BUST THE BUGS It's more like zap the bugs when you set a UV-C-emitting device loose in your OR.

The St. Cloud (Minn.) Surgical Center has a matching set of germ-zapping robots, a girl and a boy. There's "Dora," which stands for Disinfecting Operating Room Apparatus. And "Gus," short for Give Us Sterility. The $100,000 robots, which generate intense pulsed UV light that's said to be 25,000 times brighter than sunlight, get quite a workout in the surgery center.

They're used primarily to decontaminate the surfaces in the 11 ORs, for daily terminal cleaning, after dirty cases — a hernia repair that follows a colonoscopy, for example — and after any procedure involving a patient known to have an infection. One of St. Cloud's surgeons insists that a robot zap his room clean before every total joint case he performs (see "UV Robot Key to Surgery Center Doing Total Joints" on page 38). And at least once a week after hours, they station a robot in just about every room in the surgery center: the equipment room, the substerile room, the garbage room, the fluid suction device docking room, even the restrooms, the waiting room and the staff lounge, says Julie Tonsager, RN, St. Cloud's operating room team leader.

"Patient safety is our top priority," says Ms. Tonsager. "We clean the rooms with traditional cleaning methods, but there are always nooks and crannies that are hard to reach. And the germs are getting tougher, so it was important for us to take the battle against infections to the next level, to ensure our patients receive the best care."

Missed a spot?
Wheeling a germ-zapping robot into the OR before you wheel the patient in is not an indictment against manual cleaning, but an admission that manually applying a liquid disinfectant to the surface with a cloth, wipe or mop is far from foolproof. The problem with manual cleaning is not the efficacy or the agents used — it's about ensuring that adequate formulation, distribution and contact time occurs repeatedly in a busy environment ... and that nothing gets missed, especially with the rise of multi-drug-resistant organisms, says Ms. Tonsager.

"We do our normal cleaning [before we use the robots], but we're all human," she says.

Studies have shown that manual cleaning disinfects only 48% of room surfaces, while UV disinfection can get rid of 99.99% of pathogens. Studies have also shown that environmentally friendly UV light penetrates cell membranes of superbugs, viruses and bacteria, preventing them from replicating or mutating. "At certain wavelengths, UV light will break the molecular bonds in DNA, thereby destroying the organism," William A. Rutala, PhD, MPH, and colleagues conclude in his 2010 research paper, "Room Decontamination with UV Radiation," published in Infection Control and Hospital Epidemiology.

The thing is, with manual cleaning there's no way of knowing when you missed a spot. "When you clean a room and look back, nothing is flashing orange and saying 'you missed this.' You don't know what you missed," says Ms. Tonsager, who calls UV light disinfection "adjunctive."

Some superbugs such as Clostridium difficile are showing resistance to chemical disinfectants, making them even more difficult to eliminate. Others, like CRE, have developed a resistance to antibiotics, making them nearly impossible to treat. When added to routine cleaning, UV light room disinfection systems let you destroy viruses, bacteria and bacterial spores in the patient environment without contact or chemicals. UV light penetrates the cell walls of microorganisms. Their DNA is instantly fused so that they are unable to reproduce or mutate, effectively killing them on surfaces and in the air without contact or chemicals.

Although bleach is routinely used in her ORs, it requires 10 minutes of drying time for adequate sporicidal effect, says Lou Ann Bruno-Murtha, DO, medical director of infection prevention and division chief of infectious diseases for the Cambridge (Mass.) Health Alliance. "UV light is able to penetrate spores that are quite hardy," says Dr. Bruno-Martha. "If a surface is missed, or not wiped properly with chlorine bleach, UV provides another level of security."

Selective use
When doing same-day, elective procedures on healthy patients, it's fair to wonder how germ-zapping robots will impact your turnover times. "Time is a key factor," says Ms. Tonsager. "We like to turn over our operating room in 15 to 20 minutes. In the OR, time is money."

At Cooley Dickinson Hospital in Northampton, Mass., they'd like to run the UV robot after every surgery, but studies show that OR contamination in the room is cumulative over time and increases after the third case. "We're trying to use it at least at that interval," says Joanne Levin, MD, FSHEA, the medical director of the department of infection prevention at Cooley.

