- Email: [email protected]
Recommended Practices for Environmental Cleaning in the Surgical Practice Setting
OCTOBER 1996, VOL 64, NO 4
Recommended Practices for Environmental Cleaning in the Surgical Practice Setting
T
he following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were available in February 1996 as proposed recommended practices through the AORN fax on demand number for comments by members and others. They are effective January 1, 1997. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians’ oftices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where surgery may be performed. Purpose. These recommended practices provide guidelines for environmental cleaning (previously titled “Recommended practices for sanitation in the surgical practice setting”). These practices should provide a clean environment for surgical patients and be carried out in a manner that minimizes health care workers’ and patients’ exposures to potentially infectious microorganisms. A basic premise of these recommended practices is that all surgical patients are considered potentially infected with bloodborne pathogens. All surgical procedures, therefore, are considered contaminated, and the same environmental cleaning protocols should be implemented for all surgical procedures. RECOMMENDED PRACTICE I
Patients should be provided a safe, visibly clean environment. Interpretive statement I :
Cleaning should be performed on a scheduled basis. Rationale: Exogenous microorganisms can contaminate ORs in surgical practice settings. Cleaning reduces the amount of dust and organic debris in surgical environments. I Discussion: Environmental cleaning measures are required before, during, and after each surgical procedure and at the end of each day. Environmental cleaning is a team effort by surgical personnel (eg, nurses, surgical technologists, anesthesia care providers, surgeons, OR assistants) and environmental services personnel. The ultimate responsibility for ensuring clean surgical environments rests with perioperative nurses. Administrative personnel must ensure that environmental cleaning practices comply with the standards established for the practice setting.2 Interpretive statement 2: All horizontal surfaces within the OR (eg, fumiture, surgical lights, equipment) should be damp dusted before the first scheduled surgical procedure of the day with a clean, lint-free cloth moistened with a facility-approved agent. Rationale: Dust and lint are deposited on horizontal surfaces in surgical practice settings. Proper cleaning of these surfaces will help reduce airborne contaminants that may travel on dust and lint.3 Interpretive statement 3: Preparation of the ORs should include visual inspections for cleanliness before case carts, supplies, and instrument sets are brought into the ORs. Rationale: Although it is difficult to define the level of contamination necessary to increase surgical wound infection rates, a clean surgical environment will reduce the number of microbial flora p r e ~ e n t . ~ Discussion: For the second-scheduled and subsequent surgical
611 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
procedures, in-between case cleaning is performed. Equipment from areas outside the OR should be damp dusted before it is brought into the OR.
patient charts) contaminated with blood, tissue, or body fluids may expose health care workers to bloodborne pathogens?
Discussion: RECOMMENDED PRACTICE II
During surgical procedures, contamination should be confined and contained within the immediate vicinity of the surgical field as much as possible. Interpretive statement I : Accidental spills of contaminated debris (eg, blood, tissue, body fluids) in areas outside the surgical field should be cleaned as promptly as possible.
Rationale: Prompt cleanup of potentially infectious pathogenic microorganisms using a lint-free cloth saturated with a facility-approved agent helps maintain a safe, clean surgical en~ironment.~
Discussion: If bleach is used for dismfection, medical devices may become damaged. It is preferable, therefore, to use the readily available facility-approved agent: Interpretive statement 2: Contaminated disposable items used in patient care should be discarded in leak-proof, tear-resistant containers.
Rationale: Contaminated, disposable items used in patient care should be placed in leak-proof, tear-resistant containers to prevent exposure of personnel to items potentially contaminated with infectious pathogenic microorganisms and to prevent contamination of the surgical en~ironment.~ Interpretive statement 3: Contaminated items should be handled using protective barriers.
Rationale: It is unknown which patients may harbor bloodborne pathogens. Use of personal protective equipment (PPE) protects health care workers from direct exposure to potentially infectious pathogenic microorganisms.8 Interpretive statement 4: All blood, tissue, and body-fluid specimens should be placed in leak-proof containers for health care workers' protection. The exterior surfaces of specimen containers received from the surgical field should be cleaned with a facility-approved agent before leaving the surgical environment.
