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Does a dirty case mean it's x-rated?
AORN education
Does a dirty case mean it’s x-rated? What is the question we receive most frequently at Headquarters? It is: “How do I clean up after a dirty case?” This question is also asked repeatedly at the “Once upon a Germ” seminar. It has been ten years since Ginsberg wrote: “These fourteen steps will make any OR safe.”’ Yet OR nurses continue to attack the dirty case with as much fervor as others might attack ”septic” movies. As a consultant, I see the OR suite where two circulators are used for known contaminated cases, one inside the OR and one outside. Nurses still pull all the OR furniture out into the corridor before bringing a known infected patient into the operating room. They tape cabinet doors or hang sheets over open shelves in preparation for a “dirty case.” Washing the walls, ceiling, and floor to insure all the “bugs” are killed is still a common procedure following a septic case. Scheduling the dirty case at the end of the day is prevalent. However, the procedures change-for the short-staffed evening, night, weekend, or holiday shifts. Miraculously, the need for the outside circulator is unnecessary. It is as if the “bugs” know when the day shift goes off duty, and they agree not to spread infections. Ginsberg, Peers, Wells, the AORN Technical Standards Committee; all have addressed or described the methodology of OR cleanup.2 We all agree on our goal and objectives in OR cleanup, that is: a simple practical method of cleaning the OR and eliminating the possibility of cross-contamination between surgical patients.
@q
With this purpose in mind, I will restate the rationale for all cases being considered contaminated. As you know, many patients arrive in the operating room with undiagnosed infections. Tuberculosis is one of the most frequent infections that is not diagnosed until after surgery. It is also possible that microorganisms existing systematically in one patient and causing that patient no apparent physical distress, when transferred to another patient, may flourish into a severe infection. Therefore, all patients should be considered potentially contaminated. Peers and the “Standards for OR Sanitation” outline four general cleanup ~ategories.~ The first category is cleaning prior to the first scheduled procedure of the day. This includes damp-dusting flat surfaces such as tables, equipment, and overhead lamps. The second category of cleanup is the important “confine and contain” period. During the surgical procedure, all areas contaminated by any organic debris such as blood, mucus, bodily secretions, or any items that have contact with these secretions must be confined to the area in which the sterile team works. Any contamination of areas outside of the sterile fieid should receive immediate attention by applying an iodophor, phenolic detergent-germicide, or other broad spectrum germicide to the soiled area. This can be accomplished by use of a squeeze bottle. For example, a bloody sponge misses the kick bucket and splatters on the floor. The circulator, who should never become contaminated by the patient’s secretions, immediately retrieves the sponge with a single-use forceps or a gloved hand, discards the sponge into the kick bucket, and decontaminates the floor by applying a good broad spectrum detergent-germicide to the area. In
dAORN Journal, June 1979, Vol29, No 7
1215
every instance, any item that has been in contact with the patient or his secretions is contained within the sterile field or if it leaves the sterile field, the item is promptly decontaminated by the circulator. If by accident the circulator should become contaminated with the patient’s secretions, then the circulator washes or cleans the contaminated area with a good antiseptic or germicide solution. Gloves may be used if the patient requires the help of the circulator during the procedure. Continuously policing during the surgical procedure insures that there is no chance of spreading microorganisms outside of the sterile field. This protects personnel and other surgical patients from cross-contamination. Policing includes controlling traffic. Traffic in and out of the operating room is kept to a minimum to curtail dust turbulence created by activity. The circulating nurse should anticipate supply needs adequately to avoid having to leave and return frequently, however, this is not a recommendation for a second circulating nurse outside the room.4 The third category of OR cleanup is known as room change over. There is always pressure from the surgeons and the anesthesiologist to complete the cleanup between cases as rapidly as possible. No other single problem has plaguedthe OR nurse as much as the time between cases. Therefore, it is important to understandwhat must be done, how the cleanup technique