By Kelly M. Pyrek
Experts are pushing for a surgical conscience in the operating room that also encompasses a heightened awareness of intraoperative transmission of potentially pathogenic organisms and a comprehensive environmental hygiene program in which both processes and outcomes issues related to the role of the operating room environment in pathogen transmission are monitored and measured. While the role of the environment continues to be an imperative, renewed focus is being placed on the operating theater's obligation to control and prevention infections.
The Imperative for OR Cleaning
Experts like Munoz-Price, et al. (2012) say that a greater degree of objective evaluation of cleaning and disinfection performed in operating rooms is needed. Recent studies indicate suboptimal environmental hygiene in ORs; for example, Jefferson et al. (2011) evaluated 71 operating rooms in six acute-care hospitals and found an average daily cleaning rate of 25 percent of the objects monitored. Loftus, et al. (2008) evaluated 61 operative suites and found that potentially pathogenic, multidrug-resistant bacterial organisms are transmitted during the practice of general anesthesia to both the anesthesia work area and intravenous stopcock sets, and they say that implementation of infection prevention and control measures in this area may help to reduce both the evolving problem of increasing bacterial resistance and the development of life-threatening infectious complications.
As Munoz-Price, et al. (2012) observe, "Based on our findings and existing literature, operating rooms might not be the clean settings that healthcare providers commonly believe them to be."The researchers continue, These findings illustrate the fact that interactions between patient body surfaces, hands, and the operating room environment play an important role in the transmission of bacteria. In their studies, these authors described transmission of organisms to intravenous stopcocks in 11.5 percent of patients, with approximately half of these cases associated with the anesthesia providers. Nevertheless, studies have yet to be performed that systematically evaluate the potential for relatively more contaminated operating room surfaces leading to greater rates of hospital-acquired infection."
In their study, Munoz-Price, et al. (2012) evaluated the environmental contamination and cleaning practices in the 43 operating rooms at a 1,500-bed teaching hospital by objectively evaluating pre-intervention cleaning effectiveness and the degree to which improvement in the thoroughness of cleaning influenced bacterial contamination of OR surfaces. The impetus for the study, according to the researchers, was an opportunity to evaluate the possible role of the OR environment in the horizontal transmission of A. baumannii. After confirming episodic surface contamination with this organism, the researchers implemented an evaluation of the thoroughness of cleaning in the ORs using the results of both fluorescent marking and environmental culture. At baseline, Munoz-Price, et al. (2012) found that less than half of tested surfaces had been cleaned by 24 hours after target application. Ongoing performance feedback over the next four months led to an 82 percent increase in the cleaning of markers by the final month of follow-up. The researchers attribute the significant improvement in cleaning of anesthesia equipment to the subsequent reassignment of cleaning duties.
Let's take a closer look at the study by Munoz-Price, et al. (2012) to highlight some key issues in environmental cleaning in the OR.
According to the researchers, OR cleaning was coordinated by the perioperative nursing director, who evaluated cleaning practices performed by operating room technicians between surgical procedures and by environmental services staff at the end of the day (terminal cleaning). Four cycles of observations using UV markers were performed one week per month. Overall, 194 operating rooms and 2,820 objects were evaluated during the study. At baseline, the proportion of UV marks removed by 24 hours after placement was 0.47 (284 of 600 marks). This proportion increased during and after the educational intervention and reached 0.82 (634 of 777 marks) during the last month of observations.
Munoz-Price, et al. (2012) note that the most significant improvement during the study was related to the anesthesia equipment, particularly the cleaning of anesthesia machines, which increased more than 150 percent. Other objects that showed significant improvement in thoroughness of cleaning included bed control panels, Mayo stands, and overhead lamps. The objects that failed to show clear improvement included floors, intravenous poles, and operating room entry door handles. Over a nine-month period, 427 objects were cultured in 35 operating rooms. Overall, 65 objects (15.2 percent) had culture results that were positive for pathogens, 246 (57.6 percent) had cultures that grew skin flora, and 116 (27.2 percent) had negative culture results. According tot he researcjhers, pathogens identified during the study included Pseudomonas species, Enterobacter aerogenes, S. aureus, Enterococcus species, Acinetobacter species, Klebsiella pneumoniae, Escherichia coli, and 10 other Gram-negative bacilli. Acinetobacter species were isolated from eight objects in seven operating rooms; the objects contaminated with Acinetobacter species included intravenous poles, operating room beds, Mayo tables and floors.