Rationale: Inanimate objects (eg, laboratory slips, x-rays,
Contamination of inanimate objects that leave the OR should be prevented. RECOMMENDED PRACTICE 111
After each surgical procedure, a visibly clean environment should be reestablished. Disposable items should be disposed of according to local, state, and federal regulations and in accordance to the AORN recommended practices for environmental responsibility in the practice setting. Reusable items should be processed according to the policies and procedures at the surgical practice setting. Interpretive statement I : Disposable items that are so grossly contaminated with blood and tissue that they would produce dripping upon compression should be placed in closable, leak-proof containers or bags that are color coded, labeled, or tagged for easy identification as infectious waste. Items that are not dripping upon compression are considered noninfectious and should be placed in separate receptacles. These containers should be transported in closed, washable carts or vehicles.
Rationale: Contaminated disposable items are placed in leak-proof containers to prevent exposure of personnel to blood, tissue or body fluids and to prevent contamination of the environment.1° Enclosure in leak-proof and color-coded or labeled bags identifies the presence of items potentially contaminated with infectious pathogenic microorganisms, prevents exposure of personnel to infectious waste, and prevents contamination of the environment."
Discussion: Disposable items may include gowns and gloves; procedural linens; suction tubing, liners, and canisters; and opened and used supplies. Interpretive statement 2: Reusable items that are so grossly contaminated with blood and tissue that they would produce dripping upon compression should be placed in closable, leak-proof containers or bags that are color coded, tagged, or labeled as infectious waste. Reusable items that are not dripping upon compression are considered noninfectious and should be place in separate receptacles. These containers should be transported in closed, washable carts or vehicles.
612 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
Rationale:
with patients blood, tissue, and body fluids.17
Contaminated reusable items are placed in leakproof containers to prevent exposure of personnel to blood, tissue and or body fluids and to prevent contamination of the environment.l’ Enclosure in leak-proof and color-coded or labeled bags identifies the presence of items potentially contaminated with infectious pathogenic microorganisms, prevents exposure of personnel to infectious waste, and prevents contamination of the environment.’?
Discussion: In addition to equipment and furniture, walls, doors, and surgical lights should be spot-cleaned if soiled with blood, tissue, or body fluids. Interpretive statement 7: Mechanical friction should be used while cleaning.
Rationale:
Discussion: Reusable items may include procedural linens, gowns, and other items. Interpretive statement 3: All disposable sharps (eg, needles, scalpels, electrosurgical tips, pins) are considered infectious waste and should be placed in special puncture-resistant containers that are labeled as containing biohazardous material.
Effectiveness of the cleaning depends on the use of scrubbing action.IX Interpretive statement 8: Patient transport vehicles, including straps and attachments, should be cleaned with a facilityapproved cleaning agent.
Rationale: Transport vehicles are considered contaminated through patient contact.19 Interpretive statement 9: Visibly soiled areas on the floors should be cleaned using a facility-approved agent.
Rationale:
Rationale:
Puncture wounds from used sharp items expose personnel to potentially infectious pathogenic microorganisms. I 4 Interpretive statement 4: Until used surgical instruments, basins, trays, and other items are decontaminated, they should be handled only by health care workers wearing PPE.
Floor cleaning removes soil, organic debris, and dust.20
Discussion:
Rationale: Use of PPE reduces health care workers’ risk of exposure to blood or other potentially infectious pathogenic microorganisms when personnel are handling used surgical items.I5 Interpretive statement 5: If reusable suction tubing and canisters are used, they should be carefully emptied, cleaned, and disinfected by personnel wearing PPE.
