminants due to skin shedding which further
increases the microbial count within the suite potentially predisposing the patient to an infection.
This increase in contaminants from personnel and multiple door openings decreases the
effectiveness of the ventilation system in clearing contaminants from the OR suite thus allowing
pathogens to enter the space surrounding the wound site. In any given case, there are a multitude
of interdisciplinary team members entering and exiting the OR suite for various reasons. The
circulating nurse often has to leave the room several times for supplies, unanticipated concerns,
or unpreparedness. There is also an exchange of personnel during break and lunch times, sales
representatives leaving to get pertinent supplies not kept in the OR room, and an overabundance
of staff entering for communication or social purposes.
Relevance to nursing, nursing practice, and patient outcomes
Perioperative nurses in the operating room adhere to strict standards issued by AORN.
These recommended standards guide perioperative nursing practice in ensuring quality of care
and patient safety is being delivered in achieving best patient outcomes. AORN outlines that
doors to the operating room should be kept closed except for necessary personnel, patient,
equipment, and supplies; as well as keeping operating room personnel to a minimum
(Association of PeriOperative Registered Nurses, 2006). The word minimum is considered
vague as personnel feel it is essential to enter and exit the room as often as deems necessary for
the given case.
Surgical site infections increase healthcare costs and increase a patient’s mortality and
morbidity. An increase in door openings and excessive personnel add to distraction and
interruptions, as well as increasing a patients risk to a surgical site infection. Door openings
disturb proper air filtering and an increase in personnel subject the patient to an increase in
bacterial contaminants. The outcome of a patient’s surgical experience is highly dependent on
the competence, knowledge, and skill of the operating room staff. Perioperative nurses have the
professional duty to be accountable in carrying out the AORN standards of care in an attempt to
reduce OR traffic in the operating room.
There is a correlation between operating room foot traffic during total joint replacement
surgery and the incidence of surgical site infections. Prosthetic joint infections are the second
most common complication of total joint replacement which can be devastating on a patient’s
quality of life (Teixeira & Johnson, 2007). While a patient’s general health, age, gender,
nutritional status, metabolic disorders, obesity, and smoking all could influence one’s
susceptibility; the OR environment plays a large part in infection control (Gould, 2012). Early
joint infection found within the first three months has been linked to bacteria acquired during the
surgical procedure (Teixeira & Johnson, 2007).
In a study by Parikh, Grice, Schnell, & Salisbury (2010), found an increase in bacterial
contaminants was directly related to a high number of door openings and personnel in and out of
the operating room suite. This research study will attempt to show that a high amount of foot
traffic is related to patients developing a surgical site infection and will demonstrate the reasons
for the foot traffic. Strict aseptic techniques, adherence to AORN standards and decreasing foot
traffic within the OR is imperative by all operating room personnel in reducing a patients risk in
developing a surgical site infection.
Expected outcomes
This study is expected to find a positive correlation between door openings and increase
personnel thru the OR room. These variables will be measured, analyzed, and tested through
statistical studies where a positive correlation will be shown that the number of door openings
and increase in personnel has a direct relationship in patients developing a SSI. Research has
shown door openings disrupt air flow, and personnel introduce higher levels of microbial counts
into the room.
It is expected that the longer the surgery, the more occurrences in foot traffic, therefore,
the more susceptible the patient is in acquiring an infection. If a surgical site infection has been
detected, the data will reveal that there was a higher amount of foot traffic recorded during that
case in comparison to other cases. Recording the reasons for foot traffic will show that the
circulating nurse is the main cause of frequent door openings related to obtaining supplies and
informational issues. Using a pie chart categorical system will identify the reasons for foot
traffic in an effort to improve awareness in staff and implement new processes to eliminate
unjustifiable foot traffic in the operating room.
The study is expected to show a positive correlation coefficient closer to +1 between
variables yet the probability of error will be high as patients risk factors cannot be ruled out on
their influence in causing surgical site infections.
Nursing Theorist and theory
Nursing theory is grounded in nursing practice as it guides our behaviors and
interventions in caring for patients. Perioperative nurses develop a unique set of skills,
knowledge, and clinical expertise over time in the ability to make clinical decisions that affect
patient outcomes. In 1984, Dr. Patricia Benner published From Novice to Expert by describing
how knowledge and skills are acquired through five stepping stages (novice, advanced beginner,
competent, proficient, and expert), and clinical experience (Altmann, 2007). She proposed one
could gain knowledge and skills (knowing how) without ever learning the theory (knowing that):
and that practical knowledge (know how) can be achieved through research and clinical
experience (Dracup & Bryan-Brown, 2004). As one moves through these stages, their intuition
and past clinical experiences help guide their behavior.
OR nurses strictly adhere to the AORN standards and recommendation which are based
on clinical evidenced based research that help define the perioperative nurses scope of practice.
