- Email: [email protected]
Clinical Issues—March 2014
CONTINUING EDUCATION Clinical Issues
0.9
AMBER WOOD, MSN, RN, CNOR, CIC, CPN
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn .org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14508 Session: #0001 Fee: Members $7.20, Nonmembers $14.40
Conflict of Interest Disclosures
The CE contact hours for this article expire March 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to sweeping the OR floor before wet mopping, mopping the OR floor between procedures, cleaning hallway floors in semirestricted areas, and peripheral IV skin prep.
Amber Wood, MSN, RN, CNOR, CIC, CPN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.12.001
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 435
CLINICAL ISSUES
0.9
www.aorn.org/CE
This Month Sweeping the OR floor before wet mopping Key words: sweeping, cleaning, mopping, floors, OR.
Mopping the OR floor between procedures Key words: cleaning, mopping, floors, OR.
Cleaning hallway floors in semirestricted areas Key words: cleaning, mopping, hallway, corridor, semirestricted areas, floors.
Peripheral IV skin prep in the ambulatory setting Key words: intravenous, IV, skin prep, alcohol, chlorhexidine gluconate, CHG.
Sweeping the OR floor before wet mopping QUESTION: Should debris on the OR floor be swept up with a broom before mopping? ANSWER: The OR floor should not be swept before mopping.1 In an observational study, Andersen et al2 compared the effectiveness of soil removal and air contamination of four mopping methods (ie, dry, spray, moist, wet mopping) in two-bed patient rooms in a hospital in Norway. For dry mopping procedures, the researchers used a dry microfiber mop to clean a 1 meter 1 meter preset area at the foot of the first bed in the room.2 The researchers found that all methods of mopping increased bacterial contamination of the air immediately after mopping but that dry methods produced more aerosols than wet methods.2
Further research is needed to confirm the level of air contamination from dry sweeping and the role of air contamination in the OR; however, the study by Andersen et al2 implies that dry sweeping before wet mopping may cause floor contaminants to be aerosolized. When a floor is wet mopped after dry sweeping, some of the contaminants remain in the air during mopping and then resettle on the clean floor. Furthermore, cleaning tools and equipment for dry sweeping the floor (eg, brooms) can be difficult to disinfect thoroughly after each use. Because floor debris in the OR is very likely contaminated with blood, body fluids, or other potentially infectious materials (eg, suture remnants), cleaning tools and equipment that cannot be thoroughly disinfected should not be used in the OR.
http://dx.doi.org/10.1016/j.aorn.2013.12.001
436 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
CLINICAL ISSUES To prevent floor debris from interfering with disinfection, personnel should don gloves to manually remove the debris (eg, suture remnants or other suture material) before mopping. A perioperative team member who is wearing gloves1 may pick up nonsharp or nonhazardous items manually or may remove them by using a moistened cloth or paper towel or a product designed for debris pickup that can be disinfected after use. Any sharp debris (eg, suture needles, blades) should be removed from the floor using an instrument.3,4 After discarding the debris into a suitable waste receptacle (eg, sharps container, trash), the team member should remove his or her soiled gloves and perform hand hygiene before resuming cleaning activities.1
www.aornjournal.org
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 2. 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):57-65. 3. Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030(2012). Occupational Safety & Health Administration. https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_table¼standards&p_id¼10051. Accessed November 12, 2013. 4. Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:e1-e24.