Rationale: Any item that has been in contact with blood, tissue, or body fluids potentially is contaminated with infectious pathogenic microorganisrns.l6 Interpretive statement 6: Equipment and furniture that are visibly soiled should be cleaned with a facility-approved agent at the end of each surgical procedure. Anesthesia equipment should be cleaned according to the AORN “Recommended practices for anesthesia equipment, cleaning and processing.”
Rationale: Equipment and furniture used for surgical procedures are considered contaminated through contact
For end-of-case cleaning, it is only necessary to clean a 3- to 4-ft perimeter around the surgical field when it is visibly soiled. The area cleaned is extended as necessary to adjacent contaminated areas. For terminal daily cleaning, the entire floor is cleaned.*I There are no data to support cleaning the entire floor after each procedure. RECOMMENDEDPRACTICE W
Surgical procedure rooms and scrub/utility areas should be terminally cleaned daily. Interpretive statement I : Mechanical friction and use of a facilityapproved agent are used to clean equipment and areas that should include, but are not limited to, surgical lights and external tracks; fixed and ceiling-mounted equipment; all furniture and equipment, including wheels and casters; hallways and floors; handles of cabinets and push plates; ventilation faceplates; horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving); substerile areas; scrub/utility areas; and scrub sinks.
613 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
ability and serve as operational guidelines. The AORN recommended practices that deal with environmental cleaning should be consulted when developing those policies and procedures. An introduction to and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient outcomes. Policies and procedures also assist in the development of continuous quality assessment/ improvement activities.
Rationale: Terminal cleaning in the surgical practice setting reduces the number of microorganisms, dust, and organic debris present in the surgical environment.** Interpretive statement 2: Refillable liquid soap dispensers should be disassembled and cleaned before being filled with fresh soap solutions.
Rationale: Liquid soap dispensers can become contaminated and serve as reservoirs for micro~rganisms.~~ Interpretive statement 3: Cleaning equipment should be disassembled, cleaned with a facility-approved agent, and dried before storage.
GLOSSARY
Cleaning: The process by which any type of soil, including organic material, is removed. Cleaning is accomplished with detergent, water, and scrubbing action. Confine and contain: A principle that recomRationale: Equipment is cleaned to prevent growth of mends prompt cleanup of items contaminated with microorganisms during storage and to prevent subse- blood, tissue, or body fluids. Contaminated: The presence of potentially quent contamination of the surgical practice setting.24 infectious pathogenic microorganisms on animate or inanimate objects. RECOMMENDED PRACTICE V All areas and equipment in the surgical practice Decontamination: A process that removes consetting should be cleaned according to an estab- taminating infectious agents and renders reusable lished schedule. medical products safe for handling. Interpretive statement 1: Disinfection: A process that kills most forms of Areas and equipment to be cleaned should microorganisms on inanimate surfaces. include, but are not limited to, End-of-procedure cleaning: Cleaning that is perducts and filters; formed at the end of one surgical procedure before the air-conditioning equipment; start of another surgical procedure in the same room. return ventilation and heating grills; Exogenous: From a source other than the recessed ceiling tracks (eg, overhead lighting patient (eg, personnel, equipment, the environment, instruments, supplies). tracks); closets, cabinets, and shelves; Facility-approved agent: A microorganism sterilizers, warming cabinets, refrigerators, and killing agent registered with the US Environmental Protection agency (EPA). The EPA classifies germiice machines; cides as sporicides, general disinfectants, hospital walls and ceilings; and offices, lounges, and locker rooms. disinfectants, detergents, sanitizers, and others. Rationale: High-level disinfection: A process that kills all A clean environment will reduce the number of microorganisms with the exception of high numbers of bacterial spores. microorganisms present.25 Intermediate-level disinfection: A process that kills Mycohacterium tuberculosis, vegetative