Isolation Rooms, ORs Demand Rigorous Cleaning
By Kelly M. Pyrek
Two areas of a hospital can pose some of the greatest opportunities for the transmission of pathogens: the room of an isolated patient and the operating room (OR). Both demand rigorous ongoing and terminal cleaning and disinfecting.
Patients under isolation precautions require healthcare workers and environmental services (ES) personnel to follow Standard Precautions when delivering patient care and performing terminal cleaning. All bodily fluids, secretions and non-intact skin of isolated patients are treated as potentially infectious.
One of the first steps in the terminal cleaning of isolation-designated patient rooms is the bagging of used articles in order to prevent personnel exposure to contaminated items and to prevent contamination of the environment through aerosolization or contact transmission of pathogens.
According to the infection control manual of the University of Virginia Health System, ES personnel first should don a protective gown, gloves and a mask before proceeding to other tasks. Items and equipment that can be steam autoclaved, such as hinged equipment, should be placed in a brown paper bag, while a clear plastic bag should be used for equipment that must be gas autoclaved, such as respiratory tubing. All special procedure tray linens should be placed in the linen hamper, while all dressing materials visibly contaminated with bodily fluids should be disposed of in the regulated medical waste (RMW) container. All opened packages can be disposed of in the regular trash. Sharps should be placed in a rigid container designed for that purpose.
Soiled equipment should be washed with a germicidal solution, rinsed and dried with a paper towel. The items should be placed in the appropriate bag, labeled and placed in the soiled utility room, where the bags will be picked up by sterile processing department personnel.
Although microorganisms may be present on surfaces such as walls and floors, unless visibly soiled, they are infrequently associated with the transmission of infection. However, walls, blinds and curtains can be washed periodically. Curtains must be changed if the patient was on contact or contact/droplet precautions, according to the University of Virginia Health System. ES personnel should bucket-clean the rooms of patients with vancomycin-resistant enterococcus (VRE), as per facility policy. RMW containers from VRE-contaminated rooms must be emptied and bucket-cleaned, while RMW containers from other isolation rooms do not need to be emptied and cleaned at the time of discharge unless the container is more than three-quarters full or is malodorous. Egg-crate mattresses from isolation rooms can be disposed of after being carefully sealed in a plastic trash bag. If soiled with bodily fluids, they should be placed in a large RMW container in the designated soiled utility room, not in the trash chute.
According to the infection control manual of Yale-New Haven Hospital, the bed frame and handrails, mattress and all other patient-room furniture should be cleaned with an Environmental Protection Agency (EPA)-approved disinfectant and used according to manufacturers' guidelines. Suction containers should be removed and prepared for disposal or reprocessing, and all other reusable equipment should be decontaminated according to the healthcare facility's nursing, engineering, sterile processing and ES policies. The bathroom in an isolation room should be thoroughly cleaned, with particular attention paid to the sink, toilet and door-handle areas. Soap in dispensers and toilet paper rolls do not have to be discarded routinely during the terminal cleaning process, according to Yale-New Haven.
The cleaning of airborne/droplet precaution rooms dictates that ES personnel wear proper barrier-protection attire as well as an N-95/HEPA respirator mask at all times. A standard surgical mask is sufficient for cleaning a room of a patient who has been on droplet precautions.
The Operating Room
Sanitation practices should aim to provide a clean environment for the perioperative patient and carried out in a manner that poses minimal risk of exposure to infectious waste to the patient as well as the surgical team, according to the University of Kentucky Hospital's policy on sanitation in the operating room. The circulator is tasked with keeping the OR orderly during surgery, including spot-cleaning any contamination of blood or bodily fluids with a hospital-grade germicide, maintaining a sterile field, keeping the floor clean and using the proper receptacles for waste. Other sanitation responsibilities in between cases in the OR include ensuring the disposal of sharps in appropriate containers; removing instruments to appropriate locations on the case cart; suctioning all contaminated fluids into the closed suction system; removing all drapes and linen used during the procedure and segregating the materials according to red-bag waste and brown-bag waste criterion.
ES personnel should clean the OR furniture with a hospital-grade germicide, making sure to unlock the OR bed and removing the pads so that the entire surface can be cleaned, including joints, table attachments and patient rollers. Using the germicide, all surfaces of instrument tables should be wiped, especially areas showing visible soil. Spot cleaning with the germicide should be done on electrosurgical units and any specialty equipment including video carts and warming units, as well as OR lights. Excess debris should be removed from the floor with a counter brush and then cleaned using a wet vacuum over the area adjacent to the soiled operative area. Walls can be spot cleaned, and clean linens can be placed on the OR bed after it has been cleaned.
Terminal cleaning of the OR is conducted weekly, according to the University of Kentucky, using mechanical friction and a hospital-grade disinfectant. Areas that must be cleaned include walls and ceiling, surgical lights and arms, instrument tables, mayo stand, prep stand, linen hamper, top and frame, suction holder, trash containers, kick buckets, entire floor, face plates of vents, tops of C lockers and entire OR bed.
In the perimeter area of the OR, corridors and scrub areas should be cleaned by ES personnel daily and as needed. Floors should be cleaned daily and scrubbed weekly. Utility rooms, case cart rooms and instrument rooms should be cleaned once a day and as needed, and should be the responsibility of the night ES or housekeeping staff. Holding rooms, lounge/locker areas and bathrooms should be cleaned daily and as needed. End-of-day cleaning should mirror the steps outlined in between-cases cleaning procedures, as well as moving equipment to one side and wet-vacuuming the entire floor, including corners.