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Cleanup techniques in the operating room
Cleanup techniques in the operating room
Jerry
G Peers, RN
A wvicw of opcmting ~ o o mcleanup techniques p?.ovidcs a mtionalixrd
chccklist that i s
to ?*cad and
casy
follow. Ccjtain recommcndataons, such as thc lack of ncccssit?] of plat-
of the schcdulc and the dismissal of thc ultrawolet light techniquc, arc of prime interest to su?-geons. ing “dirty cases” at the end
Although Lister’s use of carbolic acid spray in the operating room in 1865 ushered in the era of antiseptic surgery, no one, especially nurses, should ~~
~~
Jerry G Peers, RN,
~
BS,
i s the Executive Director
of A O R N . A graduste of M e r c y H o s p i t a l School of Nursing, Denver, and Western Reserve University, Cleveland, she was
of
director rooms a t
operating
UCLA
Hos-
p i t a l Center f o r H e a l t h Sciences, before
Los Angeles, assuming
her
post a t AORN i n 1970.
This a r t i c l e i s reprinted with
permission
from of Surgery, (October l973),
Archives
107 596-599.
ignore the contribution of Florence Nightingale to medical history. In her time a t Scutari in the Crimean War of 1854, Miss Nightingale demonstrated that manual soap and water scrubbing was necessary in combating infection and disease. This concept is still very pertinent in any treatment of environmental cleanliness. Although methods of alleviating infection to reduce morbidity and mortality remain very real problems today, operating rooms have come a long way from those with outside windows which were opened to provide fresh air-and allow entry of flies, dust, and germs. Advances have been made since using the old enamel pans with their chipped finishes capable of housing organisms, but much remains to be learned and put into the realm of practical application. We must dispel the remaining concept of quarantine of operating rooms following “dirty cases”;’.’ requiring that
AORN Journal, Januarg 1974, Vol 19, N o 1
53
contaminated procedures be done at the end of the day’s schedule; utilizing the “sterile prep,” and many other vestiges of unsupportable theory. Studies of the contribution to operating rooms of such concepts as laminar air flow, space project clean rooms and vented personnel apparel are under intensive investigation and clinical evaluation. What is least understandable is the negation of proved concepts and practices because of budget limitations, convenience, and pressure of work loads. Equipment, such as wet vacuum pickup, is available and has proved effective, but is often not utilized because of expense, longer cleanup time, and other excuses. Any discussion of cleanup methods must be based on acceptance of the concept that every surgical procedure deserves the same care as every other. That is, every patient merits the same degree of safety and precaution. Additionally, personnel working in surgery must be protected. Therefore, every case should be treated as potentially contaminated. Cleanup techniques must be set up to contain and confine organisms so as to prevent contamination of the entire operating suite. Cleaning in the operating room should ideally be done by trained housekeeping personnel subject to direction of the operating room (OR) supervisor. Individual situations may necessitate modification of this concept, but whoever is charged the responsibility should have specific established routines which are implemented conscientiously.
54
Cleanup may be divided into four general categories for discussion: (1) preparatory, (2) operative, (3) interim, and (4) terminal.
Preparatory cleaning. We may assume that each OR suite has specific daily “down time” during which special cleaning can be planned, most frequeiitly during the late evening or night. Although daily terminal cleaning is accomplished, some preparation is necessary before beginning the first scheduled procedure of the day. Damp-dusting is a fairly routine practice in each operating room-the removal of particles of dust, which may have settled in the room during the inactivity following daily terminal cleaning. A clean cloth dampened with detergent o r disinfectant is used to dust flat surfaces of tables, equipment, and especially overhead lights. Alcohol is a popular agent for this dusting since it tends to evaporate rapidly without filming on surfaces. A reminder here that personnel entering even an empty OR must be properly garmented and wearing a cap and mask. Since ventilating systems should provide 10 to 20 room air changes an hour,3 damp-dusting should be done a t least one hour before scheduled incision time. At the same time, the tops and rims of autoclaves and counter tops in sub-sterile rooms should also be damp dusted. This is an often-forgotten detail and is a potential source of contamination to sterile material being removed from autoclaves. Unnecessary tables and equipment should be removed from the room when they are not in use. This is in keeping with the concept that all cases are potentially contaminated
AORN Journal, January 1974, Vol 19, N o I
and so elimination of extraneous items makes for easier and faster interim cleaning. The woeful lack of storage space in most surgical suites is responsible for so much unused furniture being stored in ORs.
Operative period. Areas contaminated by organic debris, such as blood and sputum, during the operation should receive immediate attention. An in-use dilution of phenolic detergent germicide, iodophor, or other broad-spectrum germicide can he applied from a squeeze bottle to the ~ o i l a g e This . ~ prompt decontamination helps prevent organisms from drying and becoming air-borne and, thus, potentially hazardous. Sponges should be discarded to plastic-lined receptacles. For their own protection, personnel must use gloves, instruments, or both in counting and collecting soiled sponges and lap tapes before disposal in plastic bags. All other discarded material that can be incinerated or compacted should be collected in plastic-lined waste receptacles for later disposal. Once a patient is in the room and an operation has started, supplies and equipment should not leave the room. Sponge buckets, prep trays, and stands remain, although preparation sponges and waste may be bagged in plastic and stored temporarily. Not only is this preferred technique, but may be important in the event of sponge count discrepancy a t the conclusion of the operation. Traffic in and out of the room is kept a t a minimum to curtail dust turbulence created by the activity. The circulating nurse should anticipate supply needs adequately to avoid having to leave and return frequently; however, this is not a rec-
ommendation for a second circulating nurse outside the room.
