Cleaning and Disinfection of Operating Rooms A

Improving the Operating Room
Environment to Drive Down
Infections
Prepared by:
Sarah Simmons and Maria Rodriguez
MPH CIC
RN BSN CIC
Activity Disclosures
 Requirements for successful completion
Attendance of entire presentation
Completion/submission of Evaluation
Once successful completion has been verified, a “Certificate of Successful
Completion” will be rewarded for 1 Contact Hour.
This continuing nursing education activity was approved by the Texas Nurses
Association, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.

Conflicts of interest - No conflicts of interest exist
 No Sponsorship or commercial support was provided
 No endorsement of products will be done
Purpose Of Activity
The purpose of this education activity is to enhance the knowledge
base and skills of Registered Nurses working as infection prevention
nurses and surgical nurses in the area of hospital associated
infections by addressing how the environment can be a contributor
and by reviewing current environmental disinfection options in an
effort to decrease risk of an infection.
This will result in improved attention to cleaning and a new
perspective for adding environmental disinfection in the operating
room cleaning process which will promote safer patient
environments as evidenced by Evaluation results and/or Comments.
Learning Objectives
 Define the role the environment plays in postop
surgical site infections
 Describe the impact of hospital associated infections
(HAIs) on patient outcomes and hospitals
 Discuss environmental disinfection
 Describe two types of environmental disinfection
Hospital Acquired Infections
 1.7 million hospital acquired infections (HAIs) annually
 99,000 of these infections lead to death
 8,000 deaths related to surgical site infections
Consequences of SSI
 Doubles the risk of death after surgery
 Five-fold increased risk for readmission
 60% more likely to require ICU care
 Length of stay increases 6 days
The Cost of SSIs
 Increased cost of care
Total Knee/Total Hip Replacement (TKR/THR): $17,708
Coronary Artery Bypass Graft Risk 1 (CABG) ,
C-section, Bariatrics, Hysterectomy: $20,000
Coronary Artery Bypass Graft Risk 2 ( CABG): $31,597
 Mandatory reporting of infections
 HCAHPS - Hospital Consumer Assessment of Healthcare
Providers and Systems
 Liability
Mandatory Public Reporting
CMS – Center for Medicare and Medicaid Services
For payment from CMS, hospitals are required to report
data about certain infections to the Centers for Disease
Control and Prevention’s (CDC) National Healthcare Safety
Network (NHSN).
Current CMS reporting through NHSN are central lineassociated bloodstream infections, catheter-associated
urinary tract infections, surgical site infections and
healthcare worker influenza vaccination coverage. Future
reporting will include multidrug-resistant organisms and
more.
The public reporting of these data is part of a movement
by the Department of Health and Human Services to make
healthcare safer.
http://www.medicare.gov/hospitalcompare/Data/Healthcare-Associated-Infections.html
State HAI Reporting Laws
27 state laws require public reporting of
hospital-acquired infection rates.
2 state laws allow confidential reporting of
infection rates to state agencies (NE NV).
3 states have voluntary public reporting of
infection information (AR, AZ, WI).
5 states have study laws on public reporting
(AK, GA, IN, NM, NC).
13 states and D.C. have no laws on public
reporting of hospital infections, though
some have bills pending on the matter
http://www.health.ny.gov/statistics/facilities/hospital/h
ospital_acquired_infections/2011/docs/hospital_acq
uired_infection.pdf
Permission received to use legislative map from APIC website-http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/Advocacy_Updates/Static_map_-_HAI_revised_7-6-11.gif
Federal regulations are not reflected on the map, even though the national regulations require that hospitals in all states that receive Medicare
reimbursement now have Hospital Acquired Infection (HAI) reporting requirements whether or not state law requires it.
.
CDC’s National Healthcare Safety
Network (NHSN)
National Health Safety Network -NHSN
Conduit for facilities to comply with Centers for Medicare and Medicaid
Services (CMS) infection reporting requirements.
Provides healthcare facilities data collection abilities in order to
see their data in real-time and to share with facility leaders and
other external partners.
For Patients
Patients can use NHSN data posted publicly on the Hospital Compare site.
Patients are encouraged to visit the website to see how their local facilities
are doing and discuss concerns with their healthcare providers.
Many patients are choosing their hospital after checking the Hospital
Compare website. http://www.cdc.gov/nhsn/about.html
HCAHPS
As of Federal Fiscal Year 2013 (Oct. 1 2012), hospitals are paid on how well
they perform.