is accomplished, and the teamwork between the scrubbed persons and the circulator. As previously stated, during the operative period the scrubbed person handles all the items within the sterile field; the circulator handles the equipment and supplies that have not been in contact with the patient. Prior to leaving the room, all personnel must leave their gowns and gloves in appropriate receptacles. There is a correct procedure for removing the gown and then the gloves and disposing of them into the linen hamper or the trash bag for disposal. All linens must be placed carefully into the linen hamper and nonwovens must be placed in plastic bags for disposal. Care should be taken to insure that instruments are not included in the laundry or trash bags. Reusable sponges should be collected in impervious plastic bags and sent to the laundry. Disposable sponges and waste
articles should be collected in plastic bags for disposal. The best procedure is to place all instruments into perforated trays for decontamination in the washer-sterilizeror to enclose them in an impervious plastic bag for transportation to a central cleanup area.5Another acceptable alternative for decontamination of the instruments is rinsing carefully in a basin of water (never saline) in the OR, then putting all of the instruments in a perforated tray and sterilizing at 132 C (270 F) for three minutes. All metal basins and trays should be washed and terminally sterilized. The circulator disconnects the wall suction unit. Reusableglass suction containers should be emptied into a flushing hopper, or the contents of the suction bottle may be decontaminated with a proper disinfectant before disposal. The suction container should then be washed and sterilized with the metal basins and trays. Disposable suction and tubing is preferred because of the difficulty in cleaning the lumen of reusable suction tubing. The overhead lamp should be cleaned with a detergent-germicide or a disinfectant such as alcohol. The top surfaces of the back table, Mayo stand, prep table, OR bed, and any other equipment used within the sterile field must be washed with the correct dilution of a detergent-germicide. The wheels and castors should be pushed through the detergentgermicide used for cleaning the floor. If necessary, spot cleaning of walls and ceilings should be done whenever blood, mucus, or any secretions contaminate them. Finally, floors should be cleaned by the wet-vacuumingmethod. If a wet vacuum is not available, a garden-typesprinkling can may be used to pour a detergent-germicide on the floor. Just the area of the floor in which the sterile field was contained should be cleaned. The detergent-germicideis mopped up with a clean mop head for each surgical procedure. It is not necessary to use buckets. This technique eliminates the need to clean buckets between cases. The mop head is discarded in the laundry hamper after use. The room is now ready for use. This procedure, with organized teamwork, should be completed within fifteen minutes for most major procedures. Terminal cleaning at the completion of each
AORN Journal, June 1979, V o l 2 9 , No 7
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day's schedule is all-inclusive. Thoroughly clean all OR furniture and equipment with a good detergent-germicide and lots of "elbow grease." Wheels and castors are cleaned and kept free of debris. Spotlights and overhead tracks are cleaned. Kick buckets and waste baskets are scrubbed and sterilized, if possible. Scrub sinks must be cleaned thoroughly daily. Spray heads of faucets are discouraged for use in the OR. However, if they are used to control water flow, each day they must be disassembled,cleaned, and the appropriate parts sterilized. Soap dispensers must be disassembled, thoroughly cleaned, and the appropriate parts sterilized. If reusable brushes are used, the brush dispenser should be removed, rinsed, refilled with clean brushes, and sterilized. Doors of cabinets and operating rooms should be cleaned thoroughly, especially around handles and push plates. Floors should be machine scrubbed and the solution picked up with a wet-vacuum. If mops are used, a clean mop for each room is recommended. Utility carts and transportation stretchers must be cleaned thoroughly with specific care to cleaning the wheels and castors. All cleaning equipment and supplies must be disassembled, cleaned, and allowed to dry thoroughly before storing. For many of you, this article is not new and the question will surely be asked, why go through the OR sanitation procedure again? My only defense is there is a need to reinforce the concept that one OR cleanup can be used safely for all surgical procedures. When this concept is accepted by the majority of OR nurses, we will not have to keep answering repeatedly the question, "How do I cleanup after a dirty case?"
