Fluid management might not be the worst problem at your surgery center, but it might well be your messiest. "We just dump it down the sink or toilet," says a surgeon. "We have a big, bulky, cumbersome machine that attaches to suction at one end and a big rubber mat at the other," says an OR manager. "Mops, spill kits, suction canisters," says another.

Collecting and disposing of blood and bodily fluids can be simple and straightforward (mops, floor vacs, absorbable pads, solidifying agents) or it can be sophisticated (wall-mounted fluid-evacuation systems with disposable suction canisters, mats and discs that wick the fluid away underfoot while the OR staff works).

To find out how you're keeping your OR floors dry and what you're doing with your treated infectious waste and nontreated liquid waste (yes, you may be able to dispose of both directly into the sewer system), we surveyed a sample of our readers. The 86 responses we received show that while most of you still mop up or solidify and red-bag your fluid waste, several of you have invested in high-tech devices that virtually eliminate spilling, splashing and aerosolization.

"It's dangerous if you have to use canisters and solidifier. Even with personal protective equipment, there's a high potential of overflow and splashing," says Pat Spera, RN, MS, CNOR, CRNFA, the director of clinical services at the Tampa Bay Specialty Surgery Center in Pinellas Park, Fla.

It's a dirty job
It's no secret that staff loathe fluid waste disposal (we heard "gross" and "heavy" more than a couple times) and fear exposure to infectious waste. "I frequently find that staff will procrastinate disposal or leave fluid waste for someone else," says one administrator.

Many of you told us that you wished that OR suites could have floor drains. After all, that would make the fluid - and its attendant problems - disappear. However, the American Institute of Architects' Guidelines for Design and Construction of Hospital and Health Care Facilities says floor drains have been shown to disseminate a heavily contaminated spray during flushing. And unless flushed regularly with large amounts of fluid, drains tend to dry out and let gases, vapors, odors, insects and vermin pass directly into the room.

The appeal of higher-tech equipment is growing, especially among staff who have to handle fluid cleanup. As one OR supervisor puts it, "Everyone hates it. Who would like it?"

Those who have invested in closed suction systems for fluid collection and disposal report a positive staff reception. Alice English, RN, the nursing director of Digestive Health Clinic in Boise, Idaho, is planning to invest in such a system, in large part because her by-the-pound transportation and disposal company has raised its rates 7.5 percent so far this year. Patient volume is up by about one-third, she says. Ms. English figures that 80 percent of her waste is solidified liquid waste, which accounts for 95 percent of the weight. "We found that by putting a capital expense of about $50,000 for equipment and $10,000 for remodel, we could have a return on investment in about 15 months," she says.

An industry source senses a lack of interest in surgical waste disposal on the part of administrators - "until, of course, there is an injury or infection or the inspectors show up. Then administrators show genuine interest in alternate disposal systems."

Beyond surgical waste disposal systems, alternatives to sopping up liquids with mops and towels include a circular disc with suction that users say is effective in pulling up fluid. But one of our panelists notes that it has to be nudged by foot to the wet spot. When everyone is busy with other surgery tasks, the disc can get ignored, she says. And while mats that wick fluids away can keep staff from slipping and contain the fluid until it can be disposed, they can be expensive, going for at least $30, say several administrators.

Bigger fish to fry
Not many of you are staying up at night worrying about fluid management, according to our online survey. Slightly more than 75 percent told us fluid management was no big deal expense-wise. For 71 percent, fluid management and disposal costs less than $25,000 a year. For 18 percent more, the costs were between $25,000 and $50,000.

In terms of gallons of fluid waste a day:

• 44 percent of respondents deal with less than 10 gallons a day;
• 24 percent deal with between 11 and 20 gallons; and
• 9 percent deal with between 21 gallons and 30 gallons of fluid a day.

Nearly 30 percent of our survey respondents reported at least one slip-and-fall accident, though no one reported a serious injury (see "Slip and Fall"). "Every OR I have been in has had a staff fall simply due to the residual wet floors after mopping between cases," says one respondent.

Capital expense
Often how a surgical center handles fluid management depends on how much of a capital expenditure it's willing to make. Many respondents reported that their staff was much happier once they invested in an automated suctioning or vacuuming system. About three-fourths of respondents spent less than $10,000 on capital equipment, but 8 percent spent more than $50,000.

Fluid management equipment can quickly add up. Debbie Runyan, RN, MSA, director of surgical services at Froedtert & Medical College of Wisconsin in Milwaukee, says the Dornoch High Fluid Cart and the accompanying Safety Station that dispose of the waste cost her center almost $31,000. Dick Farr, OPA-C, CASC, director of Outpatient Orthopedic Surgery Center in Statesboro, Ga., says he laid out $27,000 for the Neptune Rover, with its four suction tubes and its 20-liter canister.

Not every center has the volume - in fluid or in patients - to justify a capital purchase and some might not even want to do it anyway. Nancy Underwood, RN, DCNOR, BSS, the director of surgical services at Richardson Regional Medical Center in Richardson, Texas, doesn't think she'll get around to owning a big piece of fluid management equipment any time soon. Bottles of solidifier cost her $3 and she can put sanitized medical fluids in the regular trash.