Munoz-Price, et al. (2012) report that 24 floor areas were cultured, including 22 at baseline and 12 at follow-up; pathogens were isolated from 63 percent and 66 percent of floor areas, respectively. Gram-negative bacilli were identified in 63 percent of floor samples at baseline and in 41.6 percent of floor samples at follow-up. As they explain, "An evaluation of the thoroughness of floor cleaning was included in the study, because earlier observations by our group disclosed the fact that objects that fall onto the floors are frequently placed back either on horizontal work surfaces or on patients themselves. For example, intravenous tubing frequently contacts the floor as it drapes between the patient and the intravenous pump. Anesthesia providers have frequent and multiple contacts with such objects, including intravenous tubing, mixture controls, and intravenous administration hubs as well as with patients and horizontal surfaces. Consequently, the operating room floor can potentially transmit organisms to the patient through inadvertent contamination of surfaces during routine care."
Recommended Practices for Environmental Cleaning
Updated guidance can be found in the revised 2014 Recommended Practices for Environmental Cleaning produced by the Association of periOperative Registered Nurses (AORN). New content in this RP includes diagrams depicting what to clean and when, as well as an emphasis on whole-suite cleaning, encompassing between-case cleaning, routine cleaning and terminal cleaning. The RP's authors more clearly define and discuss cleaning technique, including high-touch objects, as well as address emerging technologies with suggestions for evaluation that acknowledges a gap in research. Education competencies content has also been strengthened for the 2014 RP.
As the 2014 Environmental Cleaning RP acknowledges, "Historically, perioperative registered nurses (RNs) have played a critical role in providing a clean environment for patients undergoing operative or other invasive procedures. In recent years, researchers have developed an increasing awareness of the role of the environment in the development of healthcare-associated infections and transmission of multidrug-resistant organisms (MDROs)."
Healthcare professionals understand that thorough, routine cleaning of high-touch objects is an effective approach to limiting transmission of pathogens when implemented as part of a comprehensive environmental cleaning and disinfection program, yet environmental cleaning in the operating room may be subpar at some hospitals. As the RP states, "Researchers have shown that cleaning practices in the operating room (OR) have not been adequately thorough or consistent with the policies of the healthcare organization ... All perioperative team members have a responsibility to provide a clean environment for patients. Perioperative and environmental services leaders can cultivate an environment where perioperative and environmental services personnel work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support."
Ramona Conner, MSN, RN, CNOR, manager of standards and recommended practices at AORN, acknowledges perioperative nursing's longstanding commitment to hygiene in the OR. "Environmental cleaning in the OR has been a primary concern for the 40 years I have been in practice" she says. "That's one of the basic issues that all perioperative nurses learn from day one when they begin their practice. What's really exciting now is that with the intense scrutiny related to the prevention of surgical site infections, there is renewed focus on environmental cleaning issues. I think it also coincides with our new efforts related to evidence rating and evidence-based recommendations. We have always based our RPs on the evidence, but in the last few years we now have a structured process for conducting that evidence review and rating, and it could not have come at a better time now that there is so much discussion of the role of the environment in HAI transmission. I am very proud of the environmental cleaning RP because we worked closely with our colleagues at the Association for Professionals in Infection Control and Epidemiology (APIC) and the Association for the Healthcare Environment (AHE). This RP is a true collaboration."
That sense of teamwork is reflected in the RP's emphasis on the need for a multi-disciplinary team to establish cleaning and disinfection policies and procedures in the perioperative practice setting. As the RP notes, "Involvement of a multidisciplinary team (e.g., perioperative nursing, sterile processing, environmental services, infection prevention) allows input from personnel who perform environmental cleaning in perioperative areas and from personnel with expertise beyond clinical end-users (such as infection prevention personnel)." Various researchers have suggested developing cleaning procedures as part of a multidisciplinary team as well as part of a bundled approach to implementing best practices for environmental cleaning.