Colleen K Harvey, RN Consultative specialist Notes 1. Francis Ginsberg, "These fourteen steps will make any OR safe," Modern Hospital 110 (June 1968) 130. 2. Jerry G Peers, "Cleanup technique in the OR," Archives of Surgery 107 (October 1973) 596-599, reprinted AORN Journal 19 (January 1974) 53-60; Association of Operating Room Nurses, "AORN standards for OR sanitation," AORN Journal 21. (June 1975) 1228-1231; Phyllis Wells, '' 'Confine
1220
and contain' approach to OR cleanup," AORN Journal 25 (January 1977) 60-65. 3. Peers, "Cleanup technique in the OR," 53-60; "Standards for OR sanitation,"AORN Standards of Practice (Denver: Association of Operating Room Nurses, Inc, 1978) part 3, 14-16. 4. Peers, "Cleanup technique in the OR," 55. 5. "Standards for OR sanitation," part 3, 15.
Appendix misdiagnosis for children reported Too many physicians misdiagnose appendicitis or a ruptured appendix in children, according to an assistant professor of surgery at West Virginia University, Morgantown. Ronald A Savrin, MD, discussed the problem of misdiagnosis in an article in Medical World News. His findings showed physicians send children home with diagnoses of gastroenteritis, urinary infection, pharyngitis, or "nothing to worry about." Dr Savrin based his conclusions on a review of the records of 49 children operated on for ruptured appendix in 1975 at Children's Hospital, Columbus, Ohio. Nearly half the cases had initially been misdiagnosed, Dr Savrin said. In 16 cases the error was made by one physician, and in 6, several physicians had been wrong. There was little excuse for a misdiagnosis in many of the cases, Dr Savrin continued. Of those misdiagnosed,69% had abdominal tenderness, and 86% had cramping pain and vomiting. A surgical consultation is usually warranted when there is mild suspicion of appendicitis, he said, advocating admitting a child for 12- to 24-hour observation to minimize risk of rupture and unnecessary surgery. Dr Savrin noted, however, that the misdiagnosed children's symptoms during examination were not as suggestive as they had become at the time of hospitalization an average of 27 hours later. At that time more showed voluntary guarding, rebound tenderness, rectal tenderness, and an abdominal mass. Further, some parents failed to bring their children to the hospital for hours after symptoms began.
AORN Journal, June 1979, Vol29, No 7
Does a dirty case mean it’s x-rated? What is the question we receive most frequently at Headquarters? It is: “How do I clean up after a dirty case?” This question is also asked repeatedly at the “Once upon a Germ” seminar. It has been ten years since Ginsberg wrote: “These fourteen steps will make any OR safe.”’ Yet OR nurses continue to attack the dirty case with as much fervor as others might attack ”septic” movies. As a consultant, I see the OR suite where two circulators are used for known contaminated cases, one inside the OR and one outside. Nurses still pull all the OR furniture out into the corridor before bringing a known infected patient into the operating room. They tape cabinet doors or hang sheets over open shelves in preparation for a “dirty case.” Washing the walls, ceiling, and floor to insure all the “bugs” are killed is still a common procedure following a septic case. Scheduling the dirty case at the end of the day is prevalent. However, the procedures change-for the short-staffed evening, night, weekend, or holiday shifts. Miraculously, the need for the outside circulator is unnecessary. It is as if the “bugs” know when the day shift goes off duty, and they agree not to spread infections. Ginsberg, Peers, Wells, the AORN Technical Standards Committee; all have addressed or described the methodology of OR cleanup.2 We all agree on our goal and objectives in OR cleanup, that is: a simple practical method of cleaning the OR and eliminating the possibility of cross-contamination between surgical patients.