Hospitals subject to the Inpatient Prospective Payment System (IPPS)
annual payment update provisions must collect and submit HCAHPS data in
order to receive their full annual payment update. The Hospital Value-Based
Purchasing (Hospital VBP) program links a portion of IPPS hospitals'
payment from CMS to performance on a set of quality measures.
The Hospital VBP Total Performance Score (TPS) for FY 2013 has two
components: the Clinical Process of Care Domain, which accounts for 70% of
the TPS; and the Patient Experience of Care Domain, 30% of the TPS. The
HCAHPS Survey is the basis of the Patient Experience of Care Domain.
The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), further
strengthened the incentive for IPPS hospitals to improve patient
experience of care by providing the public with access to HCAHPS scores on
the Hospital Compare website.
http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html;
http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-Domain.html
HCAHPS cont.
Patient Experience Measures
• Nursing Communication
• Doctor Communication
• Hospital Cleanliness and
Quietness
• Hospital Staff Responsiveness
• Pain Management
• Medicine Communication
• Discharge Information
• Overall Hospital Rating
http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-domain.html
Hospital Compare example
CMS Hospital Compare
Infection Identification--NHSN
Required adherence to the NHSN Surgical Site Infection definitions/criteria
Superficial Incisional SSI:
Infection occurs within 30 days after any NHSN operative procedure and involves only skin and subcutaneous tissue
of the incision and the patient has at least one of the following:
 Purulent drainage from the superficial incision
 Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
 Superficial incision is deliberately opened by a surgeon, and is culture positive or not cultured and at
least one of the following signs and symptoms : Pain/tenderness; Localized swelling; Redness, or Heat.
A culture negative finding does not meet this criterion.
 Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Deep Incisional SSI:
Infection occurs within 30 or 90 days after the NHSN operative procedure and involves deep soft tissues of the
incision (e.g., fascial and muscle layers) and patient has at least one of the following:
 Purulent drainage form the deep incision
 A deep incision that spontaneously dehisces or is deliberately opened by a surgeon and is culture
positive or not cultured and the patient has at least one of the following signs or symptoms: Fever
(>38ºC) or Localized pain or tenderness
 An abscess or other evidence of infection involving the deep incision is found on direct examination,
during invasive procedure, or by histopathologic examination or imaging test.
Diagnosis of a deep incisional SSI by a surgeon or attending physician
Organ/Space SSI:
Infection occurs within 30 or 90 days after the NHSN operative procedure and the incision involves any part of the
body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative
procedure:
 Purulent drainage from a drain that is placed into the organ space
 Organisms isolated from an aseptically obtained culture of fluid/ tissue in the organ/space
 An abscess or other evidence of infection involving the organ/space is found on direct examination,
during invasive procedure, or by histopathologic exam. or imaging test
 Diagnosis of an organ/space SSI by a surgeon or attending physician
AND meets the criteria for a specific infection location
Causes of SSIs
 Bacteria!
 Skin vs. Environment
Common Organisms for SSI
Organism
% of infections reported
Staphylococcus aureus
20%
Coagulase-negative Staphylococci
14%
Enterococcus spp.
12%
Escherichia coli, Pseudomonas aeruginosa
8% each
Enterobacter spp.
7%
Proteus mirabilis, Klebsiella pneumoniae, other
Streptococcus spp.
3% each
Group D Streptococci, Bacteroides fragilis,
other gram positive anaerobes
2% each
The Problem
Known issues with cleaning:
The best cleaning still doesn’t thoroughly clean all
of today’s new types of surfaces
Climbing infection rates
Inadequate staffing
Pressure on housekeeping staff to turn over rooms
quickly
Cleaning Practices
Overall cleaning compliance is only 47%:
 Anesthesia medication cart 38%
 Anesthesia knobs 25%
IV poles 55%
 Bed controls 64%
 Floors 93%
Cleaning Compliance
73% of surfaces positive for bacterial growth after
cleaning, including:
 Pseudomonas spp.
 Enterococcus spp.
 Methicillin-resistant Staphylococcus aureus (MRSA)
 Acinetobacter spp.
