July 1, 2021

Make sure your staff isn’t wasting effort or using cleaning products the wrong way.

CREDIT: Karen Tjelmeland
TAKES A VILLAGE The delicate ballet seen in the most efficient and safe OR turnovers doesn't happen by accident.

Random spot checks and direct observation are absolutely required to ensure your surface disinfection practices are up to snuff. However, there are extra steps you can take to get an even better handle on just how well this vital task is being performed:

• Define roles. Spell out the exact cleaning duties for each member of your housekeeping and nursing staffs. This will not only ensure all surfaces get clean, but also that none of them get cleaned twice, wasting precious time in the turnover process. Put the assignments in writing so there is no confusion or ambiguity.
• Evaluate cleaning agents. It’s not just about who’s cleaning what. It’s also about what they’re using to clean. Find out if the products being used are best for your facility. Maybe your staff could use a cleaner with a quicker dry time. Maybe sprays would be better than wipes for certain scenarios. Above all, no matter what products your staff uses, make absolutely sure they follow the instructions for use to the letter.
• Monitor and measure compliance. Put together a strategy and schedule for assessing cleaning compliance. How often will you audit staff? How often will you randomly perform spot checks? What tool — such as an adenosine triphosphate (ATP) tester, UV light or fluorescent marker — will you use to check surfaces for residual bioburden that might have been missed?

Ultimately, a solid surface disinfection protocol encompasses the right products, used the right way by educated and diligent staff, with an administrator keeping close tabs on compliance.

Solid surface disinfection practices protect patients and staff from exposure.

SMART WIPING Rigorous manual cleaning is key to surface disinfection strategies in the COVID-19 era, but a closer look at the process can reveal inefficiencies and errors.

As an enveloped virus, COVID-19 is very easy to kill on hard surfaces. That's the good news. The bad news is that it can live on any surface for several days.

"Think about all the stainless steel and plastic in operating rooms," says J. Darrel Hicks, BA, Master REH, CHESP, a St. Louis-based infection prevention consultant. "That's where COVID-19 lives longest." He suggests using adenosine triphosphate (ATP) or invisible fluorescent markers to confirm these and other surfaces are being wiped effectively to determine if additional staff training or supervision is needed.

Defining roles is vital. "Identify who is responsible for cleaning the different surfaces in the OR," adds Mr. Hicks. For example, is environmental services hesitant to touch equipment such as anesthesia carts and video monitors, assuming your anesthesia providers and nurses clean them? Find out, and then set clear expectations of which staff members are responsible for cleaning specific surfaces in the OR.

Don't overlook often-missed items such as IV pumps, side rails and patient transport equipment, warns Mr. Hicks, who suggests performing audits with staff present. Walk through the entire facility with staff and ask for feedback on who cleans every surface. Their responses will reveal where you need to refocus.

Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of infection prevention at University of Rochester (N.Y.) Medicine, and president of the Association for Professionals in Infection Control and Epidemiology (APIC), stresses keeping tabs on staff compliance with manufacturer's instructions for use for the disinfectant they're using at any given time. "Constantly remind your team that they need to be aware of what those specs are, and the importance of following them to the letter," she says."

Staff might be accustomed to using a cleaning agent with a two-minute contact time, but will they properly adjust to a disinfectant with a five-minute contact time? "Post visual reminders about dry times where disinfectants are used, and update that information on a real-time basis," says Ms. Pettis, who also emphasizes that soft surfaces require specialized cleaning agents.

Ms. Pettis encourages the use of technology such as ultraviolent (UV) disinfecting robots and air purification systems to supplement manual cleaning. "It's one more tool in your toolbelt," she says. "No matter how well-intentioned staff are, they're in a hurry and under pressure. It's easy for them to miss surfaces. Technology is a safeguard to add on top of the basics. It provides an added sense of security and protection."

Performing proper surface disinfection to protect from COVID-19 and other pathogens is needed beyond the perioperative department. You should also regularly disinfect common areas, including waiting rooms and restrooms. Make sure you incorporate this cleaning into your process.

In the COVID-19 era, patients and even some staff are far more aware of cleanliness than ever before, so the openly performative aspect of manual cleaning serves as a reassurance. "Perception is reality," says Ms. Pettis. "If patients perceive your facility as a safe environment, they'll be more comfortable being there."

Proper disinfection is a team effort with attention paid to the details.

Credit: Sharon Ward-Fore
Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC, Infection Prevention Advisor for Metrex.

Surface disinfection is a critical step in every OR facility, and it involves every team member to get it right. While each facility may have its own preferences, the right tools and training are key to successful disinfection and patient safety.

Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC, Infection Prevention Advisor for Metrex, shares her thoughts about how to optimize surface disinfection for your team:

When it comes to surface disinfection in healthcare settings, who is responsible to ensure that surfaces are properly cleaned and disinfected? Anyone who plans on using patient care equipment – nurses, physical therapy, respiratory therapy, radiology, doctors, dietary, environmental services, patient escort and more. It's everyone's responsibility to make sure contaminated items are cleaned before and after they are used for patient care.

What guidelines and practices are important for proper surface disinfecting? Every facility has its own cleaning protocols. Most important is to follow all manufacturer instructions for use (IFU) regarding what to use to clean and how to use it. Also adhering to the recommended contact or "dwell" time. Unless that equipment surface stays wet for the specified time, you have no guarantee of actually achieving disinfection.

What can be done to arm health care professionals with the right tools for success? Provide proper training and education on how to clean and why it's important. Work with device manufacturers to design and build medical devices that are more easily cleaned, leading to better disinfection. Make equipment with less "nooks and crannies" that have better material compatibility with the most commonly used disinfectant ingredients.

