Infection Control Today: Environmental Services

Environmental Cleaning in the Operating Room

Adapted from the September 2004 presentation by Rose Seavey, RN, MBA, CNOR, ACSP, at the ASHES Annual Conference in Orlando in September, 2004, based on the Jan. 1, 2003, AORN Recommended Practices for Environmental Cleaning in the Surgical Practice Setting. Reprinted with permission.

The Association of periOperative Registered Nurses (AORN) recommended practices are intended to be attainable recommendations for an optimal level of environmental cleaning practice. The extent to which the recommended practices may be implemented will be indicative of variations in practice settings and clinical situations, and will also be influenced by differing policies and procedures. However, they are also adaptable to the many surgical settings from traditional operating rooms (ORs) to ambulatory care settings and a host of additional areas where invasive procedures and operative services are performed.

The desired outcome of proper application of the recommended practices is to minimize staff and patient exposure to potentially infectious microorganisms and to create a clean environment for surgical patients. Since all patients are deemed potentially infected, all surgical procedures are also considered infectious and the same environmental cleaning procedures must be carried out for all procedures. For the purposes of this article, not all areas of each recommended practice will be covered in detail. For additional information on AORNs recommended practice for the OR, readers should go to the AORN Web site at 

Recommended Practice I states that all patients should be provided with a safe, clean environment. To achieve this, environmental cleaning should be performed on a regular basis to reduce dust, organic debris, and the microbial load in the surgical environment. The OR suites should be cleaned before and after each surgical procedure and at days end. There will be times, when cleaning may be necessary during a surgical procedure with guidance provided in RP II.

Environmental cleaning should be a team effort between the surgical and environmental services professionals; however, the ultimate responsibility for ensuring a clean surgical environment rests upon the perioperative nurse. Administrative personnel should ensure that environmental cleaning practices comply with the standards established for the practice setting. Prior to the first case of the day, all horizontal surfaces in the OR should be damp-dusted with a clean, lint-free cloth moistened with an EPA-registered, hospital-grade disinfectant to remove dust and lint. These surfaces include furniture, surgical lights and booms, and all equipment.

Recommended Practice II states that during surgical procedures, contamination should be confined and contained, meaning prompt clean-up of contaminated items such as blood, tissue, or body fluids, and kept within the immediate vicinity of the surgical field. Spills outside the surgical field should be removed as promptly as possible. When cleaning spills of blood or other potentially infectious material (OPIM), appropriate personal protective equipment (PPE) should be used.

Small spill of less than 10 ml should be cleaned and disinfected using a soft, absorbent, low-linting cloth, and using either an intermediatelevel germicide (an EPA-registered product that is suitable for TB), an EPA-registered product with a label claim effective for HIV and/or hepatitis B; or a 1:10 ration of sodium hypochlorite for non-porous surfaces. It is vital to adhere to the recommended dilution rate and full contact time for the disinfectant. For spills greater than 10 ml, use the disposable absorbent material first, followed by the germicidal product following the same aforementioned guidelines. Before clean-up, a 1:10 solution of sodium hypochlorite may be added to the spill. All used cleaning materials should be discarded in the proper biohazard-labeled containers.

Disposable patient-care items should be discarded in labeled, leakproof, tear-resistant containers to prevent exposure to personnel and to prevent contamination to the surgical environment. Cleaning professionals should wear gloves, gowns and other protective appropriate to the task and dispose of materials according to state, local and federal regulations. Re-useable items should be reprocessed according to prescribed policies and procedures.

Recommended Practice III states that after each surgical procedure, a safe, clean environment should be re-established. Implementation includes disposing of items according to state, local and federal regulations. Patient-transport vehicles, including non-disposable straps and attachments, wheelchairs, and wagons should be cleaned after each use using an EPA-registered, low- to intermediate-level germicide.