By applying these standards on a regular basis, nurses develop the knowledge and skills (know
how) necessary in caring for patients. These experiences and critical thinking help advance the
nurse through the five stages as a more proficient or expert nurse has the knowledge and
confidence in controlling the flow of personnel throughout the OR suite. Therefore, in the OR,
all of our tasks and behaviors are based upon practical knowledge through research, standards,
intuition, and clinical experience which according to Brenner’s theory guides our competence in
caring for our patients. These qualities provide nurses with the foundational background in
perioperative nursing and clinical and ethical decision making.
Review of the literature
Historical studies have found that one of the main routes of wound contamination and
infection was the air in the operating room (Evans, 2011). In a study by Anderson, Bergh,
Karlsson, Eriksson, & Nilsson (2012), airborne contamination near the surgical wound was
found to be directly related to the dispersal of bacteria particles from the number of people in the
room. It is estimated that people shed over 10,000 skin cells per minute, in which ten percent
carry bacterial clusters (Krueger, Murray, Mende, Guyman, & Gerlinger, 2012). Anderson et al.,
(2012) investigated airflow by using sterile filters near the sterile wound area in correlation to the
number of people in the room during 20 minute intervals. High bacteria counts were noted near
the surgical site when there was a higher amount of personnel in the room along with the
duration of surgery.
In a blind study monitoring door openings, Lynch et al., (2009) found the average rate of
door openings was 40 per hour with a 20 second delay in door closure disrupting airflow: and
door openings had a positive correlation to cases length. Lynch et al. (2009) also found the
majority of foot traffic occurred for informational purposes and retrieval of supplies. The
researchers determined that the circulating nurse and core staff together contributed to 37%-51%
of door openings, while Anderson et al., (2012) found 26% were for supply issues, 20% for staff
breaks, and 27% were for social visits.
Using computational fluid dynamics, Brohus, Balling, & Jeppessen, (2006) found door
openings and movement of people in the room disrupt proper airflow within the OR suite
subjecting the patient to an increase in contaminants from unfiltered air from the outside
corridors. Scaltriti et al. (2007) conducted a study measuring microbial counts of the air
compared to the frequency of door openings. They found the more frequent the doors were
opened, the higher the bacterial count rose. Their conclusion suggests that human movement is a
major source of microbial contaminants in the OR (Scaltriti et al., 2007).
Expected Outcomes
Comparing past research studies to this study, it is expected that a high amount of
personnel entering and exiting the room will also produce a high frequency rate of door
openings. It is expected that as the duration of case increases, so will the amount of personnel
and door openings. The cases with the highest number of foot traffic will result in patients
developing an infection. Based on the quantitative data obtained and placed in frequency
distribution tables and scatter plot graft, the study will show there is a positive correlation
coefficient close to +1 in increased amount of foot traffic directly correlates with the patient
acquiring a SSI during an OR procedure.
By reviewing the study done by Anderson et al., (2012) in determining multiple door
openings disrupts airflow and personnel increase microbial load in room, a expected correlation
between surgical site infections will be seen, yet the data findings may be unable to correlate that
an increase in foot traffic is the cause of patients acquiring a surgical site infection.
In comparison to Lynch et al. (2009) study on monitoring reasons for foot traffic, it is
expected that the circulating nurse will also produce the highest rate of door openings due to the
retrieval of supplies. If the case is performed in the midmorning, the study will show a higher
rate of personnel entering and exiting the room with an increase in door openings due to breaks
and lunches.
Statistical study
Quantitative statistical analysis of 50 total joint replacement surgeries will be measured in
ratio measurement by collecting data from the OR Measurement Tool and retrospective studies.
The results will be analyzed on terms of descriptive data statistics and the relationship of data
will be examined and presented through a histogram and a frequency distribution table. A pie
chart will display the reasons for foot traffic in percentages. The Pearson correlation coefficient
will be used to assess the degree of correlation between door openings, personnel, and infections
acquired. A paired t-test will measure the significance of the correlation and probability.
Research Design
Experimental design
Preventing surgical site infections is conducive to professional behaviors and
environmental factors in the operating room. A descriptive quantitative non-experimental study
through a correlation research design will be used in collecting data to determine the relationship
between foot traffic (door openings and personnel), and the incidences of patients acquiring a
surgical site infection during total joint replacement surgery. Non-experimental research is
descriptive because there is no manipulation of variables such as all subjects will be observed in
a natural and unchanged environment.
The correlation study will attempt to examine whether the strength of relationships
between higher amounts of foot traffic increase the incidence of surgical site infections. The
independent variable of operating room traffic (personnel and door openings) influences the
dependent variable (incidence of surgical site infections). A collection of data will be recorded
on the reasons for the occurrences in foot traffic in and out of the OR suite.
Recruitment of subjects and sampling technique
A study population is a complete set of persons that possess common characteristics for
researchers to study (Nieswiadomy, 2012). Recruitment of subjects will be performed in the
orthopedics doctor’s office during preoperative evaluation prior to the surgical procedure.