Interim cleaning. As soon as an operation is completed and the patient is taken from the room, cleanup is initiated to ready the room for the next patient. Personnel must leave their gowns and gloves in appropriate receptacles prior to leaving the room. All linen, soiled or not, is placed in linen hamper bags for the laundry. Care must be taken to see that instruments and other nonlaundry items not go in with the linen. Even if not obviously soiled, all linen from open packs should be subjected to laundering in order to replace moisture lost to the fabric by sterilization. Wet drapes and linens should be placed a t the center of the laundry bundle to prohibit soaking to the outside of the bag. If nonwoven fabrics are used, these materials may be placed in plastic bags for disposal. Soiled sponges and other waste items are discarded in a separate plastic or treated-paper bag for disposal. Instruments. The gloved scrub nurse should prepare instruments, metal, and glassware for decontamination prior to handling by other personnel. Instruments should be placed directly into perforated trays for processing in a washer sterilizer, or may be covered for transportation to the central service for terminal sterilization. In either case, all hinged instruments should be in the open position. An alternate procedure in the absence of a washer sterilizer is to carefully rinse instruments in the solution basins used during the operation and then to put them directly into perforated trays and autoclave at 132 C
AORN Journal, January 1974, Vol 19, N o 1
55
(270 F) for 3 minutes or at 121 C (250 F) for 15 to 20 minutes. Brushes should not be used for removing gross soilage, since this tends to aerosolize organisms. Only after this care should instruments be handled for definitive cleaning and checked for repair prior to reuse. Basins and trays are also washed and autoclaved. Wall suction units should be disconnected by circulating personnel to avoid contamination of the wall outlet. Disposable suction units and suction tubing simplifies disposal, but heat-resistant trap bottles may be used, rinsed, and subjected to autoclaving together with the basins and trays. Disposable suction tubing is recommended over reusable tubing, which presents formidable problems of decontamination. Howeves, if tubing is reused, special care must be given to cleansing the lumen prior to placing the tubing in sterilizers with instruments. Suction bottle contents should be decontaminated by appropriate disinfectant prior to hopper disposal.
ilized by ethylene oxide and aerated prior to reuse. If this method is not available, cold chemical disinfection may be employed, using a solution of activated gl~taraldehyde.~.~
Floors. Experts agree that wet vacuuming is the method of choice for floor care in the operating room. Pryor, writing in the February 1970 Executive Housekeeper says, “Unfortunately, mops are still in fairly wide use despite the overwhelming evidence that mopping, even at its best, cannot achieve the degree of microbiological cleanliness felt necessary by most authorities.” He goes on to say, “Actually, in most instances, the spraying and wet vacuum pickup procedure need not take any more time than a good mopping procedure and in fact often takes less.”8 Mallison states that, in general, machine cleaning is more effective than cleaning by hand, but that if wet mopping is used, a double-bucket technique should be used and all mops laundered daily.g
Furniture. Horizontal surfaces of tables and equipment which have been involved in the surgical procedure should be cleansed with an appropriate in-use dilution of detergent germicide. This may be readily dispensed from a squeeze bottle or pressure spray dispenser. Wheeled furniture may be pushed through detergent used for floor care in order to cleanse the furniture casters.
If a wet mop must be used, a fresh mop must be used each time and no buckets at all. The floor can be flooded with detergent disinfectant (as discussed later) and a fresh mop head placed on the mop handle just prior to use. Following its one-time use, the mop head is removed and placed in the laundry hamper with other soiled linen from the operation. The mop handle may then be stored in the work area until needed again.
Anesthesia equipment. It may seem redundant to say that all anesthesia masks and tubing must be cleaned and sterilized before reusing; but in many hospitals, this is still not done routinely. This equipment can often be autoclaved or, if not, may be ster-
Litsky recommends that “no dry mop should be used in the operating room-treated o r nontreated. . . . The vacuum cleaner with a filter diffuser exhaust is the cleaning tool of choice.”1° A central wet vacuum is ideal, but
56
A O R N Journal, January 1974, Vol 19, N o 1
portable equipment is readily available. If a factual cost analysis were done, purchase of equipment would, I believe, prove economical after consideration of all alternate costs. Purchase, replacement, laundering, and maintenance and personnel time involved in using mops is not inconsequential. And, as stated earlier, wet vacuum pickup is so far superior as to necessitate its use for patient safety. If waste and gross soilage are great, the wet vacuum equipment may be used dry for first treatment. The operating room floor is then flooded with detergent germicide dispensed from garden-type pump spray cans or automatic spraying devices which inject the germicide into a hosp line equipped with a special spray wand. If these devices are not available, a spray-type watering can may be used, although this method is slower and may wet unevenly. Following flooding of the floor, the wet vacuum pickup is used to pick up the solution before repositioning furniture. Pryor recommends that OR floors be machine scrubbed periodically to remove accumulated deposits and films. After scubbing and pickup with wet vacuum, the floor should be rinsed with dilute vinegar solution (.12 liter [Ih cup] in 3.79 liters 11 gal 1 water) to help dissolve deposits.8 The exterior of the equipment, the wand, and tubing are cleaned following each use, and special attention is given to cleaning the rubber blade before the next case. If the wand has a brush attachment, this should be washed and autoclaved between uses. Walls need not be washed between operations, except for spot washing
in the event of direct spray contamination. Overhead light reflectors should be wiped using a clean cloth wet with detergent germicide. After these cleaning measures have been completed, cloths should be put into laundry hamper bags, which are then fastened securely. Plastic bags containing waste disposal are also securely fastened and all removed to appropriate areas for handling and transit. The room is now ready for the next operation. With appropriate care, there is no need for quarantine of a room or for discrimination of types of operative procedures scheduled to follow in the same room. Since all cases are to be treated alike, there is no need for discussion on outmoded “septic carts.”
