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 EnvironmentalCleaning in the Surgical Practice Setting. Reprinted with permission.

The Association of periOperative Registered Nurses (AORN)recommended practices are intended to be attainable recommendations for anoptimal level of environmental cleaning practice. The extent to which therecommended practices may be implemented will be indicative of variations inpractice settings and clinical situations, and will also be influenced bydiffering policies and procedures. However, they are also adaptable to the manysurgical settings from traditional operating rooms (ORs) to ambulatory caresettings and a host of additional areas where invasive procedures and operativeservices are performed.

The desired outcome of proper application of the recommendedpractices is to minimize staff and patient exposure to potentially infectiousmicroorganisms and to create a clean environment for surgical patients. Sinceall patients are deemed potentially infected, all surgical procedures are alsoconsidered infectious and the same environmental cleaning procedures must becarried out for all procedures. For the purposes of this article, not all areasof each recommended practice will be covered in detail. For additionalinformation on AORNs recommended practice for the OR, readers should go tothe AORN Web site at http://www.aorn.org/products/standardstoc.pdf 

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

Environmental cleaning should be a team effort between thesurgical and environmental services professionals; however, the ultimateresponsibility for ensuring a clean surgical environment rests upon theperioperative nurse. Administrative personnel should ensure that environmentalcleaning practices comply with the standards established for the practicesetting. Prior to the first case of the day, all horizontal surfaces in the ORshould be damp-dusted with a clean, lint-free cloth moistened with anEPA-registered, hospital-grade disinfectant to remove dust and lint. Thesesurfaces include furniture, surgical lights and booms, and all equipment.

Recommended Practice II states that during surgicalprocedures, contamination should be confined and contained, meaning promptclean-up of contaminated items such as blood, tissue, or body fluids, and keptwithin the immediate vicinity of the surgical field. Spills outside the surgicalfield should be removed as promptly as possible. When cleaning spills of bloodor other potentially infectious material (OPIM), appropriate personal protectiveequipment (PPE) should be used.

Small spill of less than 10 ml should be cleaned anddisinfected using a soft, absorbent, low-linting cloth, and using either anintermediatelevel germicide (an EPA-registered product that is suitable for TB),an EPA-registered product with a label claim effective for HIV and/or hepatitisB; or a 1:10 ration of sodium hypochlorite for non-porous surfaces. It is vitalto adhere to the recommended dilution rate and full contact time for thedisinfectant. For spills greater than 10 ml, use the disposable absorbentmaterial first, followed by the germicidal product following the sameaforementioned guidelines. Before clean-up, a 1:10 solution of sodiumhypochlorite may be added to the spill. All used cleaning materials should bediscarded 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 toprevent contamination to the surgical environment. Cleaning professionals shouldwear gloves, gowns and other protective appropriate to the task and dispose ofmaterials according to state, local and federal regulations. Re-useable itemsshould be reprocessed according to prescribed policies and procedures.

Recommended Practice III states that after each surgicalprocedure, a safe, clean environment should be re-established. Implementationincludes 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 anEPA-registered, low- to intermediate-level germicide.

When procedures involve neonates, avoid unnecessarily exposingthem to disinfectant residue on surfaces and do not use phenolics or otherchemical germicides to disinfect bassinets or incubators. If a disinfectant isused, the solution must be prepared in concentrations directed by themanufacturer. After the use of disinfectants, the surface(s) should be rinsedwith water.

Between case cleaning, OR furniture and equipment areconsidered contaminated by patient contact and OPIM. Visibly soiled furnitureand equipment should be cleaned with EPA-registered, hospital-grade germicidalagents following each procedure. Walls, doors, and surgical lights and ceilingsshould be spot-cleaned if soiled with blood, tissue, or body fluids. Anesthesiaequipment should be cleaned according to the AORN Recommended Practices forCleaning and Processing Anesthesia Equipment. Mechanical friction should beused when cleaning and the efficacy of the cleaning is dependent on thescrubbing action.

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

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

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

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

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

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