When procedures involve neonates, avoid unnecessarily exposing them to disinfectant residue on surfaces and do not use phenolics or other chemical germicides to disinfect bassinets or incubators. If a disinfectant is used, the solution must be prepared in concentrations directed by the manufacturer. After the use of disinfectants, the surface(s) should be rinsed with water.

Between case cleaning, OR furniture and equipment are considered contaminated by patient contact and OPIM. Visibly soiled furniture and equipment should be cleaned with EPA-registered, hospital-grade germicidal agents following each procedure. Walls, doors, and surgical lights and ceilings should be spot-cleaned if soiled with blood, tissue, or body fluids. Anesthesia equipment should be cleaned according to the AORN Recommended Practices for Cleaning and Processing Anesthesia Equipment. Mechanical friction should be used when cleaning and the efficacy of the cleaning is dependent on the scrubbing action.

For floors, visibly soiled areas must be cleaned using a new or freshly laundered mop head and EPA-registered, hospital-grade germicidal agent. Unless the germicidal agent is changed after each use, the mop head should be immersed into the solution only when it is clean and before the mopping action begins. Soiled or used mop heads should not be re-dipped into the germicidal solution. If re-dipping is deemed necessary, the solution should be thrown away and fresh solution prepared for continued mopping. Soiled mop handles should also be cleaned with the germicide or discarded. For end-of-procedure cleaning of floors, it is only necessary to clean a three- to four-foot perimeter around the surgical field when visibly soiled. The area cleaned should be extended to adjacent visibly soiled areas and the OR table should be moved to check for items such as sponges or instruments that may have been dropped.

For daily terminal cleaning, the entire floor should be cleaned including the area under the OR bed. Disposable items contaminated with blood and/or tissue must be considered biohazard trash meaning, that which would release infectious materials in a liquid or semi-liquid state if compressed, or caked with dried blood or OPIM. Biohazard containers should be closable, leak-proof containers or bags that are color-coded, labeled, or tagged for easy identification and transported in washable carts or vehicles. State regulations for transport and disposal or regulated waste should be consulted.

All used, disposable sharps are considered infectious waste and placed in designated puncture resistant containers to prevent staff from the potential of a puncture injury that would expose them to potentially infectious microorganisms. If a re-useable system is used, the contents should be disposed of according to local, state and/or federal regulations and engineering controls and PPE should be used to protect the employee if they are required to conduct the emptying, cleaning and disinfecting of the equipment. The same applies for contaminated instruments, basins, trays and other items.

Recommended Practice IV states that surgical procedure rooms and scrub/ utility areas should be terminally cleaned daily. ORs in which procedures may be performed regardless of use, should be terminally cleaned once every 24-hour period during the regular work week. Areas and equipment to be cleaned with an EPA-registered agent include: surgical lights and external tracks, fixed and ceiling mounted equipment, all furniture including wheels, casters step stools, kick buckets, foot pedals, telephones and light switches, hallways and floors, handles on cabinets and push plates, ventilation faceplates all horizontal surfaces, sub-sterile areas, and scrub sinks. It is further recommended that scrub sink soap dispensers be single-use. OR floors should be wet-vacuumed with the appropriate EPA-registered, hospital-grade disinfectant after the last scheduled procedure of the day and at least once during a 24-hour period.

Recommended Practice V states that all areas and equipment in the surgical practice setting should be cleaned according to an established schedule. These areas include ducts and filters, HVAC equipment, closets cabinets and shelves, storerooms, ice machines walls, ceilings, offices, lounges lavatories and locker rooms. It is important that the Environmental Services department and the OR management team determine and agree to an established schedule for these areas. Recommended Practice VI, related to policies and procedures for environmental cleaning, states that the policies and procedures should be written, reviewed annually, and readily available in the surgical practice setting.

Utilizing the AORN Recommended Practices as a guideline for the initial development of the policies and procedures establishes authority, responsibility and accountability and serve as the operational guidelines for a strong partnership between environmental services and surgical services. They also help to ensure a clean and safe surgical environment for the patients and staff, as a means to facilitate positive patient outcomes.

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