Operating rooms must be sterile environments to ensure patient safety throughout the procedure. While you're no doubt aware of the importance of cleaning the OR both before and after every surgery, your OR cleaning checklist might overlook some areas that can harbor dirt, dust and pathogens. Keep these five trouble spots in mind to help reduce the risk of infections in your facility.
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1. Behind Equipment and Furnishings
You probably wipe down used equipment and furnishings such as tables, carts and stools after a surgery to rid them of germs. However, it's also important to move these items so that you can clean under and behind them. Pull furniture and equipment away from the wall so that you can sweep and mop behind these items. Dust and debris often collect in corners and underneath equipment, where they can harbor infectious agents. Take the time to thoroughly clean behind these items to eliminate buildup that reduces the sterility of your operating environment.
2. Floors
Surfaces like the operating table might seem like the most germ-prone spots in the OR, but the floors aren't far behind. Bodily fluids and other substances can land on the floor during a surgery, requiring prompt cleanup. The Centers for Disease Control and Prevention recommend in their Guidelines for Environmental Infection Control in Healthcare Facilities the use of approved detergents and disinfectants to clean bodily fluids or bloods from the floor. In particular, look for cleaning solutions that have been reviewed and approved by the Environmental Protection Agency.
3. Ceiling
It's easy to assume the ceiling in your OR is always going to stay untouched and spotless, but the ceiling is still a place that can harbor germs, dust and buildup. Accumulated debris can eventually fall, posing a serious health risk during a procedure. Mitigate this risk by regularly cleaning the ceiling (including lighting fixtures) in your operating room. Use a microfiber cloth to easily wipe away any dust, and take the opportunity to inspect the ceiling area for any spots that require more intensive cleanup and disinfection.
4. Cabinets
As a standard practice, you probably wipe down the outside of the cabinets in your OR. However, be sure not to overlook the interior, where germs can easily lurk until they are introduced into the room. (Think of how many hands reach into those cabinets during a given procedure.) Always wipe down the cabinet shelves, handles and contents to minimize the spread of harmful agents during and after an operation.
5. Biohazard Trashcans
The biohazard trashcan in your operating room allows you to dispose of biohazardous waste safely and properly. But even if your waste has been properly bagged and disposed of, the trashcan itself can be a hot spot for pathogens. Take the time to properly disinfect all biohazard containers and trashcans to ensure that any medical waste doesn't spread infectious disease around your healthcare facility.
As an industry-leading provider of patient-centered healthcare cleaning services, we know that a properly cleaned OR is a safe OR. Checking these five often-overlooked areas for dirt and debris can go a long way toward reducing germs and minimizing the risk of infection. Browse the ServiceMaster Clean blog for additional tips on how to keep your healthcare facility clean, and don't hesitate to contact us to learn more about professional cleaning services that create a safe and sterile environment for your patients.
In recent years, there is an increasing consensus that improved cleaning and disinfection of environmental surfaces is needed in healthcare facilities [1–4]. Experts generally agree on a number of areas, including the fact that careful cleaning and/or disinfection of environmental surfaces, daily and at time of patient discharge, are essential elements of effective infection prevention programs. Moreover, when disinfectants are used, they must be used appropriately to achieve the desired effects. However, there are a number of areas of disagreement and controversy regarding best practices for cleaning and disinfection of environmental surfaces. Some experts favor physical removal of microorganisms using only a detergent solution [3]. Other individuals believe that manual disinfection of surfaces using currently available disinfectants is adequate, and that newer approaches to disinfection are not necessary.
The purpose of this article is to summarize the many factors that affect standard cleaning and disinfection practices and to discuss modern technologies that can supplement traditional cleaning and disinfection methods.
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Multiple studies have shown that manual cleaning and disinfection of surfaces in hospitals is suboptimal. In many facilities, only 40 to 50 % of surfaces that should be cleaned are wiped by housekeepers [5]. In addition, observational methods combined with use of adenosine triphosphate (ATP) bioluminescence have shown that individual housekeeper performance varies considerably [6]. One study found variations among housekeepers in the amount of time spent cleaning surfaces, the number of wipes used in each room, and the level of cleanliness achieved [6]. Specialized cleaning teams that included infection control personnel have been shown to reduce C. difficile surface contamination more effectively than routine housekeepers [7]. Personnel turnover among Environmental Services departments is a significant problem [8, 9], which may reach 30 to 50 % in some facilities. As a result, shortages in Environmental Services personnel were reported by more than 50 % of hospitals in a recent survey conducted in the United States [10]. Among housekeepers and nursing personnel, there is often confusion about who is responsible for cleaning various surfaces and equipment [11, 12].