Terminal cleaning. At the completion of the day’s schedule for each operating room, more stringent and rigorous cleaning should be done in all areas previously discussed. Furniture should be thoroughly scrubbed down, using good mechanical friction in addition to chemical disinfection. Mallison notes that “disinfection is only an adjunct to good physical cleaning; ‘elbow grease’ is probably the most important ingredient of any program of hospital sanitation.”9 Kick buckets and other waste receptacles should be cleaned and disinfected, even autoclaved when feasible. In cleaning equipment, such as electrosurgical units, care should be taken not to saturate surfaces to the degree that cleaning solution runs into mechanism causing malfunction and unnecessary repairs. Cleaning
AORN Journal, January 1974, Vol 19, N o 1
57
personnel should receive special instruction on the handling and cleaning of delicate equipment.
intensively cleaned a t such other intervals as traffic, use, and a good level of cleanliness require.
Casters and wheels should be cleaned and kept free of suture ends and debris. Equipment is available which automatically washes such things as carts, supply tables, and platforms, then steam cleans and dries within a matter of minutes.
All cleaning equipment should be taken apart, cleaned with detergent germicide, and allowed to dry thoroughly so that it does not become a portable source of contamination.
Walls should be checked daily for soil spots and cleaned as necessary. Floors should be treated to a thorough wet vacuum cleaning in the daily terminal cleaning. Scrub sinks, soap dispensers, and spray heads on faucets should undergo thorough cleaning daily with a mild abrasive for the sinks to remove oily film residue left by scrub detergents. Spray heads and soap dispensers should be disassembled for thorough cleaning and, if possible, sterilization of parts. Cabinet and OR doors should be spot-cleaned daily, especially around handles or push plates where contamination is apt to occur. All floors in the operating suite should receive daily cleaning with wet vacuum pickup used dry and then wet; counter tops in work areas should be cleaned and sinks scrubbed. Walls around scrub sink areas should receive daily attention, since there is unusual spray and splash. Scrub detergents tend to build up on splash boards or wall around the sink and it is very hard to remove an accumulation. Transportation and utility carts need to be cleaned well and specific attention given to wheels and casters daily. Offices and lounge areas should be thoroughly cleaned daily, as well as
58
Janitorial closets must be cleaned thoroughly and cleaning cloths put in laundry hamper bags to go to the laundry. Extra careful attention must be given to daily cleaning in trash and linen disposal areas since these may often be grossly soiled. Odor accumulation is not uncommon in these rooms and deodorant spraying is often advisable. The foregoing remarks have been addressed primarily to daily housekeeping measures in individual rooms. However, there are additional needs for routinely scheduled cleaning in these rooms, as well as ancillary and supportive areas in the suite. Weekly cleaning. The exterior of air conditioning grilles should be vacuumed at least weekly. Additional cleaning should be instituted around the grille frame when filters are checked and changed by hospital engineers or maintenance personnel. While use of storage cabinets is tending to be replaced by portable cart storage, cabinets still exist and should be cleaned a t least weekly or more often if needed. The same applies to cabinets and storage shelves in work areas. Regular cleaning of autoclaves must not be neglected-it should be done weekly, or as recommended by the manufacturer.
AORN Journal, January 1974, Vol 19, N o 1
Additional cleaning considerations. At this time, there are not sufficient data t o evaluate steam cleaning for furniture and vehicles, but this may prove t o be economical and practical in the future. Cleaning of walls on a rotational basis is not recommended for daily, weekly, o r even monthly routines.
