Q I have an eye surgeon who says he doesn't want sterile processing to decontaminate his instruments between cataract cases. He has his scrub wipe down the instruments with irrigation solution (balanced salt solution) and then sterilize them. He's concerned about enzymatic solution getting into the eye and causing problems. My training and experience tell me this isn't a good practice. What should I do?

A The purpose of decontamination is to remove all soil and debris. If wiping down the instruments with irrigation solution renders them free of all contamination, then it is okay.

However, what happens after the wipe down is key. Are the instruments rinsed in a neutral, chemical-free water? If there are any chemical (salt) or biologic remnants on the instruments when they're subsequently sterilized, they'll be baked on and difficult to remove. If he's been doing this for eight years, he's probably seen all the potential problems this procedure could create.

I presume your surgeon prefers this abbreviated version of a complete decontamination process because he uses the same instruments for several cases in a row without enough time between cases for proper decontamination and sterilization. I assume also that he flash sterilizes the instruments between cases. Do they come out of the flash sterilizer hot and wet - and therefore optimized for risk of contamination with airborne infectants?

He'd be better served if he had two sets so that you could properly process one set while he used the other. His concern over enzymatic solution contamination is valid if your process doesn't include a thorough cleaning and rinse after instruments are received in decontam. Remember, the use of an enzymatic solution is only necessary to keep debris from hardening on and in the instruments between the time they're used and the time they're cleaned. If you can shorten this time, or even just use distilled water to soak the instruments until they're cleaned, you don't need to use enzymes to assist in the cleaning.

Head Coverings for All Patients
Q My last facility only required hair coverings for patients with long hair. My present facility requires head coverings for all patients, even bald men. Is this necessary?

A Head coverings for patients in the OR serve several functions:

• They create a barrier between the hands of the anesthetist and the patient's hair, head and scalp.
• They allow the positioning of the patient's head without contaminating the hands of the nurse or anesthesiologist.
• They keep hair out of the eyes, nose and mouth of the patient.
• They protect the patient's hair from contamination by cleaning solutions, blood, vomit or other fluids during surgery.
• They keep the patient's non-sterile hair, dandruff and lice out of the OR environment.
• They contain long hair so that it doesn't interfere with monitoring lines and intubating tubing.

These are all good reasons to adopt standard operating procedures to require head coverings for all surgical patients, even bald men.

Protecting Your Flooring
Q Spilled povidone iodine prep is staining the new seamless flooring in our ORs. The contractor suggests that we use wax to seal the floors, both to protect against staining and also because if the floor isn't sealed with a wax, the warranty will be voided. However, the manufacturer gives no product recommendations, and AORN doesn't recommend wax because it builds up. Can we protect the floor without causing a maintenance or infection control problem?

A It sounds to me that you have chosen the wrong contractor for your flooring. No one uses "wax" to seal floors anymore. The coating put on vinyl floors these days is a polymer, usually laid in two layers: first a sealer, then a polish.

Once a year, strip the floor and reapply the coating. If your supplier won't recommend a product, it should be required to give you a list of products that won't void the warranty.

Then ask your materials manager or purchasing department to get advice from floor sealer experts regarding which approved sealer will be hard-wearing and low-maintenance. Many products are available, so I hesitate to recommend one. Infection prevention would require that the sealer should stand up to your regular between-case, daily and terminal cleaning procedures.

Terminal Cleaning After MDRO Cases
Q We're terminally cleaning our ORs after procedures on patients diagnosed with multi-drug-resistant organisms. Washing the walls as well as the usual environmental surface cleaning takes a lot of time between cases, drastically slowing our OR schedules. What is your opinion on the need for terminal cleaning after MDRO cases?

A The use of the term terminal cleaning is usually confined to a process that is conducted on a scheduled basis (such as weekly or bi-weekly) that includes the cleaning of all surfaces - including ceilings and walls - in all the ORs. Between-cases cleaning consists of cleaning the immediate operative area within a four-foot perimeter - and beyond, if visibly soiled. Daily cleaning should include all horizontal surfaces, sinks and floors.

To handle MDRO patients differently negates the rationale behind Standard Precautions for all patient care. You should clean after each case - as I just described - the same, because you don't always know who has what types of infectious problems. The AORN guidelines give excellent guidance in this area.

Don't be lulled into a false sense of security with patients who haven't been diagnosed with drug resistant organism infections. The Standard Precautions are the reality in healthcare today. Ensure they're practiced on all your patients, in all your procedures.