One of the responsibilities of this multidisciplinary team is to establish cleaning frequencies for high-touch objects and surfaces. As the RP explains, "In a literature review, Dancer found that contamination of environmental surfaces that are touched frequently provides an opportunity for hands to acquire pathogens, which could be transmitted to patients. Stiefel, et al. demonstrated in an observational study that touching environmental surfaces in the inpatient room of a patient colonized with methicillin-resistant Staphylococcus aureus (MRSA) was just as likely to contaminate the gloved hands of healthcare personnel as was touching the patient’s skin. The results of this study showed that environmental surfaces may be a reservoir for pathogens that can contaminate the hands of healthcare personnel."
The RP recommends that a facility's multidisciplinary team and the infection prevention committee determine when enhanced environmental cleaning procedures should be implemented to prevent the spread of infections or outbreaks, and that it should also designate personnel responsible for cleaning perioperative areas and equipment. As the RP explains, "Designating cleaning responsibilities is an important component of defining cleaning procedures. In a literature review, researchers identified the importance of assigning cleaning responsibilities to reduce the number of items that personnel forget to clean."
Conner says a shared sense of responsibility is key to boosting cleaning and disinfection compliance in the OR. "Whenever you are working with teams there are different dynamics involved. Within the OR, everyone on the perioperative team is responsible for environmental cleaning and keeping the environment clean. You often don't see as much debate about who does what in the operating room because hopefully everyone is striving toward a common goal -- t provide the patient with a clean environment and to move quickly. OR time is very valuable, and we don't want to keep the patient in the OR any longer than is necessary. So the orchestration of all of the tasks that are needed to care for the patient and clean the environment creates a more time-sensitive situation than in other hospital environments."
That quickness related to case cleaning and room turnover is a double-edged sword. "Speed is addressed in the RP, and it is always a challenge for every setting," Conner says. "In the past, there was a belief that between every case you had to mop the floor from wall to wall. That's no longer the recommendation. Our current recommendation is that the floor be mopped in high-traffic areas or when there is a spill. When you are doing cataract surgeries, you may not need to mop the floor between every case, for example. Those cataracts are moving at 5 to 10 minutes per patient, so that would require a lot of mopping, so it's not practical or necessary thing to do, but it all depends on the case, what's going on, and the level of contamination."
"The debate between quality and speed will always be a challenge," Conner adds.
A recommendation in the 2014 RP sums up the issue succinctly: "The patient should be provided with a clean, safe environment." This responsibility falls to the perioperative RN, who should assess the perioperative environment frequently for cleanliness and take action to implement cleaning and disinfection procedures. As the RP notes, " The perioperative RN should visually inspect the OR for cleanliness before case carts, supplies, and equipment are brought into the room." The RP outlines specific measures to take before the first case of the day, as well as indicates interventions for case cleaning and terminal cleaning. Another recommendation is that "A clean environment should be reestablished after the patient is transferred from the area." As the RP explains, " Reestablishing a clean environment after the patient leaves the area decreases the risk of cross-contamination and disease transmission. Environmental cleaning has been associated with a decreased risk of the patient acquiring MRSA or vancomycin-resistant enterococci (VRE) when the previous room occupant was infected or colonized with one of these MDROs."
The 2014 RP indicates that "Cleaning of high-touch objects after each patient use should include cleaning of any soiled surface of the item and any frequently touched areas of the item (e.g., control panel, switches, knobs, work area, handles). Contamination of environmental surfaces that are touched frequently provides a risk for hands to acquire pathogens, which could be transmitted to patients."
"One of the things we emphasized in the new environmental cleaning RP is the cleaning of high-touch objects, and I think clinicians will benefit from that guidance," Conner says. "Cleaning and disinfecting high-touch items are a challenge, especially items such as keyboards. There are now products such as washable keyboards, so we are encouraging people to evaluate those kinds of tools -- if your keyboard can't be washed then you need to have a protective cover placed over it so you can clean it. I think our diagram of cleaning frequencies related to high-touch areas is very helpful. Keyboards are one of the areas of concern for everyone and certainly IPs have really helped us bring attention to these problems, and the same goes with the mobile electronic devices everyone is carrying."
