Using a planned, disciplined program

by Beth Hohl and Kirsten M. Thompson

The spread of healthcare-associated infection (HAI) in surgical environments has become a major concern and priority for healthcare facilities around the globe. This is not due to lack of efforts to contain infections through conventional means but is instead a result of the processes and procedures that were widely accepted and effective in the past now being ineffective against multi-drug resistant organisms (MDROs).

The emergence of MDRO’s has outpaced traditional methods of infection control in the surgical environment and leaves no room for error in every risk reduction measure taken by healthcare facilities and their staff. Without new and evolving infection prevention and control measures, patients and medical personnel will continue to be vulnerable to infections.

The very nature of an operating room (OR) makes it an environment of high risk for transmission and acquisition of pathogens. According to a 2008 report by the Centers for Disease Control and Prevention (CDC), approximately 46.5 million surgical procedures and even more invasive medical procedures, including approximately 5 million gastrointestinal endoscopies, are performed each year. The procedures each involve contact by a medical device or surgical instrument with a patient’s tissue or mucous membranes. This creates a major risk for introduction of pathogens that can lead to infection in the clinical environment, making disinfection and sterilization are essential for reducing transmission of infectious pathogens. Indeed, failure to comply with scientifically-based guidelines has led to numerous outbreaks.¹

Organisms such as Staphylococcus aureus, Enterococus, Acinetobacter and Clostridium difficile have been demonstrated to survive for extended periods of time in the open environment. One notable study demonstrated environmental contamination in three different ORs after terminal cleaning. ²

Environmental samples of five standardized items were collected from cardiac, trauma and general surgery rooms. The five standardized items in each room were:

1. Oxygen flowmeter on the anesthesia machine;
2. OR bed control;
3. Ventilator valve (manual to automatic);
4. Telephone handle;
5. Right hand door handle inside the OR.

To assure the integrity of the study, a microbiology technician supervised a single investigator who used an identical method to take samples from each of the three OR environments for evaluation. Samples were taken in each room at the beginning of the day prior to the first patient entering the OR, during a random time in the day while a surgery was in progress and at the end of the day before initiation of room cleaning processes.

At the end of the study, coagulase-negative Staphylococcus was the most common organism found in all three rooms. Micrococcus, Bacillus, and diphtheroids were also found scattered on different items throughout the three different OR environments.

During random midday sampling Streptococcus was found on the door handle of the trauma OR and the phone handle of the cardiac OR. In the morning and at midday, Escherichia coli (E. coli) was found in the general surgery OR door handle.

Samples from the cardiac OR produced the most E. coli. It was found on all morning samples, except for the door handle. The midday sample found E. coli only on the bed control.

The most surprising aspect of these findings is that the most infectious organisms were found most frequently in the morning, after terminal cleaning had been performed, when each OR would have been expected to be the most clean. These findings indicate that the cleaning procedures from the prior day were not producing a clean environment. ³

Beyond the OR, intensive care units (ICUs) and standard patient rooms are also areas where cleaning can have a big impact. For example, a poster presented at the 2009 Society of Hospital Epidemiologist Association (SHEA) Annual Meeting offered the following insights into direct linkage between the clinical environment and transmission of infection. ⁴

In their original study, it was found that when an ICU room was previously occupied by a MRSA or VRE infected patient, the risk for the next patient to acquire either of these two pathogens was increased by up to 40 percent. A subsequent study further showed that a multi-modal cleaning intervention can reduce environmental cultures for MRSA and VRE. Currently, a study at the University of California Irvine also now suggests that this same intervention reduces acquisition of these pathogens, particularly MRSA, in subsequent room occupants. ²

Cleaning and environmental services is a critical component of infection control in the OR and other patient areas in healthcare facilities. A comprehensive approach to cleaning is the most effective means to removing pathogens and minimizing the risk of infection. To properly address environmental hygiene in the OR and other patient areas, there are several key components that must be in place to deliver improved cleaning outcomes:

• Training and education on best practices;
• Standardized processes to consistently disinfect high touch objects;
• Objective metrics to measure program effectiveness;
• Infection control practices to prevent cross contamination;
• Consistent delivery of correct disinfectant concentration;
• Ergonomic tools and practices to prevent injury and promote efficiency.