Mopping the OR floor between procedures QUESTION: Do we have to mop the entire OR floor, including the area under the OR bed, after every procedure? ANSWER: The OR floor should be cleaned and disinfected after a surgical or other invasive procedure if the floor was soiled or potentially soiled during the procedure by splash, spray, or splatter of blood, body fluids, or other potentially infectious materials.1 Cleaning refers to the physical removal of soil by using a detergent with mechanical action, whereas disinfection refers to the inactivation of microorganisms.2 Cleaning an area by using a detergent with mechanical friction to remove gross soil is crucial before applying a disinfectant because disinfectants may be inactivated in the presence of organic material, such as blood.2 Applying the detergent and disinfectant in separate steps is referred to as a two-step process.2 In instances in which contamination is limited, soil may be removed and the floor cleaned and disinfected in one step by using a combination detergent/disinfectant
product; this application is referred to as a one-step process. For example, large amounts of blood or organic tissue on the floor should be physically removed before the disinfectant is applied using a two-step process, whereas a very small amount of blood on the floor may be cleaned and disinfected in one step by using a detergent/disinfectant product. Any areas of the floor with visible soil consisting of blood, body fluids, or other potentially infectious materials should be cleaned as soon as possible after soiling occurs.3 After removing visible soil, personnel should use an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant to disinfect the area. If it is not possible to clean this type of soil on the floor until the end of the procedure, the soiled areas should be cleaned and disinfected before postprocedure mopping of the room. When mopping, personnel should apply an EPAregistered disinfectant to the floor and work from the cleaner to the dirtier areas of the floor.1 The OR bed should be moved to inspect the cleanliness of the floor beneath it, especially if the OR bed was
AORN Journal j 437
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moved and the floor underneath was exposed during the procedure. In the absence of visible soil, the area in which the procedure was conducted is most likely the dirtiest area of the floor. Because procedures typically are performed in the center of the room, this area generally is considered the dirtiest and should be cleaned last. Personnel should change the disposable or reusable mop head or cleaning cloth after cleaning any visibly soiled areas of blood, body fluids, or other potentially infectious materials. Removing any visible soil and changing the mop or cleaning cloth before mopping the cleaner areas of the room will reduce the risk of distributing infectious material throughout the room. To reduce the risk of cross-contamination of the floor, personnel should not return either the mop head or the cleaning cloth to the cleaning solution container after they have come into contact with the floor.1 If more cleaning solution is needed to complete the mopping, personnel may pour the cleaning solution onto the floor or cleaning cloth in a manner that prevents splashing. Essentially, the decision about whether to mop certain areas of the floor or the entire floor after surgical or other invasive procedures should be made by a multidisciplinary team (eg, perioperative nursing, environmental services, infection prevention) during the development of policies and procedures for environmental cleaning. The decision about which area of an OR floor to mop should be based on the level of contamination of the floor and the traffic patterns in the room.1 At a minimum, soiled areas of the floor should be mopped as soon as possible after contamination, in accordance with Occupational Safety and Health Administration (OSHA) regulations.3 In this situation, the multidisciplinary team may develop a policy based on
the OSHA regulations stating that floors need only be spot cleaned if they are contaminated with blood, body fluids, or other potentially infectious material during a procedure, rather than stating that floors need to be mopped in their entirety. If the multidisciplinary team members identify issues with floor cleanliness or transmission of infections through quality monitoring activities, they may decide to develop policies that require more stringent cleaning procedures at the facility. Examples include requiring personnel to mop the entire OR floor after performing certain procedures (eg, total joint procedures), when caring for certain patient populations (eg, stem cell transplant), or after large areas of the floor are soiled (eg, trauma). Policy decisions about the area or amount of floor to mop after each procedure need to be clearly communicated to all team members who are responsible for environmental cleaning in the OR, including the environmental services and perioperative services team members, and these policies should be reevaluated periodically. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 2. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Society for Healthcare Environmental Services; 2012. 3. Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030(2012). Occupational Safety & Health Administration. https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_table¼standards&p_id¼10051. Accessed November 12, 2013.
Cleaning hallway floors in semirestricted areas QUESTION: How often should floors in the hallways of semirestricted areas be cleaned? 438 j AORN Journal
ANSWER: A multidisciplinary team, including representatives from perioperative services, environmental
CLINICAL ISSUES services, and infection prevention, should determine how frequently the floors in the hallways of semirestricted areas should be cleaned. The multidisciplinary team should consider establishing cleaning frequency, for example, weekly or monthly and whenever soiled.1,2 Determinations and any policy decisions should be based on the activity that occurs in the area. For example, if there is heavy traffic, consider daily cleaning; if there is light traffic, consider weekly cleaning. The multidisciplinary team also should determine which mopping materials and tools should be used (eg, reusable or single-use mops made of either string or microfiber, mops that dispense cleaning solutions).2 Regardless of the type of mopping materials or tools used for cleaning, team members who perform the cleaning should change the mop after mopping a visibly soiled area and, to prevent contamination of the solution, should not return the mop to the cleaning chemical container.2 If additional cleaning solution is needed while mopping the floor of a large corridor, team
www.aornjournal.org
members may pour cleaning solution onto the floor in a manner that prevents splashing or use a new moistened mop or cleaning cloth. There is insufficient evidence to support a requirement for wet-vacuuming hallway floors; however, the multidisciplinary team may consider this cleaning method as an alternative to mopping. Determining the mopping method in a semirestricted area should be based on a risk/cost/benefit analysis. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Society for Healthcare Environmental Services; 2012. 2. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254.