What considerations do you take when choosing a surface disinfectant product? Ease of use, efficacy, contact time, material compatibility, cost.

Do you have any other advice when it comes to surface disinfection? Select a surface disinfectant with input from the end user. If you like it and they don't, they won't use it. Also look to the future of potential pathogens in your facility. You might not have something like C.auris now, but you might see it in the future, unfortunately¹. So, plan ahead because it is really difficult to introduce or change surface disinfectants. We learned that with the COVID-19 pandemic.

Note: Metrex Research, LLC (Metrex) has worked for more than 30 years to provide value-added infection prevention products and services in global healthcare environments. Metrex offers a complete line of enzymatic detergents, high-level disinfectants/sterilants, surface disinfectants for use in hospitals, liquid medical waste disposal products, hand hygiene products, eye shields and many other infection prevention products. For more information, visit www.metrex.com.

When every second counts, staff must work diligently and collaboratively.

There's a lot going on in between surgical cases. Linens get changed. Critical supplies are restocked. Horizontal surfaces get wiped down and disinfected. Every square inch of floor space is thoroughly mopped. No matter how quickly everyone works, the clock keeps ticking — and as they say, time is money.

Many facilities work on razor-thin profit margins, where high case volumes are required to make the numbers work. So, in addition to making sure the OR is safe for the next patient and surgical team, cleanups must be done at warp speed, and the transition is expected to be seamless. Other than that — no pressure.

Designing and maintaining a room turnover system that essentially demands perfection is a perpetual challenge. Romel Jimera, MSN, RN, CNOR, clinical educator at USC's Keck School of Medicine in Los Angeles, says OR teams can succeed if they adopt three principles:

• Roles. Give every member of your team something to clean. Specific assignments ensure staff don't reclean spots a colleague already treated. Make sure everyone knows the dry times of the cleaning agents they've been assigned and follows them, despite time pressures.
• Communication. This is particularly important on days when regular team members are absent from work or a pressing situation makes them unable. The team must make the necessary adjustments so others can pick up the slack. Mr. Jimera suggests developing a protocol that enables quick training of new hires and temporary fill-ins.
• Collaboration. Involve staff from nursing, anesthesia and infection prevention for input as you perfect your turnover protocols. Inform surgeons when significant changes will be made. Conduct periodic audits to monitor the process.

Mr. Jimera says employees should push back if they feel pressured to clean so fast that it prevents protocols from being followed. Keep motivation high by recognizing and rewarding staffers in some way when they get 100% scores on their cleaning audits. "When you're pointing out improvement areas, mix in positive feedback whenever possible," he says. "I shoot for five pieces of positive feedback for each negative item I relay to staff."

This California facility used a comprehensive strategy to reduce SSIs by 72%.

Lowering your facility's rate of surgical site infections (SSI) is not a quick fix or a small task. That's why Sutter Health in Modesto, Calif., focused on the long game by implementing a three-year infection reduction strategy. The results were highly encouraging; it reduced its SSI rate by 72%, from 66 infections in 2016 to 19 infections in 2018. Here are some pillars of its strategy:

• Teamwork. A multidisciplinary group of surgical nurses, anesthesia providers, an infection control practitioner, surgeons and reps from environmental services and sterile processing was assembled. The team utilized lean management principles — strategies designed to minimize waste in every process, procedure and task through an ongoing system of improvement — to initially focus on areas that needed the most improvement.
• Patient involvement. All patients were contacted prior to their procedures to make them aware of the active role they had to play in preventing post-op infections. Patients received written instructions on using chlorhexidine gluconate (CHG) wipes to clean around the surgical site for several days before their surgeries, as well as an explanation on the necessity of taking full-body CHG showers the night before and morning of their procedures. Increased emphasis was placed on managing modifiable risk factors, including diabetes, high blood glucose levels and smoking.
• Proper skin prep and disinfection. Extra importance was placed on staff following skin prepping protocols and infection prevention procedures. For instance, when performing a CHG skin prep, staff was instructed to scrub the skin around the surgical site for at least 30 seconds and ensure the solution dried for three minutes before the incision was made.
• Surface disinfection. Increased emphasis was placed on ensuring ORs were thoroughly cleaned and sanitized, with adenosine triphosphate (ATP) testing performed randomly on terminally cleaned rooms to confirm sufficient cleaning and disinfection. Robust manual cleaning was enhanced by overnight terminal cleanings using ultraviolet light technology.
• Individualized antibiotic dosing. Anesthesia providers followed weight-based protocols for pre-incision antibiotic administration. This was driven by a discovery during research that preoperative antibiotic prophylaxis decreases the risk of postoperative infections by as much as 80%," says Maricris V. Demayo, BSN, RN, PHN, of Sutter's Memorial Medical Center.
• Wound classification. Some wounds have a higher risk of infection; a wound resulting from trauma is considered contaminated and a high infection risk, while an incision made for an elective surgery is considered a clean wound. "Proper classification can assist in determining appropriate postoperative care, and accurate tracking of sources of SSIs," says Ms. Demayo. While CHG is used as a prep for elective surgeries, povidone-iodine is used on open wounds, for spine surgeries or for patients with known allergies to CHG.

Ultimately, says Ms. Demayo, Sutter Health's success was about creating a culture around SSI prevention. Comprehensive training on infection control practices is now part of new staff orientation. Because every facility has a different culture and can use different prepping agents and practices, Sutter Health makes sure to educate new hires on how its specific facility handles infection prevention.