Published on December 6, 2013
Recommended Practices for Environmental Cleaning Amber Wood, MSN, RN, CNOR, CIC, CPN November 13, 2013
Amber Wood, MSN, RN, CNOR, CIC, CPN Amber Wood is a Perioperative Nursing Specialist at AORN where she has served as lead author for the AORN Recommended Practices for Environmental Cleaning. Amber offers clinical information to members via the AORN Consult Line and contributes regularly to the Clinical Issues column in the AORN Journal. She serves as the staff liaison to the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), as a member of the Association for Professionals in Infection Control and Epidemiology (APIC) and the Association for the Healthcare Environment (AHE). Amber’s clinical experience includes infection prevention, pediatric perioperative nursing, and clinical research. Amber completed her BSN and MSN in Nursing Education at Texas Woman's University in Dallas, TX and she is certified as a CNOR, infection prevention and control professional (CIC), and pediatric nurse (CPN).
Disclosure Information Speaker: Planning Committee: Amber Wood, MSN, RN, CNOR, CIC, CPN Ellice Mellinger MS, BSN, RN, CNOR Disclose No Conflict Perioperative Education Specialist, AORN Disclose No Conflict AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are indicated according to the following numeric categories: 1. Consultant/Speaker’s Bureau 2. Employee 3. Stockholder 4. Product Designer 5. Grant/Research Support 6. Other relationship (specify) 7. No conflict of interest Successful completion of this educational activity includes attendance at 90% of the webinar and completion of the evaluation form. Accreditation Statement AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.
Objectives 1. Discuss recent revisions in AORN’s recommended practices for environmental cleaning. 2. Describe the evidence supporting the recommended practices for environmental cleaning.
Purpose & Scope
Role of the Environment • Possible infection transmission from contaminated surfaces in the environment – Dancer SJ. The role of environmental cleaning in the control of hospitalacquired infection. J Hosp Infect. 2009;73(4):378-385. [VB] – Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol. 2011;32(7):687-699. [VA] • High transmission risk in perioperative setting – Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. [IIIA]
Cleaning in the OR • May not be as good as we think it is… – 25% mean cleaning rate for objects cleaned in the OR at 6 acute care hospitals – Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93(3):358-364. [IIIB]
Issues in Environmental Cleaning • Many unanswered questions in the field – Carling PC, Huang SS. Improving healthcare environmental cleaning and disinfection: current and evolving issues. Infect Control Hosp Epidemiol. 2013;34(5):507-513. [VA]
New Scope • All perioperative areas – Pre- & Postoperative areas – Operating and procedure rooms – Semirestricted areas – Sterile processing areas
Modified Evidence Rating Model
New concepts added • • • • • Multidisciplinary Teams High Touch Objects Enhanced Environmental Cleaning Cleaning Methodology Measurement of Cleanliness
Gaps in the Literature • What is clean? • Defined cleaning procedures • Cleaning frequencies
Recommendation I Multidisciplinary Teams
Multi-Disciplinary Team Perioperative Nursing Infection Prevention Environmental Services Sterile Processing Havill NL. Best practices in disinfection of noncritical surfaces in the health care setting: creating a bundle for success. Am J Infect Control. 2013;41(5 Suppl):S26- S30. [VB]
Team Decisions • • • • Cleaning chemicals Cleaning materials, tools, equipment Cleaning frequencies Cleaning procedures – Enhanced environmental cleaning – Special situations (eg, C diff, airborne precautions, CJD, construction, environmental contamination)
High Touch Objects • Determine which items are high touch • Clean those items more frequently – Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM,Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185-187. [IIIC]
Cleaning Responsibilities Item to Clean • Missed items Personnel Anesthesia cart and equipment (eg, IV pole) Nursing (Anesthesia Tech) Anesthesia machine Nursing (Anesthesia Tech) Patient monitors Nursing OR bed Environmental Services Reusable table strap Environmental Services Dancer SJ. Hospital cleaning in the 21st century. Eur J Clin Microbiol Infect Dis. 2011;30(12):1473-1481. [VA]
Recommendation II Cleaning Basics
Damp dust • Top to bottom Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: Association for the Healthcare Environment; 2012. [IVC]
Disinfectants • Dwell times – Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008. [IVA] • Spraying and misting should not be used – Sehulster L, Chinn RY; CDC, HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. [IVA]
Dry methods of cleaning • Should not be used in semirestricted & restricted areas – Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):5765. [IIIB]
Floors • The floor is always considered dirty – Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. [IIIA] – Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):5765. [IIIB] • Items that touch the floor are dirty
Recommendation III Between Patient Cleaning
Operating or Procedure Room • High touch objects • Contaminated surfaces • Trash removal CMS & CDC Guidance
High Touch Objects in the OR • Anesthesia cart and equipment (eg, IV pole) • Anesthesia machine • Patient monitors • OR bed • Reusable table strap
High Touch Objects in the OR…(If used) • • • • • • OR bed attachments Positioning devices Patient transfer devices Overhead procedure lights Tables and Mayo Stand Equipment, mobile or fixed
Cleaning the OR…(If soiled) • Floors • Walls
Pre- & Postoperative Areas • High touch objects • Contaminated surfaces CMS & CDC Guidance
High Touch Objects in Pre- & Postoperative Areas • • • • • Patient monitors Patient bed Overbed table Television remote control Call light
High Touch Objects in Pre&Postop… (If used) • Equipment, mobile or fixed
Cleaning Pre&Postop…(If soiled) • Floors • Walls
Recommendation IV Terminal Cleaning
Operating or Procedure Room • Daily when the area is being used • Disinfect all exposed surfaces of all items, including wheels and casters • Mop or wet-vacuum the entire floor CMS & CDC Guidance
Pre-&Postoperative Areas • Daily when the area is being used • Disinfect all exposed surfaces of all items, including wheels and casters • Mop or wet-vacuum the entire floor • Trash removal CMS & CDC Guidance
Sterile Processing • Daily when the area is being used • Disinfect work areas and high touch objects • Damp dust horizontal surfaces • Mop or wet-vacuum the entire floor • Trash removal • Dirty work areas last ANSI/AAMI ST79:2010 & A1:2010, & A2:2011, & A3:2012: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington,VA: Association for the Advancement of Medical Instrumentation; 2012. [IVC]
What about… Weekends? Perioperative Nursing Unused rooms during the week? Infection Prevention We just did 1 case… Environmental Services Sterile Processing
Semirestricted & Restricted Areas • If the area is closed with no personnel present, the team may determine that terminal cleaning is unnecessary. • If perioperative team members are present in the area briefly, the team may determine that the area may only need damp dusting on horizontal surfaces.