In addition to the above personnel-related issues, there are many other factors that can potentially have adverse effects on the efficacy of traditional cleaning and disinfection practices. The type of surface being cleaned or disinfected can affect the completeness with which bacteria are removed. For example, Ali et al. found that the type of material from which bed rails were made affected how well they could be cleaned by microfiber cloths, and that bacteria were removed more effectively by antibacterial wipes than by microfiber [13]. Disinfectants may be applied using inadequate contact times. Failure of housekeepers to use an adequate number of wipes per room can result in poor cleaning of surfaces [6]. Use of wipes without sufficient antimicrobial activity against target pathogens can result in poor disinfection of surfaces and can lead to spread of pathogens from one surface to another [14, 15]. Binding of quaternary ammonium disinfectants to cloths made of cotton or wipes containing substantial amounts of cellulose may reduce the antimicrobial efficacy of the disinfectant [16, 17]. At least one laboratory-based study has shown that detergent wipes have variable ability to remove pathogens from surfaces, and may in fact transfer pathogens between surfaces [18].
Inappropriate over-dilution of disinfectant solutions by housekeepers or by malfunctioning automated dilution systems may result in applying disinfectants using inappropriately low concentrations [9, 17]. For example, an investigation of housekeeping practices at a large teaching hospital included an audit of 33 automated disinfectant dispensing stations that mix concentrated disinfectant with water to yield a desired in-use quaternary ammonium concentration of 800 ppm [17]. Quaternary ammonium concentrations of solutions dispensed were tested using commercially-available test strips. The audit revealed that several dispensing stations yielded solutions with less than 200 ppm, approximately 50 % of stations delivered solutions with 200 to 400 ppm. An investigation revealed several flaws in the dispensing system. Inexpensive test strips and more complicated titration kits are available to monitor quaternary ammonium concentrations of disinfectants.
Contamination of disinfectant solutions can occur, particularly if recommendations for their use are not followed [19–21]. For example, Kampf et al. recently reported that 28 buckets from 9 hospitals contained surface-active disinfectants (e.g., quarternary ammomium solutions) that were contaminated with Achromobacter or Serratia strains [21]. Buckets and roles of wipes had not been handled according to manufacturer recommendations. In studies that involved culturing high-touch surfaces in patient rooms before and shortly after housekeepers had performed routine cleaning, we found that cultures obtained from several surfaces in one room after cleaning yielded large numbers of Serratia and smaller numbers of Achromobacter which were not present before cleaning [Fig. 1] [20]. The housekeeper’s bucket of quaternary ammonium-based disinfectant contained 9.3 × 104 CFUs/ml of gram-negative bacilli (mostly Serratia marcescens and fewer numbers of Achromobacter xylosoxidans). Pulsed-field gel electrophoresis demonstrated that Serratia isolates recovered from the disinfectant were the same strains as those recovered from surfaces in the patient room. Genome sequencing of one of the Serratia strains by collaborating investigators revealed that it contained four different qac resistance genes that permitted the organism to grow and survive in the disinfectant (unpublished data). If disinfectant contamination is suspected, a sample of the product can be used to inoculate a broth medium or solid agar containing neutralizers effective against the active agent(s) in the disinfectant solution.
Fig. 1Contact agar plate cultures showing bacterial colonies recovered from a patient’s overbed table before (left) and after (right) the surface was cleaned by a housekeeper using contaminated quaternary ammonium disinfectant. Colonies on right are Serratia marcescens and Achromobacter xylosoxidans
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Numerous studies have found that standard manual cleaning or disinfection of surfaces can reduce, but often does not eliminate, important pathogens such as C. difficile, staphylococci including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multi-drug-resistant Acinetobacter [7, 22–28]. Failure to adequately disinfect patient rooms at the time of hospital discharge contributes to the increased risk of acquisition of resistant pathogens among patients admitted to a room where the prior room occupant was colonized or infected with a multidrug-resistant pathogen [29–31].
In order to improve standard cleaning and disinfection practices, it is recommended that the practices of housekeepers be monitored and that they receive feedback regarding their performance. However, monitoring of housekeeper performance is often not performed as frequently as needed, if at all [10]. Recently, fluorescent marking systems (Fig. 2) and ATP bioluminescence assays (Fig. 3) have proven useful for evaluating cleaning practices and providing housekeepers with feedback [32, 33]. Unfortunately, such objective means of monitoring the adequacy of cleaning/disinfection practices are not routinely used in many facilities [10]. Perhaps the lack of monitoring of housekeepers is due in part to the fact that monitoring activities can be time-consuming and must be conducted on an ongoing basis in order to be effective [34].
Fig. 2Photographs of a fluorescent marker visible with a “black light” on a high touch surface before cleaning (left), and absence of the fluorescent marker after cleaning was performed (right)
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Fig. 3Three steps of an ATP bioluminescence assay for monitoring cleanliness of surfaces. Step 1: a special swab is used to sample the surface. Step 2: the swab is placed in a reaction tube and shaken for 10–15 s. Step 3: the reaction tube is placed in a luminometer and a result is reported as relative light units (RLUs). The higher the RLU value, the greater the amount of ATP detected on the surface
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Given the multitude of challenges to achieving and maintaining adequate cleaning and disinfection in healthcare facilities, there is a need to consider the use of modern technologies designed to improve disinfection of surfaces in hospitals. New technologies fall into several categories, including: (A) new liquid surface disinfectants, (B) improved methods for applying disinfectants, (C) self-disinfecting surfaces, (D) light-activated photosensitizers, and (E) no-touch (automated) technologies.
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