One of the most practical set of guidelines for disinfection available to healthcare facilities seeking guidance on improving cleanliness in the surgical suite was published by the Association of PeriOperative Registered Nurses (AORN). AORN’s best practices for environmental cleaning in surgical practice settings recommend that procedure rooms and utility areas of the surgical suite should be terminally cleaned every 24 hours. This daily cleaning should include:

• Surgical lights and tracks;
• Fixed and ceiling-mounted equipment;
• Furniture and equipment, including wheels and casters;
• Cabinet handles;
• Horizontal surfaces (e.g., countertops, open shelving, sterilizers);
• Air-handling vent covers;
• Substerile areas;
• Scrub sinks;
• Scrub and utility areas.

AORN further recommends that floors be cleaned after the last operation of the day or night. ⁵

AORN’s recommended practices for environmental cleaning in the perioperative settings further mandates specific timeframes for cleaning that include surgical and invasive procedure rooms and scrub/utility areas that should be terminally cleaned daily, including:

• Unused rooms that should be cleaned once during each 24-hour period during the regularly scheduled work week.
• The entire floor should be wet-vacuumed with an Environmental Protection Agency (EPA)-registered disinfectant after scheduled procedures are performed.
• OR beds should be moved to observe for any items that may be hidden under the bed.

Equipment should be disassembled, disinfected, cleaned with an EPA-registered disinfectant, and dried before reuse and storage. ⁶

Additionally, AORN recommends that any OR with a patient in it is considered contaminated by that patient. This means that extensive cleaning must be completed between each procedure, and that the cleaning process should not be started until the current patient has left the room. Beginning the cleaning processes before the patient has been fully removed can result in ongoing contamination.

From a practical standpoint, the availability of cleaning supplies and tools for use between cases and at the end of the day contributes to reducing transmission of infectious disease. Having these items within easy reach can eliminate delays in cleaning a room. While OR turnover time needs to be kept to a reasonable minimum, achieving optimum cleaning and disinfection still needs to be a higher priority. This is easier to accomplish with well established cleaning processes versus individual practices and supplies.

Effective environmental cleaning and disinfection works best when it is a result of a planned, disciplined program, not a standalone initiative. Performance, efficiency and environmental hygiene can all be improved with a well defined cleaning protocol combined with the proper cleaning agents and other supplies. Many hospitals find that turnover kits can reduce the time to clean and prepare the OR for the next procedure because they are easy to use and ensure that all the supplies needed to clean the room are together in one bag. Kits such as Ecolab’s CleanOp^® OR turnover kits, combine pre-packaged supplies and comprehensive training that help ensure that rooms are cleaned properly.

Cleaning kits typically contain a table sheet, mop, bags and wipes to help clean the OR. The absorbent table sheet is a multi-layer laminate comprised of an impervious film layer to protect the OR table mattress from bodily fluids, an absorbent layer to capture any fluids, and a soft nonwoven layer next to the patient’s skin.

It is often difficult to determine the precise source of a pathogen, especially in hospital environments, because of the high concentration of people suffering from infections, the high traffic of patients and visitors. In addition, many patients are more susceptible to infections because their immune systems are compromised. Pre-existing patient conditions and other factors independent of nursing or the environment can contribute to the development of surgical site infections. The OR offers a unique opportunity to reduce risk because of its size and closed nature. Still, no single initiative can work alone to solve the issue of healthcare-associated infections. OR cleaning best practices need to be combined with environmental services, hand hygiene, surgical site and other infection prevention practices in a comprehensive infection prevention effort.

References

1. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, William A Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC)
2. Lajoie J, Ling E. How Clean are we? Determining Growth on Commonly Touched Items in Three Operating Rooms. Anesthesiology 2006;105:A944.
3. Ibid.
4. Datta R, Platt R, Kleinman K, Huang S. Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants. SHEA Annual meeting presentation, March 20, 2009.
5. Clinical Issues; Terminal cleaning; regulated waste; sponge items; patient instructions; preoperative assessment; damaged packs; storage. AORN Journal, October 2000, Vol. 72, No. 4
6. Ibid.

Beth Hohl is a marketing manager for Ecolab’s Surgical Healthcare, managing the Surgical Room Turnover packs. She works with customers to understand their needs and directs the development efforts for new products and programs to support those clinical needs.

Kirsten M. Thompson is the senior program leader for Ecolab’s Healthcare Technical Affairs and In-Line Maintenance Department, providing technical support to sales associates by authoring technical literature and educational presentations. Her department also has responsibility of regulatory data quality of all Ecolab Healthcare antimicrobial products.