The OR has always enjoyed a reputation for being a bastion of cleanliness and sterility, but is your sacred space as hyper-hygienic as you think? When we here at the Johns Hopkins Bayview Medical Center evaluated how well we were cleaning the surfaces in our operating rooms, we were shocked at what we saw. Or, more accurately, what we couldn't see.
To the naked eye, the phones, door handles and light switches in our ORs certainly looked clean, but we found that looks can be quite deceiving. Beyond visualization, the way we chose to evaluate the effectiveness of our cleaning process was by using fluorescent gel and a black light to illuminate surfaces where the gel was placed. We evaluated cleanliness in 14 ORs by marking immobile high-touch areas with the fluorescent gel. The list of items we marked was long: tabletops, surgical lights, anesthesia equipment, furniture, monitor screens, computer keyboards, telephones, walls, doors, door handles, and cabinet doors.
On average, we marked 24 surfaces in each room. We did so after the last case of the day and before terminal cleaning. We evaluated the marked sites the following morning between 6:30 a.m. and 8 a.m. with a black light. The results, quite frankly, were dismal. Many surfaces were hardly cleaned at all, others not nearly enough. We had only cleaned those areas we tested 41% of the time a high of 61% and a low of 18%. We've improved our percentage of cleaned areas to an average of 80% (high 95%, low 65%). We've sustained that level by continuing to monitor and by celebrating our successes. Here's what we learned along the way.
1. The periphery is neglected. We discovered that our cleanup crew focused most of its attention on cleaning the area around where they know patients are going to be: the OR table, overhead lights, the equipment tower. By and large, whatever surfaces come into direct contact with the patient were cleaned. But the further away from the OR table we went, the more cleaning misses we spotted. This is understandable. You're not thinking to wipe down the handrails, the IV pole, the door handle, or the computer monitor and keyboard that were touched with gloved hands.
The lesson here: Educate your staff that all surfaces matter, even those things that didn't contact patients, especially those things far away from where the patient will be. In the quest for 5-minute turnovers and the rush to get the next patient in, this can be a challenge.
Another challenge is convincing staff that a gloved hand is in no way a sterile hand. When wearing clean gloves, think about how many surfaces you touch. If, for example, you scratch your nose and then position the overhead lights, the lights could be vectors for spreading germs to patients.
2. Work from dirty to clean. When cleaning OR surfaces, always go from dirty to clean. "Tackle your worst first," is a good way to remember this. Think about when you mop the floor. You mop from the far end of the room and work yourself toward the door, as opposed to walking back and forth. The same applies to surface cleaning. You want to start where the patient was: on the bed, in the center of the room, where the surgery took place. This is where you'll find the most splatter, fluid and gross contaminants. Strip the bed, get instruments in the case cart, wipe the back table and then work yourself outside toward the door with a clean mop head. Perhaps our tendency to focus on the OR bed explains why surface cleaning suffers more, the farther from the bed you move.
You're less likely to miss something if all members of the turnover team know what the system is. "I've got this, you're doing that," they should say to each other. It's dangerous to assume another person on the turnover team is in charge of cleaning the periphery surfaces. Don't assume. Always ask.
3. How is the disinfectant applied? Here's a question worth asking: Regardless of what cleaner you're using, how are you applying it? Are you using a minimal amount of disinfectant on a cloth, soaking a cloth in the solution or simply applying the disinfectant on the surface? Your answer should correspond with manufacturers' recommendations for all important contact and dry times.
Take OR table mattresses, for example. Most mattresses are black, so it's hard to see the cleaner on the surface, let alone in the cracks and crevices. Dry time is a key component. If you don't let the disinfectant dry on the surface for the allotted time, your cleaning efforts are for naught. If a member of the turnover team rushes to make the bed seconds after it's been wiped, someone needs to stop that person. We know turnover pressures can be fierce. A good strategy to ensure dry times: Wipe down the bed first and then wipe another nearby surface or mop the floor so that 3 or so minutes pass before you make up the bed. Or maybe the last thing you do before you leave the room is make the bed.
Think of Goldilocks when you think of how much disinfectant to apply to surfaces: not too much, not too little, but just the right amount. While we don't recommend soaking cleaning rags in solution, it's also not a good idea to use too little disinfectant. Just because you wipe a surface doesn't mean you cleaned it. Surfaces will take longer than necessary to dry if you apply too much disinfectant. Educate staff why dry times matter and that you're defeating the purpose and reducing the cleaner's effectiveness if you dry off the disinfectant yourself to speed up the process. Let it evaporate on its own so that it can do its job.
4. Let staff focus on the job at hand. Resist the temptation to pull a member of your turnover team away from cleaning a room so that he can transport a patient, move a piece of equipment or take a specimen to the lab. Distractions can lead to surfaces not being cleaned. Let them stay on task and fulfill their role in the process. Empower your OR assistants to tell a colleague, "I'm cleaning Room 6. You need to answer all calls. I'll let you know when I'm done."
Similarly, right-size your turnover team. The more people on your turnover team, the less control you have. If you have 5 people showing up to turn over a room where a clean procedure like a carpal tunnel just took place, chances are someone will be standing there waiting to open a pack long before it's time to do so. On the other hand, your turnover team's just as likely to pass over less-critical surfaces like phones and keyboards during big case turnovers. That's because there's so much to be done: more trash to be removed and more pieces of equipment to roll out and clean. Like so many things, the devil's in the details. Educate your team about why they're doing things in the order they're doing them in and why it's important.
5. Hold monthly meetings with your OR assistants. Like us, you'll learn a lot from those who are on the front lines: their challenges, their understanding of the jobs. For example, each member of our turnover team seemed to have a different definition of terminal cleaning. When we asked them how high up the wall you're supposed to go when cleaning, rather than responding that they use a telescoping broom handle with a flat mop head to go all the way up the ceiling, they said they were just cleaning spots on the wall where blood had splattered.
Download Johns Hopkins Bayview Medical Center's terminal cleaning and between-case cleaning checklists at www.outpatientsurgery.net/resources for references.
They were confusing turnover with terminal clean. It's called "normalization of deviance." They didn't clean the walls on Monday, nothing bad happened, so they figured it must be acceptable to do so again on Tuesday. We hang terminal cleaning and between-case cleaning checklists on each OR door. These checklists serve as valuable reminders. We instruct staff to sign off on both.