Keeping patients safe and infection-free are your top priorities in the operating room. Yet healthcare facilities are also under pressure to maximize efficiency through fast turnaround times.
But getting the OR ready is inherently time-consuming. It must be disinfected from high to low with an EPA- registered disinfectant. All surfaces — especially high touch ones — must be cleaned. What’s more, contact times vary
between products, with some taking up to 10 minutes to kill microorganisms.
The recommendations by the Association for periOperative Registered Nurses (AORN) and the Association for the Healthcare Environment’s (AHE) Practice Guidance for Healthcare Environmental Cleaning are the standards most facilities use in setting up their own programs and procedures.
These recommendations provide Environmental Service (ES) leaders with a framework for properly cleaning and disinfecting surgical, operating room (OR) and invasive-procedure settings.
A Team Approach
A multidisciplinary team consisting of the perioperative leader, infection preventionist, ES leaders, infectious disease and facilities personnel should be established to set guidelines for cleaning and disinfecting the perioperative areas.
The team also should be responsible for quality management, procedure review and compliance with regulatory standards in the OR setting. Cleaning and disinfecting in surgical and invasive-procedure areas is a team effort that requires consistent review of processes to identify potential gaps, open communication and team engagement.
Consistent with the AORN guidelines, the lead perioperative registered nurse has ultimate responsibility for the cleanliness of the surgical/invasive-procedure areas. However, ES leaders must be knowledgeable about the AORN guidelines as well as AHE guidance to facilitate constructive dialogue.
That knowledge will serve the ES and surgical teams well, especially when discussing areas of broad guidance interpretation, or when making changes for process improvement.
DID YOU KNOW?
• High-touch areas like X-ray monitors, cabinet doors and computer keyboards are among the worst-cleaned areas of the OR and may harbor pathogens known to be found in ORs, such as MRSA, VRE, E. coli and Acinetobacter.
• Only 50% of OR high-touch surfaces have been shown to be cleaned properly in some studies.
• 55% (33/60) and 67% (16/24) of cultures taken from tourniquets and exsanguinators, respectively, were positive for bacteria growth that included candida, P. mirabilis, S. aureus, Acinetobacter, and Coagulase-Negative Staph (CoNS).
• Three of five operating room overhead lights that were cultured had positive bacterial growth for Staphylococcus, Streptococcus, or Neisseria.
ECOLAB OPERATING ROOM PROGRAM
Studies show OR surfaces are not well cleaned. The Ecolab® OR Program was designed to support improved patient outcomes. The program consists of four elements: technology, information, service and training. For more information on this topic, go to www.ecolab.com.
A responsibility matrix should be developed by the multidisciplinary team that identifies all areas and equipment in the OR setting that require cleaning and disinfecting. This should include: the area, equipment, the person responsible for the area, cleaning frequencies and special notes. Manufacturer instructions need to be reviewed prior to cleaning such sensitive equipment as screens, keyboards and anesthesia machines. Many manufacturers will void warranties if instructions are not followed precisely. There is also facility variation related to who cleans the equipment, so the matrix and the manufacturer instructions are critical.
Walls, ceilings, waiting rooms, lounges, offices, storage areas, restrooms, locker rooms, transport carts, refrigerators, ice machines, aerators on water faucets, eye-wash stations, pneumatic tubes, heating/ air conditioning equipment and similar elements should be cleaned on a cycle schedule developed by the multidisciplinary team. The lack of a matrix or clear documentation for identifying these areas and equipment can lead to confusion and improper disinfection of critical and noncritical items utilized in the OR setting.
Procedures for cleaning and disinfecting should be written, readily available and reviewed annually. These properly written procedures are able to set operational guidelines and establish accountability with staff. The AHE’s practice guidance manual should be used as a resource to show how these procedures should be written and what needs to be addressed within them.