@q
With this purpose in mind, I will restate the rationale for all cases being considered contaminated. As you know, many patients arrive in the operating room with undiagnosed infections. Tuberculosis is one of the most frequent infections that is not diagnosed until after surgery. It is also possible that microorganisms existing systematically in one patient and causing that patient no apparent physical distress, when transferred to another patient, may flourish into a severe infection. Therefore, all patients should be considered potentially contaminated. Peers and the “Standards for OR Sanitation” outline four general cleanup ~ategories.~ The first category is cleaning prior to the first scheduled procedure of the day. This includes damp-dusting flat surfaces such as tables, equipment, and overhead lamps. The second category of cleanup is the important “confine and contain” period. During the surgical procedure, all areas contaminated by any organic debris such as blood, mucus, bodily secretions, or any items that have contact with these secretions must be confined to the area in which the sterile team works. Any contamination of areas outside of the sterile fieid should receive immediate attention by applying an iodophor, phenolic detergent-germicide, or other broad spectrum germicide to the soiled area. This can be accomplished by use of a squeeze bottle. For example, a bloody sponge misses the kick bucket and splatters on the floor. The circulator, who should never become contaminated by the patient’s secretions, immediately retrieves the sponge with a single-use forceps or a gloved hand, discards the sponge into the kick bucket, and decontaminates the floor by applying a good broad spectrum detergent-germicide to the area. In
dAORN Journal, June 1979, Vol29, No 7
1215
every instance, any item that has been in contact with the patient or his secretions is contained within the sterile field or if it leaves the sterile field, the item is promptly decontaminated by the circulator. If by accident the circulator should become contaminated with the patient’s secretions, then the circulator washes or cleans the contaminated area with a good antiseptic or germicide solution. Gloves may be used if the patient requires the help of the circulator during the procedure. Continuously policing during the surgical procedure insures that there is no chance of spreading microorganisms outside of the sterile field. This protects personnel and other surgical patients from cross-contamination. Policing includes controlling traffic. Traffic in and out of the operating room is kept to a minimum to curtail dust turbulence created by activity. The circulating nurse should anticipate supply needs adequately to avoid having to leave and return frequently, however, this is not a recommendation for a second circulating nurse outside the room.4 The third category of OR cleanup is known as room change over. There is always pressure from the surgeons and the anesthesiologist to complete the cleanup between cases as rapidly as possible. No other single problem has plaguedthe OR nurse as much as the time between cases. Therefore, it is important to understandwhat must be done, how the cleanup technique is accomplished, and the teamwork between the scrubbed persons and the circulator. As previously stated, during the operative period the scrubbed person handles all the items within the sterile field; the circulator handles the equipment and supplies that have not been in contact with the patient. Prior to leaving the room, all personnel must leave their gowns and gloves in appropriate receptacles. There is a correct procedure for removing the gown and then the gloves and disposing of them into the linen hamper or the trash bag for disposal. All linens must be placed carefully into the linen hamper and nonwovens must be placed in plastic bags for disposal. Care should be taken to insure that instruments are not included in the laundry or trash bags. Reusable sponges should be collected in impervious plastic bags and sent to the laundry. Disposable sponges and waste
articles should be collected in plastic bags for disposal. The best procedure is to place all instruments into perforated trays for decontamination in the washer-sterilizeror to enclose them in an impervious plastic bag for transportation to a central cleanup area.5Another acceptable alternative for decontamination of the instruments is rinsing carefully in a basin of water (never saline) in the OR, then putting all of the instruments in a perforated tray and sterilizing at 132 C (270 F) for three minutes. All metal basins and trays should be washed and terminally sterilized. The circulator disconnects the wall suction unit. Reusableglass suction containers should be emptied into a flushing hopper, or the contents of the suction bottle may be decontaminated with a proper disinfectant before disposal. The suction container should then be washed and sterilized with the metal basins and trays. Disposable suction and tubing is preferred because of the difficulty in cleaning the lumen of reusable suction tubing. The overhead lamp should be cleaned with a detergent-germicide or a disinfectant such as