One of the recommendations in the RP is that perioperative areas should be terminally cleaned daily if used. Another recommendation is that all areas and equipment that are not terminally cleaned should be cleaned according to an established schedule. The RP outlines specific steps to take to ensure all surfaces and patient-care items are cleaned and disinfected properly. As part of a comprehensive cleaning program for the OR, the RP acknowledges that "A multidisciplinary team may choose to evaluate emerging technologies for room decontamination (e.g., ozone, peroxide vapor, ultraviolet light and saturated steam) as adjuncts to terminal cleaning procedures."
Conner says a great place to evaluate these emerging technologies for area decontamination is AORN's upcoming Surgical Conference and Expo. "It will be very exciting to see companies' technology solutions at Expo," she says. "In the RP we did look at the evidence related to the use of UV and other forms of automatic disinfection. There are some benefits and some hazards to those, and the science is still evolving. It's not at a stage yet that we can make a recommendation but we do suggest that people stay on top of this and continue to evaluate it as an adjunct to cleaning. I don't believe it's a replacement for good cleaning but there is potential for a better solution for adjunct cleaning. Bacteria are sneaky devils and I don't believe there will be one solution as a silver bullet." As the RP notes, "Use of emerging technologies may enhance environmental cleanliness, although additional clinical studies are needed to determine their applicability in the perioperative setting."
Education and Training: Key for OR Hygiene
One of the most important recommendations made in the 2014 RP is "Perioperative and environmental services personnel should receive initial and ongoing education and competency verification on their understanding of the principles and the performance of the processes for environmental cleaning in perioperative areas."As the RP explains, "Healthcare organizations are responsible for providing initial and ongoing education and evaluating the competency of perioperative and environmental services personnel on the principles of and the performance of environmental cleaning. Initial and ongoing education of perioperative and environmental services personnel on the principles of and the performance of environmental cleaning facilitates the development of knowledge, skills, and attitudes that affect safe patient care. Periodic education programs provide the opportunity to reinforce the principles and processes of environmental cleaning and to introduce relevant new equipment or practices. Competency assessment measures individual performance, provides a mechanism for documentation, and verifies that perioperative personnel have an understanding of facility policies and potential environmental hazards to patients and personnel. Every nurse is personally accountable for maintaining competency."
The study by Munoz-Price (2012) helps to underscore educational interventions. As part of their project after two cycles of covert baseline data collection, the researchers re-educated OR cleaning personnel regarding cleaning expectations for specific objects and were provided with the UV marker and environmental culture results. As Munoz-Price (2012) explains, "Education combined with objective feedback using UV markers has previously been shown to improve the thoroughness of environmental cleaning in a range of healthcare settings, including general medical wards, intensive care units, operating room, and emergency medical vehicles. During these studies, improvement was accomplished exclusively through ongoing objective performance feedback to the environmental services staff." The researchers emphasize the need for regular, ongoing education: "Although the sustainability of improved hygienic practice needs to be evaluated more extensively, preliminary findings suggest that the impact of such programs may deteriorate once feedback is no longer ongoing."
AORN's environmental cleaning RP recommends that "perioperative and environmental services personnel must receive education and complete competency verification activities that address specialized knowledge and skills related to the principles and processes of environmental cleaning." And to keep perioperative personnel on track, the RP recommends "Policies and procedures for environmental cleaning processes and practices should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting."
Association of periOperative Registered Nurses (AORN). 2014 Recommended Practices for Environmental Cleaning.
Centers for Disease Control and Prevention: HICPAC guidelines for environmental infection control in health-care facilities, 2003. MMWR: Morb Mortal Wkly Rep 52(RR-10), Jun. 6, 2003. http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html
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Loftus RW, Koff MD, Burchman CC, Schwartzman JD, Thorum V, Read ME, Wood TA, Beach ML. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. 2008 Sep;109(3):399-407.
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