It is recommended to dedicate equipment to the surgical area, which means that all tools and equipment (including cleaning tools) used in the perioperative setting should remain in that area to reduce and prevent the potential for cross-contamination from other areas. There are occasions when this is not entirely possible, such as when novel disinfection technologies are used or when other expensive pieces of equipment need to be utilized in other areas of the facility to justify the purchase. Any equipment exiting or entering the OR should be cleaned and disinfected on entry and exit.
Aerosols and sprays should not be used in the OR space. Aerosolizing of cleaning chemicals and other products potentially could pose a health risk to workers who use the products or the spray could land in unintended areas. Pour-top, squeeze-top or flip-top bottles are preferred. Charging bucket systems for microfiber wipes or disposable wipes are other acceptable ways to deliver the chemical to the surface. Double-dipping microfiber mops and cloths is not acceptable. Doubledipping degrades the chemical and contaminates it from the used wiper.
Wipers need to be changed frequently to ensure proper wetness and to facilitate contact time of the chemical.
Tools and equipment needed to perform cleaning and disinfecting tasks should be taken into the room and the door should remain closed while cleaning. Traveling in and out of the OR suite during the cleaning process should be kept to a minimum. This helps to allow the proper air exchanges through the ventilation system and prevents microorganisms from entering during cleaning.
All perioperative areas, including utility areas, should be cleaned and disinfected when services have concluded each day after they were scheduled for use. Scheduled rooms that are not used also should be cleaned every 24-hour period because staff may enter and exit rooms to retrieve items and equipment or to restock items even though the room may not be used for procedures. If surgical suites are not scheduled for use (e.g., closed on weekends), they do not necessarily need to be cleaned every 24 hours. However, the damp dusting prior to the first scheduled case should be detailed and thorough.
The Occupational Safety and Health Administration’s Bloodborne Pathogen standards must be considered and employed in all situations in which blood or body fluids are present, a likely occurrence given the setting. Education on the proper use of personal protective equipment (PPE), including donning and doffing in sequence, is critical for all cleaning technicians. Proper donning and doffing of PPE in the correct sequencing is often misunderstood by personnel across all disciplines and should be reviewed and practiced frequently. All perioperative cleaning staff should receive initial training, ongoing education and a competency review on proper procedures, equipment, chemical selection/usage and safety.
While this may seem obvious, many facilities struggle with the competency review due to busy perioperative schedules. The review needs to be conducted annually at a minimum and should be a combination of observation, quality measurement and retention of educational information.
The following training content should be included:
• Regulatory compliance review
• Discussion and explanation of signage, labels and colorcoded systems
• Exposure control plan
• Occupational exposure discussions
• Location and use of eye-wash stations
• Use, purpose, selection, disposal and limitations of PPE
• Information on Hepatitis B vaccination
• Location of Safety Data Sheets
A quality management program should be established and maintained to ensure that all these areas are maintained. Compliance indicators should include regulatory compliance, correct selection and use of chemicals and equipment, cleaning and disinfecting procedures and adverse-event reporting. Observation also might be augmented with eitheradenosine triphosphate monitoring or fluorescent marking systems to verify cleaning and disinfecting effectiveness with additional refresher training as needed based on results. Quality measurement also should be multidisciplinary to ensure objectivity and results-focused team orientation.
High-level disinfectants should not be used for cleaning and disinfecting environmental surfaces or noncritical items. Environmental Protection Agency (EPA)-registered tuberculocidal disinfectants (i.e.,intermediate-level disinfectants) should be used for cleaning and disinfecting all surfaces and equipment above the floor, coupled with proper cleaning and disinfecting procedures.
Low-level disinfectants can be used to clean and disinfect floors and certain other items and areas outside the surgical environment. Alcohol is not an EPA-registered disinfectant because it does not remove soil. It is also highly flammable and presents safety concerns. Certain transmissionbased precaution rooms may require
multiple cleanings to thoroughly
process the room.