alcohol. The top surfaces of the back table, Mayo stand, prep table, OR bed, and any other equipment used within the sterile field must be washed with the correct dilution of a detergent-germicide. The wheels and castors should be pushed through the detergentgermicide used for cleaning the floor. If necessary, spot cleaning of walls and ceilings should be done whenever blood, mucus, or any secretions contaminate them. Finally, floors should be cleaned by the wet-vacuumingmethod. If a wet vacuum is not available, a garden-typesprinkling can may be used to pour a detergent-germicide on the floor. Just the area of the floor in which the sterile field was contained should be cleaned. The detergent-germicideis mopped up with a clean mop head for each surgical procedure. It is not necessary to use buckets. This technique eliminates the need to clean buckets between cases. The mop head is discarded in the laundry hamper after use. The room is now ready for use. This procedure, with organized teamwork, should be completed within fifteen minutes for most major procedures. Terminal cleaning at the completion of each
AORN Journal, June 1979, V o l 2 9 , No 7
1219
day's schedule is all-inclusive. Thoroughly clean all OR furniture and equipment with a good detergent-germicide and lots of "elbow grease." Wheels and castors are cleaned and kept free of debris. Spotlights and overhead tracks are cleaned. Kick buckets and waste baskets are scrubbed and sterilized, if possible. Scrub sinks must be cleaned thoroughly daily. Spray heads of faucets are discouraged for use in the OR. However, if they are used to control water flow, each day they must be disassembled,cleaned, and the appropriate parts sterilized. Soap dispensers must be disassembled, thoroughly cleaned, and the appropriate parts sterilized. If reusable brushes are used, the brush dispenser should be removed, rinsed, refilled with clean brushes, and sterilized. Doors of cabinets and operating rooms should be cleaned thoroughly, especially around handles and push plates. Floors should be machine scrubbed and the solution picked up with a wet-vacuum. If mops are used, a clean mop for each room is recommended. Utility carts and transportation stretchers must be cleaned thoroughly with specific care to cleaning the wheels and castors. All cleaning equipment and supplies must be disassembled, cleaned, and allowed to dry thoroughly before storing. For many of you, this article is not new and the question will surely be asked, why go through the OR sanitation procedure again? My only defense is there is a need to reinforce the concept that one OR cleanup can be used safely for all surgical procedures. When this concept is accepted by the majority of OR nurses, we will not have to keep answering repeatedly the question, "How do I cleanup after a dirty case?"
Colleen K Harvey, RN Consultative specialist Notes 1. Francis Ginsberg, "These fourteen steps will make any OR safe," Modern Hospital 110 (June 1968) 130. 2. Jerry G Peers, "Cleanup technique in the OR," Archives of Surgery 107 (October 1973) 596-599, reprinted AORN Journal 19 (January 1974) 53-60; Association of Operating Room Nurses, "AORN standards for OR sanitation," AORN Journal 21. (June 1975) 1228-1231; Phyllis Wells, '' 'Confine
1220
and contain' approach to OR cleanup," AORN Journal 25 (January 1977) 60-65. 3. Peers, "Cleanup technique in the OR," 53-60; "Standards for OR sanitation,"AORN Standards of Practice (Denver: Association of Operating Room Nurses, Inc, 1978) part 3, 14-16. 4. Peers, "Cleanup technique in the OR," 55. 5. "Standards for OR sanitation," part 3, 15.
Appendix misdiagnosis for children reported Too many physicians misdiagnose appendicitis or a ruptured appendix in children, according to an assistant professor of surgery at West Virginia University, Morgantown. Ronald A Savrin, MD, discussed the problem of misdiagnosis in an article in Medical World News. His findings showed physicians send children home with diagnoses of gastroenteritis, urinary infection, pharyngitis, or "nothing to worry about." Dr Savrin based his conclusions on a review of the records of 49 children operated on for ruptured appendix in 1975 at Children's Hospital, Columbus, Ohio. Nearly half the cases had initially been misdiagnosed, Dr Savrin said. In 16 cases the error was made by one physician, and in 6, several physicians had been wrong. There was little excuse for a misdiagnosis in many of the cases, Dr Savrin continued. Of those misdiagnosed,69% had abdominal tenderness, and 86% had cramping pain and vomiting. A surgical consultation is usually warranted when there is mild suspicion of appendicitis, he said, advocating admitting a child for 12- to 24-hour observation to minimize risk of rupture and unnecessary surgery. Dr Savrin noted, however, that the misdiagnosed children's symptoms during examination were not as suggestive as they had become at the time of hospitalization an average of 27 hours later. At that time more showed voluntary guarding, rebound tenderness, rectal tenderness, and an abdominal mass. Further, some parents failed to bring their children to the hospital for hours after symptoms began.
AORN Journal, June 1979, Vol29, No 7