Peripheral IV skin prep in the ambulatory setting QUESTION: Is a combination of chlorhexidine gluconate (CHG) and alcohol necessary for use as a peripheral IV skin prep in an ambulatory surgery center, or can we just use alcohol? ANSWER: In the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, the Centers for Disease Control and Prevention (CDC) recommends prepping skin with “an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution)”1(p13) for peripheral venous catheter insertion. The CDC guidelines also recommend allowing the antiseptic to dry for a length of time that is in accordance with the manufacturer’s instructions for use
before inserting the catheter.1 The Infusion Nurses Society recommends chlorhexidine solution for skin antisepsis when preparing a site for vascular access for a patient older than two months of age, although “one percent to two percent tincture of iodine, iodophor (povidone-iodine), and 70% alcohol may be used.”2(pS44) Chlorhexidine gluconate has a residual effect when allowed to dry on skin3 (ie, CHG continues to perform antisepsis on the skin for a period of time after its application). Thus, this antiseptic is preferable for reducing and maintaining lower bacterial counts near an IV insertion site or a surgical wound. In the ambulatory surgery setting, the amount of time that an IV catheter remains in place is very limited; therefore, the benefits of a residual antimicrobial effect may not be as important in this
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patient population as it is in patients who have IVs in place for longer periods. Drying time also should be considered when selecting a product for use as a skin preparation antiseptic for peripheral IV insertion. Prolonged dry times may delay patient care in any perioperative setting but could be a primary factor in selecting products for use in the ambulatory setting. Perioperative RNs should consult the facility’s infection preventionist to determine which option would be best for the facility’s patient population and which products should be selected and used in accordance with manufacturers’ written instructions.
440 j AORN Journal
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Atlanta, GA: Centers for Disease Control and Prevention; 2011. http://www .cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed November 12, 2013. 2. Infusion Nurses Society. Standards of practice, 2011. J Infus Nurs. 2011;34(1S):S1-S110. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
LEARNER EVALUATION
0.9
CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to sweeping the OR floor before wet mopping, mopping the OR floor between procedures, cleaning hallway floors in semirestricted areas, and peripheral IV skin prep. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
Ó AORN, Inc, 2014
www.aorn.org/CE
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 0.9 continuing education contact hour (54-minute) program: ________________________________
March 2014
Vol 99 No 3
AORN Journal j 441
0.9
AMBER WOOD, MSN, RN, CNOR, CIC, CPN
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn .org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14508 Session: #0001 Fee: Members $7.20, Nonmembers $14.40
Conflict of Interest Disclosures
The CE contact hours for this article expire March 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to sweeping the OR floor before wet mopping, mopping the OR floor between procedures, cleaning hallway floors in semirestricted areas, and peripheral IV skin prep.
Amber Wood, MSN, RN, CNOR, CIC, CPN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.12.001
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 435
CLINICAL ISSUES
0.9
www.aorn.org/CE
This Month Sweeping the OR floor before wet mopping Key words: sweeping, cleaning, mopping, floors, OR.
Mopping the OR floor between procedures Key words: cleaning, mopping, floors, OR.
Cleaning hallway floors in semirestricted areas Key words: cleaning, mopping, hallway, corridor, semirestricted areas, floors.
Peripheral IV skin prep in the ambulatory setting Key words: intravenous, IV, skin prep, alcohol, chlorhexidine gluconate, CHG.
Sweeping the OR floor before wet mopping QUESTION: Should debris on the OR floor be swept up with a broom before mopping? ANSWER: The OR floor should not be swept before mopping.1 In an observational study, Andersen et al2 compared the effectiveness of soil removal and air contamination of four mopping methods (ie, dry, spray, moist, wet mopping) in two-bed patient rooms in a hospital in Norway. For dry mopping procedures, the researchers used a dry microfiber mop to clean a 1 meter 1 meter preset area at the foot of the first bed in the room.2 The researchers found that all methods of mopping increased bacterial contamination of the air immediately after mopping but that dry methods produced more aerosols than wet methods.2
Further research is needed to confirm the level of air contamination from dry sweeping and the role of air contamination in the OR; however, the study by Andersen et al2 implies that dry sweeping before wet mopping may cause floor contaminants to be aerosolized. When a floor is wet mopped after dry sweeping, some of the contaminants remain in the air during mopping and then resettle on the clean floor. Furthermore, cleaning tools and equipment for dry sweeping the floor (eg, brooms) can be difficult to disinfect thoroughly after each use. Because floor debris in the OR is very likely contaminated with blood, body fluids, or other potentially infectious materials (eg, suture remnants), cleaning tools and equipment that cannot be thoroughly disinfected should not be used in the OR.