bacteRECOMMENDED PRACTICE VI Policies and procedures for environmental clean- ria, most viruses, and most fungi but does not necesing should be written, reviewed annually, and sarily kill bacterial spores. Low-level disinfection: A process that kills readily available within surgical practice settings. most bacteria and some viruses and fungi but cannot Discussion: These recommended practices should be used as be relied on to kill resistant microorganisms such as guidelines for the development of policies and proce- Mycobacterium tuberculosis or bacterial spores. dures within surgical practice settings. Policies and proOrganic debris: Blood, tissue, and body fluids. cedures establish authority, responsibility, and accountPersonal protective equipment: Specialized 614 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
equipment or clothing used by health care workers to protect themselves from direct exposures to patients’ blood, tissue, or body fluids. Personal protective equipment may include gloves, gowns, fluid-resistant aprons, head and foot coverings, face shields or masks, eye protection, and ventilation devices (eg, mouth pieces, respirator bags, pocket masks). Terminal cleaning: Cleaning that is performed at the completion of surgical practice settings’ daily surgery schedules. Terminal cleaning is performed in surgical procedure rooms and scrub/utility areas, NOTES I . W A Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed (Philadelphia: J B Lippencott Co, 1984) 11; M H Meeker, J C Rothrock, Alexander’s Care cfthe Patient in Surgery, 10th ed (St Louis: Mosby Year Book, Inc, 1995) 92-93. 2. L. Revell, “Monitoring and controlling the environment,” in Perioperative Nursing Practice, ed M Phippen, M Papmier Wells (Philadelphia: W B Saunders Co, 1994) 253. 3. P Wells, “Confine and contain approach to OR cleanup,” AORN Journal 25 (January 1977) 6 1-62. 4. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 28 1. 5. US Department of Health and Human Services, Guidelinesfor Prevention if Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers (Atlanta: Centers for Disease Control, February 1989) 40,4 1 ; “Occupational exposure to bloodbome pathogens; Final rule,” Federal Register 56 (Dec 6, 1991) 64177. 6. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Cure and Public-Safety Workers,40. 7. Federal Register, 64178.
which include, but are not limited to, surgical lights and external tracks, fixed and ceiling-mounted equipment, all furniture (including wheels and casters), equipment, handles of cabinets and push plates, ventilation faceplates, horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving), the entire floor, kick buckets, and scrub sinks. Used items: Items that are opened for a surgical procedure that may or may not have come in contact with a patient’s blood, tissue, or body fluids during surgery. A
8. Ibid, 64177; US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1,32. 9. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 37. 10. “Occupational exposure to bloodbome pathogens; Final rule,” 64178. 1 I . Ibid. 12. Ibid. 13. Ibid. 14. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Puhlic-Safety Workers, 3 1 37. 15. “Occupational exposure to bloodborne pathogens; Final rule,” 64177. 16. L K Groah, Operating Room Nursing: Perioperative Practice (Norwalk, Conn: Appleton & Lange, 1996) 151; US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1. 17. Groah, Operating Room Nursing: Perioperative Practice, 160; R E Condon, E J Quebbeman, “Prepar-
615 AORN JOURNAL
ing the operating room,” in Care of the Surgical Patient, vol2, eds D W Wilmore et a1 (New York: Scientific American, Inc, 1988) 6. 18. L J Atkinson, M L Kohn, eds, Berry and Kohn’s Introduction to Operating Room Technique, seventh ed (New York: McGraw-Hill, 1992) 232. 19. Groah, Operating Room Nursing Perioperative Practice, 161; Condon, Quebbman, “Preparing the operating room,” 6. 20. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, I 12; Groah, Operating Room Nursing: Perioperative Practice, 150. 2 1. Groah, Operating Room Nursing: Perioperative Practice, 159161; Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 114. 22. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 281; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 10th ed, 92-93. 23. J S Gamer, M S Favero, “Guidelines for handwashing and hospital environmental control, 1985,” publication no 544436/24441 (Washington, DC: US Government Printing Office, 1985) 8. 24. Groah, Operating Room Nursing: Perioperative Practice. 161. 25. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 28 I.