If spot disinfection and cleaning is accomplished immediately, there is no justification for regular special cleaning techniques. Standards and routines for general institutional wall and ceiling care a r e adequate if contamination and macroscopic soilage are cared for as specified. Acceptability of the practice of not washing operating room walls weekly, monthly, or a t other time intervals depends upon adequate continuous supervision. Since corridor walls are not under constant scrutiny for soilage, it is suggested that they be washed monthly, although the old concept of required washing a t weekly o r monthly intervals is not realistic o r necessary. Any routines for housekeeping must, of necessity, be based on construction materials and fabrics used. If the OR walls are painted, or tiled with wide porous grouting, such factors should be considered in planning cleaning routines with the housekeeping department.” Reference has been made t o cleaner-detergent-germicides and the question arises as to what constitutes a good agent. So many factors are involved in individual preferences and situations that it is not appropriate to recommend any one product. However, the one selected should meet
the following requirements: (1) effective against a wide range of pathogens, including the tubercule bacillus and Pseudomonas, (2) heavyduty, film-free detergency, (3) nontoxic and nonirritating, (4) safe on commonly used material and no adverse affect on the electrical conductivity of the operating room floors, (5) compatible with cleaning equipment,, including wet vacuum pickup units, (6) economical in-use dilutions, (7) nonoffensive and virtually odorless in use.‘2 The use of fogging techniques in the OR is frequently questioned. Hall states that “there is no valid proof that fogging, with present equipment and germicides, is an effective technique for complete sterilization of rooms. Basically i t is an inefficient method. . . . Direct application of a liquid germicide is a much more efficient method of applying the material to a surface.” Hall goes on to say that the action on airborne contaminants is only temporary since t h e sprayed agent settles o r is exhausted with the room air.l;J Walter and others have been quoted numerous times as stating that fogging is a needless occupational hazard achieving nothing in room sanitization unless everything is soaked, which is not appropriate in the OR.9.14.15 Laminar air flow in surgical ORs is defined as air flow that is predominantly unidirectional when not obstructed. A statement from the Committee on Operating Room Environment of the American College of Surgeons says that there is no conclusive evidence a t this time that
AORN Journal, January 1974, Vol 19, N o 1
59
laminar, clean air flow, in itself, has a favorable influence on the incidence of surgical wound infection.16 Studies indicate that ultraviolet irradiation for hospital use indicate a low percentile of kill for vegetative cells in the air stream and almost none for spores. Furthermore, the disadvantages of cleaning and testing the equipment and of personnel protection requirements seem to outweigh the efficacy in operating room U S ~ . ' ~ J ~ A very brief word about tacky mats is in order. Litsky holds that "tacky floor mats do not remove or destroy bacteria: they pull off dirt and give a false sense of security."1o With respect to routine bacteriologic sampling, the effectiveness of recommended proceclwes is only as valid as results obtained. Mallison says that environmental sampling in hospitals is important in developing a "hygienic index." He recommends monthly random sampling of an OR floor, weekly check of steam sterilizers, and even more frequent check of ethylene oxide sterilizers. He further suggests routine sampling of certain fomites frequently associated with transmission of infections and a routine air sampling program.9 Beck additionally suggests that scrub sinks and certain horizontal surfaces have cultures taken routinely.Ig There appears to be agreement in the literature as to the advantage of Rodac plates in good sampling programs, although swab culture may be used for nonuniform and hard-toplate areas.
0
60
FOOTNOTES I. P Dineen, "Prevention of infection i n the operating room," Bulletin of the American College
of Surgeons, 55 (1970), 18-21. 2. R B Knudsin, "Operating room bacteriology in four dimensions." AORN Journal, 8 (1968),
5 1-54. 3. J
N Glenn and F W Reckling, "Avoiding infections: Clean air operating rooms," Journal of the Kansas Medical Society, 73 ( 1972), 123-124. 4. F Ginsberg and B L Clarke, "These rules w i l l help prevent contamination of the OR," Modern Hospital, I17 (1971) 153-154.
5.
F
Ginsberg, "How t o decontaminate anes-
Modern Hospital, I15 (1970), 88. 6. B Y Litsky, "Environmental control: The operating room," AORN Journal, 14 (1971), 39-51. 7. B Y Litsky, "Simple steps t o OR asepsis," Medical Surgical Review, 7 ( 1971 ) , 20-24. 8. A K Pryor, "Cleaning procedures for the operating room," €recutive Housekeeper, 17 ( 1970), 14-20. 9. G F Mallison, "Environmental control i n hos-
thesia circuits,"
pitals," thesda,
Manual of
Md,
Clinical Microbiology,
(Be-
American Society for Microbiology,
1970). 10. B Y Litsky, "ORS should take an active role in detection, control of infections," Hospifal Topic*, 49 ( 1971 1, 78-80. I I. J S Brooks, "Which surface for asepsis?'' Canadian Hospital, 49 (1972), 29. 12. D R Peck, "Operating room sanitation,'' A O R N Journal, 7 (1968), 47-49. 13. L B Hall, "Room sterilization," Journal of the American Medical Association, I 8 I ( I962), 462. 14. C W Walter, "Multiple factors t o consider i n hospital infection control," Hospital Topics, 48 ( I970), 65-69. 15. J Hackett and C MacPherson, "Studies i n 'fogging' as applied t o hospital room disinfection," Ohio State Medical Journal, 59 ( l 9 6 3 ) , 283-285.
16. W 5 Blakemore, "Special air systems for operating rooms,"
Bulletin of the American
lege o f Surgeons, 57
cbl-
( 1972), 18.
17. H S Decker, et al. " A i r filtration of miparticles," American Journal of Public Health. 53 (1963), 1982-1988. 18. G F Mallison, "Control of the environment: Research developments," Proceedings of an Insticrobial
tute on the Control of lnfections in Hospitals, Ann Arbor, University of Michigan (1965), 140-144.
19. W C Beck, "Infection-control committee's duties outlined i n accreditation standard," Hosp i t a l Topics, 50 ( l 9 7 2 ) , 90.