http://dx.doi.org/10.1016/j.aorn.2013.12.001
436 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
CLINICAL ISSUES To prevent floor debris from interfering with disinfection, personnel should don gloves to manually remove the debris (eg, suture remnants or other suture material) before mopping. A perioperative team member who is wearing gloves1 may pick up nonsharp or nonhazardous items manually or may remove them by using a moistened cloth or paper towel or a product designed for debris pickup that can be disinfected after use. Any sharp debris (eg, suture needles, blades) should be removed from the floor using an instrument.3,4 After discarding the debris into a suitable waste receptacle (eg, sharps container, trash), the team member should remove his or her soiled gloves and perform hand hygiene before resuming cleaning activities.1
www.aornjournal.org
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 2. 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):57-65. 3. Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030(2012). Occupational Safety & Health Administration. https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_table¼standards&p_id¼10051. Accessed November 12, 2013. 4. Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:e1-e24.
Mopping the OR floor between procedures QUESTION: Do we have to mop the entire OR floor, including the area under the OR bed, after every procedure? ANSWER: The OR floor should be cleaned and disinfected after a surgical or other invasive procedure if the floor was soiled or potentially soiled during the procedure by splash, spray, or splatter of blood, body fluids, or other potentially infectious materials.1 Cleaning refers to the physical removal of soil by using a detergent with mechanical action, whereas disinfection refers to the inactivation of microorganisms.2 Cleaning an area by using a detergent with mechanical friction to remove gross soil is crucial before applying a disinfectant because disinfectants may be inactivated in the presence of organic material, such as blood.2 Applying the detergent and disinfectant in separate steps is referred to as a two-step process.2 In instances in which contamination is limited, soil may be removed and the floor cleaned and disinfected in one step by using a combination detergent/disinfectant
product; this application is referred to as a one-step process. For example, large amounts of blood or organic tissue on the floor should be physically removed before the disinfectant is applied using a two-step process, whereas a very small amount of blood on the floor may be cleaned and disinfected in one step by using a detergent/disinfectant product. Any areas of the floor with visible soil consisting of blood, body fluids, or other potentially infectious materials should be cleaned as soon as possible after soiling occurs.3 After removing visible soil, personnel should use an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant to disinfect the area. If it is not possible to clean this type of soil on the floor until the end of the procedure, the soiled areas should be cleaned and disinfected before postprocedure mopping of the room. When mopping, personnel should apply an EPAregistered disinfectant to the floor and work from the cleaner to the dirtier areas of the floor.1 The OR bed should be moved to inspect the cleanliness of the floor beneath it, especially if the OR bed was
AORN Journal j 437
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March 2014 Vol 99 No 3
moved and the floor underneath was exposed during the procedure. In the absence of visible soil, the area in which the procedure was conducted is most likely the dirtiest area of the floor. Because procedures typically are performed in the center of the room, this area generally is considered the dirtiest and should be cleaned last. Personnel should change the disposable or reusable mop head or cleaning cloth after cleaning any visibly soiled areas of blood, body fluids, or other potentially infectious materials. Removing any visible soil and changing the mop or cleaning cloth before mopping the cleaner areas of the room will reduce the risk of distributing infectious material throughout the room. To reduce the risk of cross-contamination of the floor, personnel should not return either the mop head or the cleaning cloth to the cleaning solution container after they have come into contact with the floor.1 If more cleaning solution is needed to complete the mopping, personnel may pour the cleaning solution onto the floor or cleaning cloth in a manner that prevents splashing. Essentially, the decision about whether to mop certain areas of the floor or the entire floor after surgical or other invasive procedures should be made by a multidisciplinary team (eg, perioperative nursing, environmental services, infection prevention) during the development of policies and procedures for environmental cleaning. The decision about which area of an OR floor to mop should be based on the level of contamination of the floor and the traffic patterns in the room.1 At a minimum, soiled areas of the floor should be mopped as soon as possible after contamination, in accordance with Occupational Safety and Health Administration (OSHA) regulations.3 In this situation, the multidisciplinary team may develop a policy based on
the OSHA regulations stating that floors need only be spot cleaned if they are contaminated with blood, body fluids, or other potentially infectious material during a procedure, rather than stating that floors need to be mopped in their entirety. If the multidisciplinary team members identify issues with floor cleanliness or transmission of infections through quality monitoring activities, they may decide to develop policies that require more stringent cleaning procedures at the facility. Examples include requiring personnel to mop the entire OR floor after performing certain procedures (eg, total joint procedures), when caring for certain patient populations (eg, stem cell transplant), or after large areas of the floor are soiled (eg, trauma). Policy decisions about the area or amount of floor to mop after each procedure need to be clearly communicated to all team members who are responsible for environmental cleaning in the OR, including the environmental services and perioperative services team members, and these policies should be reevaluated periodically. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 2. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Society for Healthcare Environmental Services; 2012. 3. Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030(2012). Occupational Safety & Health Administration. https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_table¼standards&p_id¼10051. Accessed November 12, 2013.