cont. • If perioperative team members are present in the area for an extended amount of time or are performing patient care activities, the team may determine that thorough terminal cleaning of the area is necessary.
Emerging Technologies • Room Decontamination (eg, ozone, peroxide vapor, ultraviolet light, saturated steam) • May enhance cleaning of perioperative areas as an adjunct to terminal cleaning, although further research is needed • Evaluation by multidisciplinary team
Recommendation V Scheduled Cleaning
Scheduled Clean • • • • • • Sinks Ventilation ducts & grilles Refrigerators & Ice machines Clean & Soiled storage areas Sterile storage areas Corridors, including stairwells and elevators • Privacy curtains
Scheduled Clean • • • • • Walls and ceilings Pneumatic tubes and carriers Sterilizers Sterilizer service access rooms Unrestricted areas (eg, lounges, waiting rooms, offices) • Environmental services closets
Recommendation VI Limiting Transmission
Cleaning Methodology • Clean to dirty • Top to bottom • Clockwise or counter-clockwise Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: Association for the Healthcare Environment; 2012. [IVC]
OSHA Regulations • Standard Precautions • Cleaning blood, body fluids, or other potentially infectious materials • Waste • Sharps
Recommendation VII Special Cleaning
Enhanced Environmental Cleaning • Multidrug-resistant organisms (MDRO) – Enhanced cleaning may reduce MRSA* and VRE** contamination & risk of transmission from prior room occupant – Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494. [IIB]. *Methicillin Resistant Staphylococcus Aureus **Vancomycin Resistant Enterococci Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of MultidrugResistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2006. [IVA]
cont. • Enhanced cleaning in ICU did not reduce contamination of worker’s gowns & gloves – Hess AS, Shardell M, Johnson JK, et al. A randomized controlled trial of enhanced cleaning to reduce contamination of healthcare worker gowns and gloves with multidrug-resistant bacteria. Infect Control Hosp Epidemiol. 2013;34(5):487-493. [IA]
cont. • Environmental contamination with MDROs was most likely to contaminate worker’s clothing, gowns, & gloves – Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012;40(4):1045-1051. [IIIA]
High Touch Objects in the OR… (Enhanced) • • • • • • • Storage cabinets, supply carts, furniture Light switches Door handles or push plates Telephones and mobile devices Computer Chairs, stools, step stools Trash and linen receptacles
High Touch Objects in Pre&Postop… (Enhanced) • Storage cabinets, supply carts, furniture • Light switches • Door handles or push plates • Telephones and mobile devices • Computer • Chairs • Trash and linen receptacles • Privacy curtains
Updated • C difficile – EPA-registered product – Effective against C diff spores • Airborne diseases & Aerosolized droplet transmissible infections – Restrict room access • Creutzfeldt-Jakob disease (CJD) – Rutala WA, Weber DJ, Society for Healthcare Epidemiology of America. Guideline for disinfection and sterilization of prion-contaminated medical instruments. Infect Control Hosp Epidemiol. 2010;31(2):107-117. [IVA]
Expanded • Construction cleaning – Clean dust & assess barriers – Terminal clean when it’s done – Clean when the environment is contaminated • Water damage, condensation, air contamination Sehulster L, Chinn RY; CDC, HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. [IVA]
Recommendation VIII Education Recommendation IX Policies & Procedures
Recommendation X Quality
Measuring Clean • Qualitative (eg, visual, fluorescent marking) & quantitative measures (eg, culture, adenosine triphosphate [ATP] monitoring) – Guh A, Carling P; Environmental Evaluation Workgroup. CDC toolkit: options for evaluating environmental cleaning. 2010. Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/toolkits/Evaluating-EnvironmentalCleaning.html. Accessed September 30, 2012. [VC] • Use multiple measures • Give immediate feedback when possible
Checklists & Log Sheets • Reduces chance of missing items during cleaning • Facilitate communication among the team when items are cleaned – Terminal cleaning – Scheduled cleaning
Frequently Asked Questions (FAQs)
FAQs • Use various methods to pickup debris, but don’t sweep the OR with a broom • At a minimum, mop the floor between cases if it’s visibly soiled • Move the OR bed when you mop or if something falls under the bed
FAQs • You can mop at terminal clean in the OR, not required to use wet-vacuum • Wait to clean until after the patient is gone • Pour cleaning chemicals rather than spray • People generate dust
FAQs • No time limit between terminal cleaning and damp dusting • Risk-Benefit-Cost Analysis • The floor is dirty • Use common sense
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The AORN Recommended Practices Advisory Board approved the updated “Recommended practices for environmental cleaning” in November 2013. The recommended ...
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• Describe the importance of a clean environment. • Define common terminology. • Explain the levels for cleaning. • Describe the recommended
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