Recommended Practices for Environmental Cleaning in the Surgical Practice Setting
T
he following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were available in February 1996 as proposed recommended practices through the AORN fax on demand number for comments by members and others. They are effective January 1, 1997. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians’ oftices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where surgery may be performed. Purpose. These recommended practices provide guidelines for environmental cleaning (previously titled “Recommended practices for sanitation in the surgical practice setting”). These practices should provide a clean environment for surgical patients and be carried out in a manner that minimizes health care workers’ and patients’ exposures to potentially infectious microorganisms. A basic premise of these recommended practices is that all surgical patients are considered potentially infected with bloodborne pathogens. All surgical procedures, therefore, are considered contaminated, and the same environmental cleaning protocols should be implemented for all surgical procedures. RECOMMENDED PRACTICE I
Patients should be provided a safe, visibly clean environment. Interpretive statement I :
Cleaning should be performed on a scheduled basis. Rationale: Exogenous microorganisms can contaminate ORs in surgical practice settings. Cleaning reduces the amount of dust and organic debris in surgical environments. I Discussion: Environmental cleaning measures are required before, during, and after each surgical procedure and at the end of each day. Environmental cleaning is a team effort by surgical personnel (eg, nurses, surgical technologists, anesthesia care providers, surgeons, OR assistants) and environmental services personnel. The ultimate responsibility for ensuring clean surgical environments rests with perioperative nurses. Administrative personnel must ensure that environmental cleaning practices comply with the standards established for the practice setting.2 Interpretive statement 2: All horizontal surfaces within the OR (eg, fumiture, surgical lights, equipment) should be damp dusted before the first scheduled surgical procedure of the day with a clean, lint-free cloth moistened with a facility-approved agent. Rationale: Dust and lint are deposited on horizontal surfaces in surgical practice settings. Proper cleaning of these surfaces will help reduce airborne contaminants that may travel on dust and lint.3 Interpretive statement 3: Preparation of the ORs should include visual inspections for cleanliness before case carts, supplies, and instrument sets are brought into the ORs. Rationale: Although it is difficult to define the level of contamination necessary to increase surgical wound infection rates, a clean surgical environment will reduce the number of microbial flora p r e ~ e n t . ~ Discussion: For the second-scheduled and subsequent surgical
611 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
procedures, in-between case cleaning is performed. Equipment from areas outside the OR should be damp dusted before it is brought into the OR.
patient charts) contaminated with blood, tissue, or body fluids may expose health care workers to bloodborne pathogens?
Discussion: RECOMMENDED PRACTICE II
During surgical procedures, contamination should be confined and contained within the immediate vicinity of the surgical field as much as possible. Interpretive statement I : Accidental spills of contaminated debris (eg, blood, tissue, body fluids) in areas outside the surgical field should be cleaned as promptly as possible.
Rationale: Prompt cleanup of potentially infectious pathogenic microorganisms using a lint-free cloth saturated with a facility-approved agent helps maintain a safe, clean surgical en~ironment.~
Discussion: If bleach is used for dismfection, medical devices may become damaged. It is preferable, therefore, to use the readily available facility-approved agent: Interpretive statement 2: Contaminated disposable items used in patient care should be discarded in leak-proof, tear-resistant containers.
Rationale: Contaminated, disposable items used in patient care should be placed in leak-proof, tear-resistant containers to prevent exposure of personnel to items potentially contaminated with infectious pathogenic microorganisms and to prevent contamination of the surgical en~ironment.~ Interpretive statement 3: Contaminated items should be handled using protective barriers.
Rationale: It is unknown which patients may harbor bloodborne pathogens. Use of personal protective equipment (PPE) protects health care workers from direct exposure to potentially infectious pathogenic microorganisms.8 Interpretive statement 4: All blood, tissue, and body-fluid specimens should be placed in leak-proof containers for health care workers' protection. The exterior surfaces of specimen containers received from the surgical field should be cleaned with a facility-approved agent before leaving the surgical environment.