AORN Journal, January 1974, Vol 19, N o 1
Jerry
G Peers, RN
A wvicw of opcmting ~ o o mcleanup techniques p?.ovidcs a mtionalixrd
chccklist that i s
to ?*cad and
casy
follow. Ccjtain recommcndataons, such as thc lack of ncccssit?] of plat-
of the schcdulc and the dismissal of thc ultrawolet light techniquc, arc of prime interest to su?-geons. ing “dirty cases” at the end
Although Lister’s use of carbolic acid spray in the operating room in 1865 ushered in the era of antiseptic surgery, no one, especially nurses, should ~~
~~
Jerry G Peers, RN,
~
BS,
i s the Executive Director
of A O R N . A graduste of M e r c y H o s p i t a l School of Nursing, Denver, and Western Reserve University, Cleveland, she was
of
director rooms a t
operating
UCLA
Hos-
p i t a l Center f o r H e a l t h Sciences, before
Los Angeles, assuming
her
post a t AORN i n 1970.
This a r t i c l e i s reprinted with
permission
from of Surgery, (October l973),
Archives
107 596-599.
ignore the contribution of Florence Nightingale to medical history. In her time a t Scutari in the Crimean War of 1854, Miss Nightingale demonstrated that manual soap and water scrubbing was necessary in combating infection and disease. This concept is still very pertinent in any treatment of environmental cleanliness. Although methods of alleviating infection to reduce morbidity and mortality remain very real problems today, operating rooms have come a long way from those with outside windows which were opened to provide fresh air-and allow entry of flies, dust, and germs. Advances have been made since using the old enamel pans with their chipped finishes capable of housing organisms, but much remains to be learned and put into the realm of practical application. We must dispel the remaining concept of quarantine of operating rooms following “dirty cases”;’.’ requiring that
AORN Journal, Januarg 1974, Vol 19, N o 1
53
contaminated procedures be done at the end of the day’s schedule; utilizing the “sterile prep,” and many other vestiges of unsupportable theory. Studies of the contribution to operating rooms of such concepts as laminar air flow, space project clean rooms and vented personnel apparel are under intensive investigation and clinical evaluation. What is least understandable is the negation of proved concepts and practices because of budget limitations, convenience, and pressure of work loads. Equipment, such as wet vacuum pickup, is available and has proved effective, but is often not utilized because of expense, longer cleanup time, and other excuses. Any discussion of cleanup methods must be based on acceptance of the concept that every surgical procedure deserves the same care as every other. That is, every patient merits the same degree of safety and precaution. Additionally, personnel working in surgery must be protected. Therefore, every case should be treated as potentially contaminated. Cleanup techniques must be set up to contain and confine organisms so as to prevent contamination of the entire operating suite. Cleaning in the operating room should ideally be done by trained housekeeping personnel subject to direction of the operating room (OR) supervisor. Individual situations may necessitate modification of this concept, but whoever is charged the responsibility should have specific established routines which are implemented conscientiously.
54
Cleanup may be divided into four general categories for discussion: (1) preparatory, (2) operative, (3) interim, and (4) terminal.
Preparatory cleaning. We may assume that each OR suite has specific daily “down time” during which special cleaning can be planned, most frequeiitly during the late evening or night. Although daily terminal cleaning is accomplished, some preparation is necessary before beginning the first scheduled procedure of the day. Damp-dusting is a fairly routine practice in each operating room-the removal of particles of dust, which may have settled in the room during the inactivity following daily terminal cleaning. A clean cloth dampened with detergent o r disinfectant is used to dust flat surfaces of tables, equipment, and especially overhead lights. Alcohol is a popular agent for this dusting since it tends to evaporate rapidly without filming on surfaces. A reminder here that personnel entering even an empty OR must be properly garmented and wearing a cap and mask. Since ventilating systems should provide 10 to 20 room air changes an hour,3 damp-dusting should be done a t least one hour before scheduled incision time. At the same time, the tops and rims of autoclaves and counter tops in sub-sterile rooms should also be damp dusted. This is an often-forgotten detail and is a potential source of contamination to sterile material being removed from autoclaves. Unnecessary tables and equipment should be removed from the room when they are not in use. This is in keeping with the concept that all cases are potentially contaminated
AORN Journal, January 1974, Vol 19, N o I
and so elimination of extraneous items makes for easier and faster interim cleaning. The woeful lack of storage space in most surgical suites is responsible for so much unused furniture being stored in ORs.
Operative period. Areas contaminated by organic debris, such as blood and sputum, during the operation should receive immediate attention. An in-use dilution of phenolic detergent germicide, iodophor, or other broad-spectrum germicide can he applied from a squeeze bottle to the ~ o i l a g e This . ~ prompt decontamination helps prevent organisms from drying and becoming air-borne and, thus, potentially hazardous. Sponges should be discarded to plastic-lined receptacles. For their own protection, personnel must use gloves, instruments, or both in counting and collecting soiled sponges and lap tapes before disposal in plastic bags. All other discarded material that can be incinerated or compacted should be collected in plastic-lined waste receptacles for later disposal. Once a patient is in the room and an operation has started, supplies and equipment should not leave the room. Sponge buckets, prep trays, and stands remain, although preparation sponges and waste may be bagged in plastic and stored temporarily. Not only is this preferred technique, but may be important in the event of sponge count discrepancy a t the conclusion of the operation. Traffic in and out of the room is kept a t a minimum to curtail dust turbulence created by the activity. The circulating nurse should anticipate supply needs adequately to avoid having to leave and return frequently; however, this is not a rec-
ommendation for a second circulating nurse outside the room.