Varies by procedure
Some procedures draw so little blood and bodily fluid and need so little water for cleaning that staff doesn't really have to worry about fluid management. At Oakview Surgery Center in Rochester, Ind., surgeons mostly do podiatric procedures. With the use of tourniquets, they have very little blood, says Laurence C. Rogers, DPM. Cleanup takes no more than a sponge or a rag. If the rag isn't soaked and no blood is showing, the rag can go right in the trash. Dr. Rogers says his center's podiatric procedures produce a liter of fluid waste at the most, sometimes only 500cc.

At the Institute for Outpatient Surgery in Columbia, Mo., liposuction wastes are sorted into a canister, says administrator Christy Cox, RN. In the tumescent technique, anesthetic liquid is shot into fatty areas. The liposuction cannula then sucks out the hardened fat. Ms. Cox says that material is usually red-bagged. As an additional precaution, the entire OR is coated with virus- and bacteria-killing Virex.

Orthopedic procedures make the most liquid waste since so much water is used to irrigate and inflate the cavity. Joints such as shoulders, knees and elbows bleed a lot, and the surgeons like the wound washed so they can see what they're doing as well as prevent infection at the surgical site. "Some surgeons are messier than others," says Faris Zureikat, MBA, CASC, administrator of the North Texas Surgery Center in Dallas. "You look up 30 liters later, and they're still there. What are they doing, watering the grass?"

Fluid on the floor
Here are thumbnail sketches of some other common methods of fluid management.

• Wet mop. The most prominent method used for fluid management was a wet mop, used in 64 percent of surgery centers, according to our survey. Most centers use mops with a disposable head for OR cleanup. The wet mop is often used with other methods. The area under a wicking mat, for example, is probably mopped after the mat's removal.
• Solidifying agent. Solidifiers are the second most frequent disposal method, chosen by 34 percent of our respondents. This method involves adding a chemical to the liquid waste that turns it into a gel. At the Richardson Regional Medical Center, staff will add a $3 bottle of Isolyzer to 3,000cc of fluid waste, says Ms. Underwood. The chemicals are said to not only physically stabilize biohazardous and infectious wastes, but also to kill pathogens contained in the wastes, so you can dispose of the resulting gel in the regular trash.
• Wicking device. Almost one-fourth of our respondents report using some kind of wicking material to take care of fluid waste. Mr. Zureikat uses a mat that looks like a plastic tablecloth - a non-slip plastic surface with softer material underneath that soaks up the liquid. This method is affordable and, because the liquid is relatively clean and the staff masked and gloved, safe as well, he says. It also helps to reduce slips and falls.
• Vacuum. About 14 percent report using a vacuuming device. Often this involves using wall-mounted suction, though some suction is available that is more mobile, including units that roll on wheels. The suction usually carries the liquid to equipment canisters, where it can be treated and easily disposed of, often emptied directly into the sewer line.

• Suction mat. A variety of mats can be hooked up to suction and thus can pull the liquid out while surgeons are operating. The mats are three about or four feet wide, more than five feet long and disposable. They cost $30 to $50 each, depending on the manufacturer and the contract pricing. Brian Lewis, ORT, case coordinator and first assistant at the Bone and Joint Surgery Center in Franklin, Tenn., helped design a suction mat for Bass Medical, where he is also a consultant. He says the mat holds at least 10 liters of liquid without suction and more when suction is used. Some administrators have balked at the mats that collect and contain fluids because of prices, though Mr. Lewis points out that the disposable mats can cut down turnover time, perhaps recouping their cost.
• Floor disc. Some centers are using small discs attached to suction that can be kicked over to where the spill is. These discs, which are a foot to 18 inches in diameter, can only suck up the area to where they're moved. Some administrators feel that surgery staff has to be so focused on surgery that they can't be expected to move the disc to spills. Others worry about a trip risk. Cory Dorman, RN, OR nurse manager of the Intermountain Surgery Center in Boise, Idaho, finds his center can effectively use the $5 Puddle Guppy for cleanup during his operations. The Puddle Guppy, he says, can be cleaned, but he chooses to use it as a disposable. Mr. Doman says you can use a cleanable aluminum wand to move the disc around the OR floor.
• Towels, blankets. When push comes to shove, surgery staff use whatever's on hand to clean up liquid waste. Blankets and towels can sop up excess liquid and, depending on the operation and your local regulations regarding handling, can often be washed with the regular laundry.

The future
Mr. Dorman has to urge his staff to dispose of fluid waste, or they'll do anything to avoid it. "It's just a nasty job," he says. Mr. Dorman, like many managers, is still in search of a way to make the job more efficient and effective. From our survey, it appears that the suction devices that take waste from the floor right to the sewer line have made life easier for OR staff. In the meantime, surgery centers will continue to do their jobs, messy and otherwise. As one manager puts it: "It's just something that comes with the territory."