Rooms in which transmission-based precautions are in effect should be cleaned and disinfected with an EPA-registered tuberculocidal disinfectant and facility-established procedures.
In rooms where Clostridium Difficile is present or suspected, an EPA-registered sporicidal disinfectant should be used because of the potential presence of spores and because C. difficile spores can survive in the environment for as long as five months.
All horizontal surfaces in the perioperative area should be dampwiped prior to the first case of the day. Dust and debris settle on horizontal surfaces and dust contains potentially harmful microorganisms. The initial damp wipe is intended to remove particles that may have settled on surfaces since the last cleaning and disinfecting were performed.
High-touch objects identified and agreed upon by the multidisciplinary team, as well as visibly soiled areas of the procedure suite, including walls, should be cleaned and disinfected between cases. Floors should be disinfected between cases within 5 feet of the procedure table and if visibly soiled. All trash and soiled linens should be handled properly and removed from the room.
End-of-day cleaning should be performed according to facility procedures using an EPA-registered, facility-approved disinfectant that is suitable for the perioperative suite. There are several acceptable methods for end-of-day cleaning, each of which offers pros and cons related to the types of perioperative cases:
1. The perimeter method involves moving all soiled equipment to the middle of the room. The perimeter of the room is then cleaned and disinfected. Lastly, soiled equipment in the middle of the room is cleaned and disinfected and moved to the clean perimeter until all items have been processed.
2. The divide-in-half method is another cleaning process. All soiled equipment is moved to the soiled half of the room. The empty half is then disinfected and items from the soiled side are cleaned and moved to the clean side. This continues until all items have been disinfected.
3. The third method is the zone cleaning method. Items in the suite are divided between two or more technicians. Each tech is responsible for specific areas, items and surfaces in the suite. Once the room is cleaned and disinfected, the team verifies and documents that all items have been processed.
Whichever method is used, AHE recommends sticking with the identified process to ensure that all areas and equipment are processed without omission.
All linen should be handled with minimal agitation to prevent aerosolizing particles. Care also should be given to soiled linens and disposable drapes because sharp objects or instruments sometimes can be found in these items. Linens should be carried away from the body to prevent injury or exposure.
Waste removal, processing and transport should follow state and local regulations. Typically, disposable items that are not saturated or caked with blood or body fluids can be placed in a noninfectious waste container for disposal. Items that are saturated or caked with blood or body fluids should be placed in a closeable, properly labeled, leakproof container for removal. Infectious regulated medical waste (RMW) should be stored in a secure area.
The storage room should have a floor drain, wipeable surfaces, proper ventilation and appropriate lighting. State and local regulations should be reviewed for information on transportation and storage of RMW within the perioperative area and the facility.
Facilities should have a special procedure for cleaning an OR suite where a confirmed or suspected case of Creutzfeldt-Jakob Disease (CJD) exists. A solution of one part sodium hypochlorite to five parts water is recommended as the disinfectant with a contact time of 30 to 60 minutes. Because obtaining a contact time of that length is extremely difficult, multiple, consecutive processing periods will be necessary. Where possible, disposable tools, equipment and supplies are used for patients with CJD. Some facilities perform drills to ensure that staff understand the process.
Cleaning equipment should be cleaned and disinfected before reuse or storage to prevent the proliferation and cross-transmission of microorganisms. Use of brooms in invasive-procedure areas is discouraged as brooms tend to aerosolize dust and debris, and they are difficult to disinfect after use. A floor squeegee works well as a replacement tool for brooms.
Tacky mats should not be utilized routinely in the OR setting for infection prevention because they have not been shown to reduce the presence of microorganisms on shoes or equipment. These mats can be effective for removing soiling of shoes and equipment where construction or renovation may be in progress.
A pest control program is necessary to reduce the risk of infestation. Packaging materials should not be in the invasive-procedures areas because they can harbor insects or rodents. A good integrated pest management system will help to prevent infestations and reduce the need for chemical use.
– American Society for Health Care Engineering