Subjects who are scheduled to receive their total joint operation (total hip or knee) within a three
month time frame will be randomly selected in order to obtain a sample size of 50 male and
female participants. While informed consent is being obtained for the surgical procedure, an
informed consent congruent with ethical standards will also be obtained for the research study.
In this study, convenience sampling will be performed as all participants are accessible
and share the common characteristic of having an orthopedic total joint (hip or knee)
replacement. Convenience sampling saves time and money as these samples are readily
available. In the operating room, the sample will be the staff involved during the surgical
procedure. The staff will be unobtrusive to what the researcher is recording so the staff does not
change their behavior.
Collection of data
Data analysis involves collecting, measuring, and analyzing data from measurement tools
and statistical studies that show the relationship between variables studied. Collection of data
will be obtained by time sampling according to the orthopedic surgeon’s allotted surgical time
for total joint replacements. Fifty total hip and total knee replacement surgeries will be
monitored during a three month time frame. Data collection will be collected based on
structured observation using an OR Measurement Tool designed specifically for this study. The
OR Measurement Tool will consist of the patient’s medical record number, ASA classification,
and past medical history to identify predisposing risk factors. It will also contain the time patient
entered and exited the OR room (duration), time of incision, and time of implants. The
frequency and rate of door openings and personnel entering the room will be counted and
Since the researcher has experience working in the OR, and knowledge of operating room
standards, he will covertly observe and interpret the reasons for door openings and personnel
entering the room by recording the reasons into a category system. The researcher observes the
staff’s behavior covertly so the staff does not alter their behavior, although the surgeon is aware
of the study.
A retrospective chart review of subjects will be analyzed after thirty days from time of
procedure in identifying any incidence of surgical site infections in correlation with data
collected from the OR measurement tool. A retrospective approach will be used to trace back in
time the association of the variables that has already occurred in the event study.
Analysis of data
Using the ratio level of measurement, data measured from the OR Measurement Tool will
be assigned numbers and labels incorporated into a histogram. A frequency of distribution data
table will show the relationship between all variables by measuring the central tendencies of
mode, median, and mean. A pie chart will identify the reasons for door openings and personnel
entering the room by using percentages to identify each category. Ratio scales will be used to
identify and compare the frequency of door openings and personnel in each case. This data will
then be compared to the retrospective studies to determine correlation between variables.
Using a scatter plot graph will assist in measuring the Pearson correlation coefficient of
the variables. The correlation coefficient ranges from -1, to +1, therefore the closer r is to +1 or
-1, the more closely the two variables are related (Nieswiadomy, 2013). If one variable
increases, then so does the other for positive correlation. It is expected that as the variables of
foot traffic increase, the incidence of surgical site infections also increases; therefore the r is
expected to be closer to +1 resulting in a positive correlation.
Interpretation of data
A paired t-test will examine the correlation significance between the mean values of door
openings and personnel, as well as foot traffic and SSI. Statistical tests show the significance of
probability (p value) between scores; and any outcome being tested is significant if the p value is
below .05. The probability of error is expected to be high as multiple patient risk factors
predispose one to infections yielding no correlation between variables, yet the t-test is expected
to show a correlation between door openings and the number of personnel in the room related to
the duration of the procedure.
Fair treatment of human subjects
Before performing any type of human research study, approval must be granted by the
Institutional Review board (IRB). The IRB is responsible in protecting patients from physical or
psychological harm by approving, monitoring, and reviewing clinical research investigations in
ensuring human research participants rights are protected through ethical standards (Labaree,
2010). While the main obligation in research is to prevent harm to the patient, nurses are
obligated in maintaining the patient’s privacy and confidentiality, communicating honestly about
all involved research, interventions and outcomes; and obtaining informed consent with patient
advocacy (Lachman, 2008). Voluntary informed consent will be obtained after discussing the
risks and complications of infection by communicating honestly, educating on the purpose of the
study and it’s benefits, how data and results will be confidentiality protected, and how the results
will aid in better healthcare practices.
A quantitative research study will be used in identifying the correlation between
operating room foot traffic (door openings and personnel), and the incidence of patients
acquiring a surgical site infection. Research has shown an increase rate of door openings during
a surgical procedure disrupts the positive pressure airflow thus decreasing the ventilation system
in clearing contaminants from within the OR suite. With the combination of door openings and
increased personnel, they both introduce more contaminants into the air potentially
contaminating the surgical wound; therefore a positive correlation coefficient close to +1 is
expected to be identified. Duration of surgery will result in a higher amount of foot traffic.
However, due to multiple patient risk factors of morbidity, a direct causation of increase
personnel in the OR suite will be difficult to determine as the direct cause of surgical site
infections, yet, it yields a high probability related to existing research studies.
Developing a surgical site infection leads to increase morbidity and mortality, prolonged
hospitalization, reduced quality of life and contributes to rising healthcare costs. The operating
room environment, personnel, and practices influence the means of acquiring a surgical site
infection. Operating room foot traffic evidenced by increase personnel and door openings during
a surgical procedure can increase the incidence of surgical site infections.
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