Interim cleaning. As soon as an operation is completed and the patient is taken from the room, cleanup is initiated to ready the room for the next patient. Personnel must leave their gowns and gloves in appropriate receptacles prior to leaving the room. All linen, soiled or not, is placed in linen hamper bags for the laundry. Care must be taken to see that instruments and other nonlaundry items not go in with the linen. Even if not obviously soiled, all linen from open packs should be subjected to laundering in order to replace moisture lost to the fabric by sterilization. Wet drapes and linens should be placed a t the center of the laundry bundle to prohibit soaking to the outside of the bag. If nonwoven fabrics are used, these materials may be placed in plastic bags for disposal. Soiled sponges and other waste items are discarded in a separate plastic or treated-paper bag for disposal. Instruments. The gloved scrub nurse should prepare instruments, metal, and glassware for decontamination prior to handling by other personnel. Instruments should be placed directly into perforated trays for processing in a washer sterilizer, or may be covered for transportation to the central service for terminal sterilization. In either case, all hinged instruments should be in the open position. An alternate procedure in the absence of a washer sterilizer is to carefully rinse instruments in the solution basins used during the operation and then to put them directly into perforated trays and autoclave at 132 C
AORN Journal, January 1974, Vol 19, N o 1
55
(270 F) for 3 minutes or at 121 C (250 F) for 15 to 20 minutes. Brushes should not be used for removing gross soilage, since this tends to aerosolize organisms. Only after this care should instruments be handled for definitive cleaning and checked for repair prior to reuse. Basins and trays are also washed and autoclaved. Wall suction units should be disconnected by circulating personnel to avoid contamination of the wall outlet. Disposable suction units and suction tubing simplifies disposal, but heat-resistant trap bottles may be used, rinsed, and subjected to autoclaving together with the basins and trays. Disposable suction tubing is recommended over reusable tubing, which presents formidable problems of decontamination. Howeves, if tubing is reused, special care must be given to cleansing the lumen prior to placing the tubing in sterilizers with instruments. Suction bottle contents should be decontaminated by appropriate disinfectant prior to hopper disposal.
ilized by ethylene oxide and aerated prior to reuse. If this method is not available, cold chemical disinfection may be employed, using a solution of activated gl~taraldehyde.~.~
Floors. Experts agree that wet vacuuming is the method of choice for floor care in the operating room. Pryor, writing in the February 1970 Executive Housekeeper says, “Unfortunately, mops are still in fairly wide use despite the overwhelming evidence that mopping, even at its best, cannot achieve the degree of microbiological cleanliness felt necessary by most authorities.” He goes on to say, “Actually, in most instances, the spraying and wet vacuum pickup procedure need not take any more time than a good mopping procedure and in fact often takes less.”8 Mallison states that, in general, machine cleaning is more effective than cleaning by hand, but that if wet mopping is used, a double-bucket technique should be used and all mops laundered daily.g
Furniture. Horizontal surfaces of tables and equipment which have been involved in the surgical procedure should be cleansed with an appropriate in-use dilution of detergent germicide. This may be readily dispensed from a squeeze bottle or pressure spray dispenser. Wheeled furniture may be pushed through detergent used for floor care in order to cleanse the furniture casters.
If a wet mop must be used, a fresh mop must be used each time and no buckets at all. The floor can be flooded with detergent disinfectant (as discussed later) and a fresh mop head placed on the mop handle just prior to use. Following its one-time use, the mop head is removed and placed in the laundry hamper with other soiled linen from the operation. The mop handle may then be stored in the work area until needed again.
Anesthesia equipment. It may seem redundant to say that all anesthesia masks and tubing must be cleaned and sterilized before reusing; but in many hospitals, this is still not done routinely. This equipment can often be autoclaved or, if not, may be ster-
Litsky recommends that “no dry mop should be used in the operating room-treated o r nontreated. . . . The vacuum cleaner with a filter diffuser exhaust is the cleaning tool of choice.”1° A central wet vacuum is ideal, but
56
A O R N Journal, January 1974, Vol 19, N o 1
portable equipment is readily available. If a factual cost analysis were done, purchase of equipment would, I believe, prove economical after consideration of all alternate costs. Purchase, replacement, laundering, and maintenance and personnel time involved in using mops is not inconsequential. And, as stated earlier, wet vacuum pickup is so far superior as to necessitate its use for patient safety. If waste and gross soilage are great, the wet vacuum equipment may be used dry for first treatment. The operating room floor is then flooded with detergent germicide dispensed from garden-type pump spray cans or automatic spraying devices which inject the germicide into a hosp line equipped with a special spray wand. If these devices are not available, a spray-type watering can may be used, although this method is slower and may wet unevenly. Following flooding of the floor, the wet vacuum pickup is used to pick up the solution before repositioning furniture. Pryor recommends that OR floors be machine scrubbed periodically to remove accumulated deposits and films. After scubbing and pickup with wet vacuum, the floor should be rinsed with dilute vinegar solution (.12 liter [Ih cup] in 3.79 liters 11 gal 1 water) to help dissolve deposits.8 The exterior of the equipment, the wand, and tubing are cleaned following each use, and special attention is given to cleaning the rubber blade before the next case. If the wand has a brush attachment, this should be washed and autoclaved between uses. Walls need not be washed between operations, except for spot washing
in the event of direct spray contamination. Overhead light reflectors should be wiped using a clean cloth wet with detergent germicide. After these cleaning measures have been completed, cloths should be put into laundry hamper bags, which are then fastened securely. Plastic bags containing waste disposal are also securely fastened and all removed to appropriate areas for handling and transit. The room is now ready for the next operation. With appropriate care, there is no need for quarantine of a room or for discrimination of types of operative procedures scheduled to follow in the same room. Since all cases are to be treated alike, there is no need for discussion on outmoded “septic carts.”
