Infection Control Today - 12/2002: Cleaning Scopes

December 1, 2002

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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.

Isolation Room

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.