The Xenex system that St. Cloud uses takes 5 to 10 minutes on average per room, depending on room size (the robot's UV has a 14-foot radius). Another leading UV disinfection device, Tru-D SmartUVC, short for Total Room Ultraviolet Disinfector, usually takes 30 to 40 minutes. After a manual cleaning, you wheel Tru-D into the center of the OR, and the robot's sensors gauge the size of the room and adjust the dose accordingly, says the company.

All UV systems are not created equal. The Xenex has a shorter cycle time of 5 minutes, but a staff member has to reposition the device after an initial cycle, depending on space and room geometry. With Tru-D, you set it and forget it, but it takes a bit longer. Tru-D can precisely calculate room UVC dose to compensate for room size, shape, color and contents for proper thorough disinfection, even reaching surfaces in the shade or in the shadows, says the company. It can disinfect an entire room, from top to bottom, from a single location so the operator can move onto other tasks during the disinfection process.

UV light can only disinfect what it touches. UV light travels in straight lines, so there's reduced efficacy in areas that are out of the unit's direct line of sight. Having to position a single unit in multiple areas to target several surfaces could add to disinfection times.

Another important distinction between the portable products is how they create UV light. Xenex uses pulsed UV light, while Tru-D and the Clorox Healthcare Optimum-UV System use mercury bulbs to create UV light. Other systems use aerosolized hydrogen peroxide, hydrogen peroxide vapor, cluster ions and ozone gas to target areas your staff might have missed.

Many say UV systems are best suited for terminal cleaning at the end of the surgical schedule, and occasionally after cases involving high-risk patients with microorganisms you don't want subsequent patients exposed to.

BEFORE EVERY TOTAL JOINT CASE
UV Robot Key to Surgery Center Doing Total Joints

The St. Cloud (Minn.) Surgical Center has 2 major milestones it can boast about — being the second-oldest freestanding surgery center in the country and being the first U.S. ASC to use a Xenex germ-zapping robot. Longevity's nice, but a commitment to decontamination and patient safety makes for a better story.

The 11-OR ASC had long been considering bringing a robot on board to tamp down its already-low infection rates, but the $100,000 price tag was tough to swallow and easy to pass on. But then orthopedic surgeon Joe Nessler, MD, made the center an offer it couldn't refuse: You invest in a germ-zapping robot and I'll bring my total joint cases to you, he told them.

"We didn't have the laminar airflow he wanted," says Julie Tonsager, RN, St. Cloud's operating room team leader. "A UV light was another layer of protection for us."

The center purchased a robot and liked it (and used it) so much that it bought another. They deploy a robot 3 separate times for Dr. Nessler's total joint cases — in this order:

• they run 2 5-minute cycles before opening a total joint case (staff reposition the robot after the first cycle so that all room surfaces are exposed to the UV light);
• they run another 5-minute cycle after the room has been set up and sterile packs and supplies have been opened for a joint replacement (yes, contamination of environmental surfaces is common even after surface disinfection, especially if there have been lapses in hand hygiene); and
• during the procedure, they run a final 5-minute cycle in the recovery room that the total joint patient will be wheeled into.

"Right before we bring the patient into the room and everything's set up, we run the UV light one last time so that we have complete sterilization and disinfection of the entire room — something you can't achieve with chemical disinfection," says Dr. Nessler, who adds that particulates that can cause post-operative infections begin to settle as soon as they begin opening for a case. "This is the only time I know when I'm going into an operating room to perform a joint replacement that I have the ultimate in sterility in the room before we start the case."

— Dan O'Connor

It's the environment
Interest in understanding the role of the OR environment in transmission of surgical site infections has increased greatly in recent years. Poor hand hygiene certainly plays a supporting role, but there's a growing awareness that the environment is getting patients sick. The room is the problem, they say. When Patient A leaves the room and you clean the room for Patient B, studies show that less than 50% of room surfaces are untouched. There's enough contaminant left when patient A leaves the room to pose a threat to infect Patient B. C. diff, methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens can live on surfaces for 5 months.

St. Cloud launches a yearlong study of Dora and Gus this month, monitoring the infection rates in total joint and back surgery patients. Ms. Tonsager is expecting to see some downward trends.

"To me, one infection a year is too many," she says.