Terminal cleaning. At the completion of the day’s schedule for each operating room, more stringent and rigorous cleaning should be done in all areas previously discussed. Furniture should be thoroughly scrubbed down, using good mechanical friction in addition to chemical disinfection. Mallison notes that “disinfection is only an adjunct to good physical cleaning; ‘elbow grease’ is probably the most important ingredient of any program of hospital sanitation.”9 Kick buckets and other waste receptacles should be cleaned and disinfected, even autoclaved when feasible. In cleaning equipment, such as electrosurgical units, care should be taken not to saturate surfaces to the degree that cleaning solution runs into mechanism causing malfunction and unnecessary repairs. Cleaning
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personnel should receive special instruction on the handling and cleaning of delicate equipment.
intensively cleaned a t such other intervals as traffic, use, and a good level of cleanliness require.
Casters and wheels should be cleaned and kept free of suture ends and debris. Equipment is available which automatically washes such things as carts, supply tables, and platforms, then steam cleans and dries within a matter of minutes.
All cleaning equipment should be taken apart, cleaned with detergent germicide, and allowed to dry thoroughly so that it does not become a portable source of contamination.
Walls should be checked daily for soil spots and cleaned as necessary. Floors should be treated to a thorough wet vacuum cleaning in the daily terminal cleaning. Scrub sinks, soap dispensers, and spray heads on faucets should undergo thorough cleaning daily with a mild abrasive for the sinks to remove oily film residue left by scrub detergents. Spray heads and soap dispensers should be disassembled for thorough cleaning and, if possible, sterilization of parts. Cabinet and OR doors should be spot-cleaned daily, especially around handles or push plates where contamination is apt to occur. All floors in the operating suite should receive daily cleaning with wet vacuum pickup used dry and then wet; counter tops in work areas should be cleaned and sinks scrubbed. Walls around scrub sink areas should receive daily attention, since there is unusual spray and splash. Scrub detergents tend to build up on splash boards or wall around the sink and it is very hard to remove an accumulation. Transportation and utility carts need to be cleaned well and specific attention given to wheels and casters daily. Offices and lounge areas should be thoroughly cleaned daily, as well as
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Janitorial closets must be cleaned thoroughly and cleaning cloths put in laundry hamper bags to go to the laundry. Extra careful attention must be given to daily cleaning in trash and linen disposal areas since these may often be grossly soiled. Odor accumulation is not uncommon in these rooms and deodorant spraying is often advisable. The foregoing remarks have been addressed primarily to daily housekeeping measures in individual rooms. However, there are additional needs for routinely scheduled cleaning in these rooms, as well as ancillary and supportive areas in the suite. Weekly cleaning. The exterior of air conditioning grilles should be vacuumed at least weekly. Additional cleaning should be instituted around the grille frame when filters are checked and changed by hospital engineers or maintenance personnel. While use of storage cabinets is tending to be replaced by portable cart storage, cabinets still exist and should be cleaned a t least weekly or more often if needed. The same applies to cabinets and storage shelves in work areas. Regular cleaning of autoclaves must not be neglected-it should be done weekly, or as recommended by the manufacturer.
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Additional cleaning considerations. At this time, there are not sufficient data t o evaluate steam cleaning for furniture and vehicles, but this may prove t o be economical and practical in the future. Cleaning of walls on a rotational basis is not recommended for daily, weekly, o r even monthly routines.