Rationale: Inanimate objects (eg, laboratory slips, x-rays,
Contamination of inanimate objects that leave the OR should be prevented. RECOMMENDED PRACTICE 111
After each surgical procedure, a visibly clean environment should be reestablished. Disposable items should be disposed of according to local, state, and federal regulations and in accordance to the AORN recommended practices for environmental responsibility in the practice setting. Reusable items should be processed according to the policies and procedures at the surgical practice setting. Interpretive statement I : Disposable items that are so grossly contaminated with blood and tissue that they would produce dripping upon compression should be placed in closable, leak-proof containers or bags that are color coded, labeled, or tagged for easy identification as infectious waste. Items that are not dripping upon compression are considered noninfectious and should be placed in separate receptacles. These containers should be transported in closed, washable carts or vehicles.
Rationale: Contaminated disposable items are placed in leak-proof containers to prevent exposure of personnel to blood, tissue or body fluids and to prevent contamination of the environment.1° Enclosure in leak-proof and color-coded or labeled bags identifies the presence of items potentially contaminated with infectious pathogenic microorganisms, prevents exposure of personnel to infectious waste, and prevents contamination of the environment."
Discussion: Disposable items may include gowns and gloves; procedural linens; suction tubing, liners, and canisters; and opened and used supplies. Interpretive statement 2: Reusable items that are so grossly contaminated with blood and tissue that they would produce dripping upon compression should be placed in closable, leak-proof containers or bags that are color coded, tagged, or labeled as infectious waste. Reusable items that are not dripping upon compression are considered noninfectious and should be place in separate receptacles. These containers should be transported in closed, washable carts or vehicles.
612 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
Rationale:
with patients blood, tissue, and body fluids.17
Contaminated reusable items are placed in leakproof containers to prevent exposure of personnel to blood, tissue and or body fluids and to prevent contamination of the environment.l’ Enclosure in leak-proof and color-coded or labeled bags identifies the presence of items potentially contaminated with infectious pathogenic microorganisms, prevents exposure of personnel to infectious waste, and prevents contamination of the environment.’?
Discussion: In addition to equipment and furniture, walls, doors, and surgical lights should be spot-cleaned if soiled with blood, tissue, or body fluids. Interpretive statement 7: Mechanical friction should be used while cleaning.
Rationale:
Discussion: Reusable items may include procedural linens, gowns, and other items. Interpretive statement 3: All disposable sharps (eg, needles, scalpels, electrosurgical tips, pins) are considered infectious waste and should be placed in special puncture-resistant containers that are labeled as containing biohazardous material.
Effectiveness of the cleaning depends on the use of scrubbing action.IX Interpretive statement 8: Patient transport vehicles, including straps and attachments, should be cleaned with a facilityapproved cleaning agent.
Rationale: Transport vehicles are considered contaminated through patient contact.19 Interpretive statement 9: Visibly soiled areas on the floors should be cleaned using a facility-approved agent.
Rationale:
Rationale:
Puncture wounds from used sharp items expose personnel to potentially infectious pathogenic microorganisms. I 4 Interpretive statement 4: Until used surgical instruments, basins, trays, and other items are decontaminated, they should be handled only by health care workers wearing PPE.
Floor cleaning removes soil, organic debris, and dust.20
Discussion:
Rationale: Use of PPE reduces health care workers’ risk of exposure to blood or other potentially infectious pathogenic microorganisms when personnel are handling used surgical items.I5 Interpretive statement 5: If reusable suction tubing and canisters are used, they should be carefully emptied, cleaned, and disinfected by personnel wearing PPE.
Rationale: Any item that has been in contact with blood, tissue, or body fluids potentially is contaminated with infectious pathogenic microorganisrns.l6 Interpretive statement 6: Equipment and furniture that are visibly soiled should be cleaned with a facility-approved agent at the end of each surgical procedure. Anesthesia equipment should be cleaned according to the AORN “Recommended practices for anesthesia equipment, cleaning and processing.”