 Klebsiella pneumoniae
 Escherichia coli
Environmental Survival
Bacteria
Survival Time
Acinetobacter baumannii
26 days
Pseudomonas aeruginosa
5 weeks
Vancomycin resistant Enterococcus
(VRE)
4 months
Clostridium difficile
5 months
Methicillin-resistant Staphylococcus
aureus (MRSA)
7 months
Escherichia coli
16 months
OR Environmental cleaning - an important strategy in
preventing infection.“Research shows that ORs may
not be as clean as they could or should be…”
Amber Wood, AORN Perioperative Nursing Specialist MSN, RN, CNOR, CIC, CPN
.
 Research linking the role of the environment to the development of
health care associated infections and transmission of multi drugresistant organisms is causing Perioperative leaders to actively partner
with environmental services and infection prevention colleagues to
help identify cleaning strategies.
 Wood cites a 2011 study in which researchers observed a mean
cleaning rate of 25% for objects monitored in the operating room
setting in 6 acute care hospitals. “It’s studies like this that show us
the concept of clean is still evolving in the perioperative setting.”
(Source – Perioperative Insider Weekly Newsletter 5 High Touch Surfaces to Clean Better July 10 2013)
OR Environmental cleaning cont.
 Wood’s concern:
“Organisms such as MRSA(Methicillin-resistant Staphylococcus aureus )
and CRE(carbapenem-resistant Enterobacteriaceae) are colonized on a
patient and health care providers are touching a patient and then
touching the environment … creating reservoirs of these pathogens.”
 Wood advises, “Identifying high-touch objects in each procedural setting
and thoroughly cleaning these areas in collaboration with environmental
services can help decrease contamination and transmission.”
 Five high-touch objects common in all procedural settings:
1. Anesthesia cart and equipment (including IV pole)
2. Anesthesia machine
3. Patient
4. OR bed
5. Table strap
6. monitors
(Source – Perioperative Insider Weekly Newsletter 5 High Touch Surfaces to Clean Better July 10 2013)
Anesthesia Equipment
 Workspace becomes highly contaminated during
cases with bacteria such as:
 Enterococcus spp.
 Micrococcus spp.
 Staphylococcus spp.
 MRSA
 VRE
 Bacteria recovered from IV administration sets after
surgery
Improper practices can increase a
patient’s risk for acquiring an infection.
http://www.7sbundle.com/uploads/4/6/4/2/4642325/implementing_aorn
_surgical_attire_recommendations_2012.ppt
Are you contributing to your
patient’s risk?
http://www.7sbundle.com/uploads/4/6/4/2/4642325/implem
enting_aorn_surgical_attire_recommendations_2012.ppt
Operating Room Terminal Cleaning
Quality Assurance Checklist
UNIT/ROOM:
DATE/TIME:
Technician: Check each number when complete/cross out non applicable areas.
3
Gather equipment. Wash hands and put on appropriate personal
protective equipment. Leave cleaning cart/supplies outside OR.
Keep OR door closed while cleaning.
Collect all linen, dispose of in appropriate hamper bags for the
laundry. Dispose of linen from open packs, whether soiled or not,
in the proper linen hamper. If linen is wet or heavily soiled, double
the bag.
Discard any soiled sponges, suction canisters, tubing, and other
waste as infectious waste as per local SOP.
4
Gather all litter from floor and deposit in waste containers.
5
Remove all trash/linen from room.
6
Clean/Disinfect waste can and replace bag.
7
Clean/Disinfect hampers and replace linen hamper bags.
8
9
Clean/ Disinfect OR Lights and high touch areas. Clean/disinfect
fixed & ceiling-mounted equipment to include hoses, cabinets and
shelves. Clean/disinfect surgical lights & external tracks. Start at
the highest point and work down. Wipe down high touch areas
with disinfectant.
Clean/ Disinfect equipment. Clean/disinfect horizontal surfaces
(counter tops, open shelves). Damp wipe all furniture, back table,
Mayo stands, ring stands, X-ray view boxes, suction bovie, kick
buckets, and scrub sinks.
10
Damp wipe the operating table with disinfectant solution,
removing all blood and soiled materials. Remove all pads, and
disinfect all surfaces, pads and table stand down to the casters.
Remake the operating table. Let disinfectant stand for 10 minutes
of contact time.
11
Clean/disinfect handles of cabinets, push plates, telephones, light
switches and all glass surfaces
12
Mop ceiling surfaces and walls with micro fiber mop.
Clean/disinfect ventilation faceplates/grills. Dust Vents.
13
Low dust ledges, counter tops, hard surface floors, & baseboards.
