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By Kelly M. Pyrek
Two areas of a hospital can pose some of the greatest opportunities for thetransmission of pathogens: the room of an isolated patient and the operatingroom (OR). Both demand rigorous ongoing and terminal cleaning and disinfecting.
Patients under isolation precautions require healthcare workers andenvironmental services (ES) personnel to follow Standard Precautions whendelivering patient care and performing terminal cleaning. All bodily fluids,secretions and non-intact skin of isolated patients are treated as potentiallyinfectious.
One of the first steps in the terminal cleaning of isolation-designatedpatient rooms is the bagging of used articles in order to prevent personnelexposure to contaminated items and to prevent contamination of the environmentthrough aerosolization or contact transmission of pathogens.
According to the infection control manual of the University of VirginiaHealth System, ES personnel first should don a protective gown, gloves and amask before proceeding to other tasks. Items and equipment that can be steamautoclaved, 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 gasautoclaved, such as respiratory tubing. All special procedure tray linens shouldbe placed in the linen hamper, while all dressing materials visibly contaminatedwith bodily fluids should be disposed of in the regulated medical waste (RMW)container. All opened packages can be disposed of in the regular trash. Sharpsshould be placed in a rigid container designed for that purpose.
Soiled equipment should be washed with a germicidal solution, rinsed anddried 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 upby 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 ofinfection. However, walls, blinds and curtains can be washed periodically.Curtains must be changed if the patient was on contact or contact/dropletprecautions, according to the University of Virginia Health System. ES personnelshould bucket-clean the rooms of patients with vancomycin-resistant enterococcus(VRE), as per facility policy. RMW containers from VRE-contaminated rooms mustbe emptied and bucket-cleaned, while RMW containers from other isolation roomsdo not need to be emptied and cleaned at the time of discharge unless thecontainer is more than three-quarters full or is malodorous. Egg-cratemattresses from isolation rooms can be disposed of after being carefully sealedin a plastic trash bag. If soiled with bodily fluids, they should be placed in alarge RMW container in the designated soiled utility room, not in the trashchute.
According to the infection control manual of Yale-New Haven Hospital, the bedframe and handrails, mattress and all other patient-room furniture should becleaned with an Environmental Protection Agency (EPA)-approved disinfectant andused according to manufacturers' guidelines. Suction containers should beremoved and prepared for disposal or reprocessing, and all other reusableequipment should be decontaminated according to the healthcare facility'snursing, engineering, sterile processing and ES policies. The bathroom in anisolation room should be thoroughly cleaned, with particular attention paid tothe sink, toilet and door-handle areas. Soap in dispensers and toilet paperrolls do not have to be discarded routinely during the terminal cleaningprocess, according to Yale-New Haven.
The cleaning of airborne/droplet precaution rooms dictates that ES personnelwear proper barrier-protection attire as well as an N-95/HEPA respirator mask atall times. A standard surgical mask is sufficient for cleaning a room of apatient who has been on droplet precautions.
The Operating Room
Sanitation practices should aim to provide a clean environment for theperioperative patient and carried out in a manner that poses minimal risk ofexposure to infectious waste to the patient as well as the surgical team,according to the University of Kentucky Hospital's policy on sanitation in theoperating room. The circulator is tasked with keeping the OR orderly duringsurgery, including spot-cleaning any contamination of blood or bodily fluidswith a hospital-grade germicide, maintaining a sterile field, keeping the floorclean and using the proper receptacles for waste. Other sanitationresponsibilities in between cases in the OR include ensuring the disposal ofsharps in appropriate containers; removing instruments to appropriate locationson the case cart; suctioning all contaminated fluids into the closed suctionsystem; removing all drapes and linen used during the procedure and segregatingthe 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 entiresurface 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 shouldbe done on electrosurgical units and any specialty equipment including videocarts and warming units, as well as OR lights. Excess debris should be removedfrom the floor with a counter brush and then cleaned using a wet vacuum over thearea adjacent to the soiled operative area. Walls can be spot cleaned, and cleanlinens can be placed on the OR bed after it has been cleaned.
Terminal cleaning of the OR is conducted weekly, according to the Universityof Kentucky, using mechanical friction and a hospital-grade disinfectant. Areasthat must be cleaned include walls and ceiling, surgical lights and arms,instrument tables, mayo stand, prep stand, linen hamper, top and frame, suctionholder, trash containers, kick buckets, entire floor, face plates of vents, topsof C lockers and entire OR bed.
In the perimeter area of the OR, corridors and scrub areas should be cleanedby ES personnel daily and as needed. Floors should be cleaned daily and scrubbedweekly. Utility rooms, case cart rooms and instrument rooms should be cleanedonce a day and as needed, and should be the responsibility of the night ES orhousekeeping staff. Holding rooms, lounge/locker areas and bathrooms should becleaned daily and as needed. End-of-day cleaning should mirror the stepsoutlined in between-cases cleaning procedures, as well as moving equipment toone side and wet-vacuuming the entire floor, including corners.