Rationale: Equipment and furniture used for surgical procedures are considered contaminated through contact
For end-of-case cleaning, it is only necessary to clean a 3- to 4-ft perimeter around the surgical field when it is visibly soiled. The area cleaned is extended as necessary to adjacent contaminated areas. For terminal daily cleaning, the entire floor is cleaned.*I There are no data to support cleaning the entire floor after each procedure. RECOMMENDEDPRACTICE W
Surgical procedure rooms and scrub/utility areas should be terminally cleaned daily. Interpretive statement I : Mechanical friction and use of a facilityapproved agent are used to clean equipment and areas that should include, but are not limited to, surgical lights and external tracks; fixed and ceiling-mounted equipment; all furniture and equipment, including wheels and casters; hallways and floors; handles of cabinets and push plates; ventilation faceplates; horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving); substerile areas; scrub/utility areas; and scrub sinks.
613 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
ability and serve as operational guidelines. The AORN recommended practices that deal with environmental cleaning should be consulted when developing those policies and procedures. An introduction to and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient outcomes. Policies and procedures also assist in the development of continuous quality assessment/ improvement activities.
Rationale: Terminal cleaning in the surgical practice setting reduces the number of microorganisms, dust, and organic debris present in the surgical environment.** Interpretive statement 2: Refillable liquid soap dispensers should be disassembled and cleaned before being filled with fresh soap solutions.
Rationale: Liquid soap dispensers can become contaminated and serve as reservoirs for micro~rganisms.~~ Interpretive statement 3: Cleaning equipment should be disassembled, cleaned with a facility-approved agent, and dried before storage.
GLOSSARY
Cleaning: The process by which any type of soil, including organic material, is removed. Cleaning is accomplished with detergent, water, and scrubbing action. Confine and contain: A principle that recomRationale: Equipment is cleaned to prevent growth of mends prompt cleanup of items contaminated with microorganisms during storage and to prevent subse- blood, tissue, or body fluids. Contaminated: The presence of potentially quent contamination of the surgical practice setting.24 infectious pathogenic microorganisms on animate or inanimate objects. RECOMMENDED PRACTICE V All areas and equipment in the surgical practice Decontamination: A process that removes consetting should be cleaned according to an estab- taminating infectious agents and renders reusable lished schedule. medical products safe for handling. Interpretive statement 1: Disinfection: A process that kills most forms of Areas and equipment to be cleaned should microorganisms on inanimate surfaces. include, but are not limited to, End-of-procedure cleaning: Cleaning that is perducts and filters; formed at the end of one surgical procedure before the air-conditioning equipment; start of another surgical procedure in the same room. return ventilation and heating grills; Exogenous: From a source other than the recessed ceiling tracks (eg, overhead lighting patient (eg, personnel, equipment, the environment, instruments, supplies). tracks); closets, cabinets, and shelves; Facility-approved agent: A microorganism sterilizers, warming cabinets, refrigerators, and killing agent registered with the US Environmental Protection agency (EPA). The EPA classifies germiice machines; cides as sporicides, general disinfectants, hospital walls and ceilings; and offices, lounges, and locker rooms. disinfectants, detergents, sanitizers, and others. Rationale: High-level disinfection: A process that kills all A clean environment will reduce the number of microorganisms with the exception of high numbers of bacterial spores. microorganisms present.25 Intermediate-level disinfection: A process that kills Mycohacterium tuberculosis, vegetative bacteRECOMMENDED PRACTICE VI Policies and procedures for environmental clean- ria, most viruses, and most fungi but does not necesing should be written, reviewed annually, and sarily kill bacterial spores. Low-level disinfection: A process that kills readily available within surgical practice settings. most bacteria and some viruses and fungi but cannot Discussion: These recommended practices should be used as be relied on to kill resistant microorganisms such as guidelines for the development of policies and proce- Mycobacterium tuberculosis or bacterial spores. dures within surgical practice settings. Policies and proOrganic debris: Blood, tissue, and body fluids. cedures establish authority, responsibility, and accountPersonal protective equipment: Specialized 614 AORN JOURNAL