14
Clean/disinfect utility areas.
15
Clean/disinfect sub sterile areas.
16
Clean storage & supply areas.
17
Clean/Disinfect OR Floor. Move all equipment and furniture to one
side of room. Flood floor w/ disinfectant solution, machine scrub &
pick up solution w/ wet-vac. Roll casters and wheels of furniture
through disinfectant solution on the floor. Move all
equipment/furniture and mop other side of room.
1
2
18
19
20
21
22
Comments
Return all furniture & equipment when floor is dry.
Replace empty soap dispensers & waterless-hand sanitizers, clean
foot pump & tubing.
Review checklist to ensure all areas have been cleaned.
Notify circulator that OR is ready.
Remove all personal protective equipment and thoroughly wash
hands, being careful to avoid self contamination.
Technician Comments/Maintenance Issues:
1. Number of Applicable Items
2. Minus number of Unsatisfactory Items
3. Equals Number of Satisfactory Items
Multiply Line 3 by 100 then divide by Line 1
Total Score for Area
Score
Litigation
“Never Events”
Surgical site infections (SSIs) after coronary artery
bypass graft (CABG), bariatric and orthopedic
procedures
Litigation against facilities
Litigation against staff/physicians
Patients and family members are becoming more
aware of their patient rights.
Enhanced Disinfection Methods
 Hydrogen Peroxide Vapor
 Ultraviolet Germicidal Irradiation
Hydrogen Peroxide Vapor
 Produces and disperses a vapor of hydrogen
peroxide (H2O2)
 Creates oxygen radicals that react with cell walls
 Room must be sealed during the process
O2-
-OH
-OH
-OH
HO2
O2-
HO2
O2-
-OH
HO2
HO2
O2-
Ultraviolet Germicidal Irradiation
(UVGI)
Mercury UV (Hg UV)
Pulsed Xenon (PX-UV)
Continuous Light
Pulsed Light
253.7 nm
200-280 nm
Photodimerization
Photodimerization
Photohydration
Photosplitting
Photocrosslinking
References
 Medicaire/Quality InitiativesPatient Assessment retrieved August 8 2013 from CMS website
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment.html
 Committee to Reduce Infection Deaths. State Laws on Reporting HAIs retrieved Sept. 11 2013 from Hospital Infections
website http://www.hospitalinfection.org/legislation.html
 Hospital Compare retrieved August 8 2013 from Medicaire website
http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
 Hospital Compare Data Patient Experience retrieved August 8 2013 from CMS website
http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-Domain.html
 http://www.cdc.gov/HAI/ssi/ssi.html
 A.Wood. OR Environmental Cleaning- an important strategy in preventing infection. Perioperative Insider Weekly
Newsletter. July 10 2013
 L Munoz-Price, et al. Decreasing Operating Room Environmental Pathogen Contamination through Improved Cleaning
Practice. Infection Control and Hospital Epidemiology. 2012;33(9): 897-904
 W Truscott. Patients, Particles, Pathology and Pathogens: The Infection Connection. Operating Room & Infection
Control. April 2009 Pg 42-50.
 R Loftus, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008;
109(3):399-407.
 C Owens, K Stoessel. Surgical Site Infections: epidemiology, microbiology and prevention. Journal of Hospital Infection.
2008; 70(S2):3-10.
 A Kramer, I Schwebke, G Kampf. How long do nosocomial pathogens persist on inanimate surfaces? A systematic
review. BMC Infectious Diseases 2006, 6:130
 C Edminston, et al. Molecular Epidemiology of Microbial Contamination in the Operating Room Environment: Is there a
risk of infection? Surgery. 2005;138(4):573-582
 To Err is Human: Building a Safer Health System (2000) Institutes of Medicine.
http://www.nap.edu/openbook.php?isbn=0309068371
 A Jawad, H Seifert, A Snelling, J Heritage, P Hawkey. Survival of Acinetobacter baumannii on Dry Surfaces: Comparison
on Outbreak and Sporadic Isolates. J. Clin. Microbiol. July 1998 vol. 36 no. 7 1938-1941
 C Wendt, B Wiesenthal, E Dietz, H Rüden. Survival of Vancomycin-Resistant and Vancomycin-Susceptible Enterococci on
Dry Surfaces. J. Clin. Microbiol. December 1998 vol. 36 no. 12 3734-3736
Thank You
Questions?