If spot disinfection and cleaning is accomplished immediately, there is no justification for regular special cleaning techniques. Standards and routines for general institutional wall and ceiling care a r e adequate if contamination and macroscopic soilage are cared for as specified. Acceptability of the practice of not washing operating room walls weekly, monthly, or a t other time intervals depends upon adequate continuous supervision. Since corridor walls are not under constant scrutiny for soilage, it is suggested that they be washed monthly, although the old concept of required washing a t weekly o r monthly intervals is not realistic o r necessary. Any routines for housekeeping must, of necessity, be based on construction materials and fabrics used. If the OR walls are painted, or tiled with wide porous grouting, such factors should be considered in planning cleaning routines with the housekeeping department.” Reference has been made t o cleaner-detergent-germicides and the question arises as to what constitutes a good agent. So many factors are involved in individual preferences and situations that it is not appropriate to recommend any one product. However, the one selected should meet
the following requirements: (1) effective against a wide range of pathogens, including the tubercule bacillus and Pseudomonas, (2) heavyduty, film-free detergency, (3) nontoxic and nonirritating, (4) safe on commonly used material and no adverse affect on the electrical conductivity of the operating room floors, (5) compatible with cleaning equipment,, including wet vacuum pickup units, (6) economical in-use dilutions, (7) nonoffensive and virtually odorless in use.‘2 The use of fogging techniques in the OR is frequently questioned. Hall states that “there is no valid proof that fogging, with present equipment and germicides, is an effective technique for complete sterilization of rooms. Basically i t is an inefficient method. . . . Direct application of a liquid germicide is a much more efficient method of applying the material to a surface.” Hall goes on to say that the action on airborne contaminants is only temporary since t h e sprayed agent settles o r is exhausted with the room air.l;J Walter and others have been quoted numerous times as stating that fogging is a needless occupational hazard achieving nothing in room sanitization unless everything is soaked, which is not appropriate in the OR.9.14.15 Laminar air flow in surgical ORs is defined as air flow that is predominantly unidirectional when not obstructed. A statement from the Committee on Operating Room Environment of the American College of Surgeons says that there is no conclusive evidence a t this time that
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laminar, clean air flow, in itself, has a favorable influence on the incidence of surgical wound infection.16 Studies indicate that ultraviolet irradiation for hospital use indicate a low percentile of kill for vegetative cells in the air stream and almost none for spores. Furthermore, the disadvantages of cleaning and testing the equipment and of personnel protection requirements seem to outweigh the efficacy in operating room U S ~ . ' ~ J ~ A very brief word about tacky mats is in order. Litsky holds that "tacky floor mats do not remove or destroy bacteria: they pull off dirt and give a false sense of security."1o With respect to routine bacteriologic sampling, the effectiveness of recommended proceclwes is only as valid as results obtained. Mallison says that environmental sampling in hospitals is important in developing a "hygienic index." He recommends monthly random sampling of an OR floor, weekly check of steam sterilizers, and even more frequent check of ethylene oxide sterilizers. He further suggests routine sampling of certain fomites frequently associated with transmission of infections and a routine air sampling program.9 Beck additionally suggests that scrub sinks and certain horizontal surfaces have cultures taken routinely.Ig There appears to be agreement in the literature as to the advantage of Rodac plates in good sampling programs, although swab culture may be used for nonuniform and hard-toplate areas.
0
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FOOTNOTES I. P Dineen, "Prevention of infection i n the operating room," Bulletin of the American College
of Surgeons, 55 (1970), 18-21. 2. R B Knudsin, "Operating room bacteriology in four dimensions." AORN Journal, 8 (1968),
5 1-54. 3. J
N Glenn and F W Reckling, "Avoiding infections: Clean air operating rooms," Journal of the Kansas Medical Society, 73 ( 1972), 123-124. 4. F Ginsberg and B L Clarke, "These rules w i l l help prevent contamination of the OR," Modern Hospital, I17 (1971) 153-154.
5.
F
Ginsberg, "How t o decontaminate anes-
Modern Hospital, I15 (1970), 88. 6. B Y Litsky, "Environmental control: The operating room," AORN Journal, 14 (1971), 39-51. 7. B Y Litsky, "Simple steps t o OR asepsis," Medical Surgical Review, 7 ( 1971 ) , 20-24. 8. A K Pryor, "Cleaning procedures for the operating room," €recutive Housekeeper, 17 ( 1970), 14-20. 9. G F Mallison, "Environmental control i n hos-
thesia circuits,"
pitals," thesda,
Manual of
Md,
Clinical Microbiology,
(Be-
American Society for Microbiology,
1970). 10. B Y Litsky, "ORS should take an active role in detection, control of infections," Hospifal Topic*, 49 ( 1971 1, 78-80. I I. J S Brooks, "Which surface for asepsis?'' Canadian Hospital, 49 (1972), 29. 12. D R Peck, "Operating room sanitation,'' A O R N Journal, 7 (1968), 47-49. 13. L B Hall, "Room sterilization," Journal of the American Medical Association, I 8 I ( I962), 462. 14. C W Walter, "Multiple factors t o consider i n hospital infection control," Hospital Topics, 48 ( I970), 65-69. 15. J Hackett and C MacPherson, "Studies i n 'fogging' as applied t o hospital room disinfection," Ohio State Medical Journal, 59 ( l 9 6 3 ) , 283-285.
16. W 5 Blakemore, "Special air systems for operating rooms,"
Bulletin of the American
lege o f Surgeons, 57
cbl-
( 1972), 18.
17. H S Decker, et al. " A i r filtration of miparticles," American Journal of Public Health. 53 (1963), 1982-1988. 18. G F Mallison, "Control of the environment: Research developments," Proceedings of an Insticrobial
tute on the Control of lnfections in Hospitals, Ann Arbor, University of Michigan (1965), 140-144.
19. W C Beck, "Infection-control committee's duties outlined i n accreditation standard," Hosp i t a l Topics, 50 ( l 9 7 2 ) , 90.
AORN Journal, January 1974, Vol 19, N o 1