OCTOBER 1996, VOL 64,NO 4
equipment or clothing used by health care workers to protect themselves from direct exposures to patients’ blood, tissue, or body fluids. Personal protective equipment may include gloves, gowns, fluid-resistant aprons, head and foot coverings, face shields or masks, eye protection, and ventilation devices (eg, mouth pieces, respirator bags, pocket masks). Terminal cleaning: Cleaning that is performed at the completion of surgical practice settings’ daily surgery schedules. Terminal cleaning is performed in surgical procedure rooms and scrub/utility areas, NOTES I . W A Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed (Philadelphia: J B Lippencott Co, 1984) 11; M H Meeker, J C Rothrock, Alexander’s Care cfthe Patient in Surgery, 10th ed (St Louis: Mosby Year Book, Inc, 1995) 92-93. 2. L. Revell, “Monitoring and controlling the environment,” in Perioperative Nursing Practice, ed M Phippen, M Papmier Wells (Philadelphia: W B Saunders Co, 1994) 253. 3. P Wells, “Confine and contain approach to OR cleanup,” AORN Journal 25 (January 1977) 6 1-62. 4. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 28 1. 5. US Department of Health and Human Services, Guidelinesfor Prevention if Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers (Atlanta: Centers for Disease Control, February 1989) 40,4 1 ; “Occupational exposure to bloodbome pathogens; Final rule,” Federal Register 56 (Dec 6, 1991) 64177. 6. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Cure and Public-Safety Workers,40. 7. Federal Register, 64178.
which include, but are not limited to, surgical lights and external tracks, fixed and ceiling-mounted equipment, all furniture (including wheels and casters), equipment, handles of cabinets and push plates, ventilation faceplates, horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving), the entire floor, kick buckets, and scrub sinks. Used items: Items that are opened for a surgical procedure that may or may not have come in contact with a patient’s blood, tissue, or body fluids during surgery. A
8. Ibid, 64177; US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1,32. 9. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 37. 10. “Occupational exposure to bloodbome pathogens; Final rule,” 64178. 1 I . Ibid. 12. Ibid. 13. Ibid. 14. US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Puhlic-Safety Workers, 3 1 37. 15. “Occupational exposure to bloodborne pathogens; Final rule,” 64177. 16. L K Groah, Operating Room Nursing: Perioperative Practice (Norwalk, Conn: Appleton & Lange, 1996) 151; US Department of Health and Human Services, Guidelinesfor Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1. 17. Groah, Operating Room Nursing: Perioperative Practice, 160; R E Condon, E J Quebbeman, “Prepar-
615 AORN JOURNAL
ing the operating room,” in Care of the Surgical Patient, vol2, eds D W Wilmore et a1 (New York: Scientific American, Inc, 1988) 6. 18. L J Atkinson, M L Kohn, eds, Berry and Kohn’s Introduction to Operating Room Technique, seventh ed (New York: McGraw-Hill, 1992) 232. 19. Groah, Operating Room Nursing Perioperative Practice, 161; Condon, Quebbman, “Preparing the operating room,” 6. 20. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, I 12; Groah, Operating Room Nursing: Perioperative Practice, 150. 2 1. Groah, Operating Room Nursing: Perioperative Practice, 159161; Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 114. 22. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 281; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 10th ed, 92-93. 23. J S Gamer, M S Favero, “Guidelines for handwashing and hospital environmental control, 1985,” publication no 544436/24441 (Washington, DC: US Government Printing Office, 1985) 8. 24. Groah, Operating Room Nursing: Perioperative Practice. 161. 25. Altemeier et al, eds, Manual on Control of Infection in Surgical Patients, second ed, 28 I.