Cleaning hallway floors in semirestricted areas QUESTION: How often should floors in the hallways of semirestricted areas be cleaned? 438 j AORN Journal
ANSWER: A multidisciplinary team, including representatives from perioperative services, environmental
CLINICAL ISSUES services, and infection prevention, should determine how frequently the floors in the hallways of semirestricted areas should be cleaned. The multidisciplinary team should consider establishing cleaning frequency, for example, weekly or monthly and whenever soiled.1,2 Determinations and any policy decisions should be based on the activity that occurs in the area. For example, if there is heavy traffic, consider daily cleaning; if there is light traffic, consider weekly cleaning. The multidisciplinary team also should determine which mopping materials and tools should be used (eg, reusable or single-use mops made of either string or microfiber, mops that dispense cleaning solutions).2 Regardless of the type of mopping materials or tools used for cleaning, team members who perform the cleaning should change the mop after mopping a visibly soiled area and, to prevent contamination of the solution, should not return the mop to the cleaning chemical container.2 If additional cleaning solution is needed while mopping the floor of a large corridor, team
www.aornjournal.org
members may pour cleaning solution onto the floor in a manner that prevents splashing or use a new moistened mop or cleaning cloth. There is insufficient evidence to support a requirement for wet-vacuuming hallway floors; however, the multidisciplinary team may consider this cleaning method as an alternative to mopping. Determining the mopping method in a semirestricted area should be based on a risk/cost/benefit analysis. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Society for Healthcare Environmental Services; 2012. 2. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254.
Peripheral IV skin prep in the ambulatory setting QUESTION: Is a combination of chlorhexidine gluconate (CHG) and alcohol necessary for use as a peripheral IV skin prep in an ambulatory surgery center, or can we just use alcohol? ANSWER: In the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, the Centers for Disease Control and Prevention (CDC) recommends prepping skin with “an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution)”1(p13) for peripheral venous catheter insertion. The CDC guidelines also recommend allowing the antiseptic to dry for a length of time that is in accordance with the manufacturer’s instructions for use
before inserting the catheter.1 The Infusion Nurses Society recommends chlorhexidine solution for skin antisepsis when preparing a site for vascular access for a patient older than two months of age, although “one percent to two percent tincture of iodine, iodophor (povidone-iodine), and 70% alcohol may be used.”2(pS44) Chlorhexidine gluconate has a residual effect when allowed to dry on skin3 (ie, CHG continues to perform antisepsis on the skin for a period of time after its application). Thus, this antiseptic is preferable for reducing and maintaining lower bacterial counts near an IV insertion site or a surgical wound. In the ambulatory surgery setting, the amount of time that an IV catheter remains in place is very limited; therefore, the benefits of a residual antimicrobial effect may not be as important in this
AORN Journal j 439
CLINICAL ISSUES
March 2014 Vol 99 No 3
patient population as it is in patients who have IVs in place for longer periods. Drying time also should be considered when selecting a product for use as a skin preparation antiseptic for peripheral IV insertion. Prolonged dry times may delay patient care in any perioperative setting but could be a primary factor in selecting products for use in the ambulatory setting. Perioperative RNs should consult the facility’s infection preventionist to determine which option would be best for the facility’s patient population and which products should be selected and used in accordance with manufacturers’ written instructions.
440 j AORN Journal
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Atlanta, GA: Centers for Disease Control and Prevention; 2011. http://www .cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed November 12, 2013. 2. Infusion Nurses Society. Standards of practice, 2011. J Infus Nurs. 2011;34(1S):S1-S110. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
LEARNER EVALUATION
0.9
CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to sweeping the OR floor before wet mopping, mopping the OR floor between procedures, cleaning hallway floors in semirestricted areas, and peripheral IV skin prep. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
Ó AORN, Inc, 2014
www.aorn.org/CE
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 0.9 continuing education contact hour (54-minute) program: ________________________________
March 2014
Vol 99 No 3
AORN Journal j 441