The New Rules of Terminal Cleaning


Has your approach to end-of-day OR disinfection evolved with the times?

a well-executed terminal clean HIGH AND LOW A well-executed terminal clean is a mostly low-tech enterprise, but high-tech tools have armed facilities with new weapons to bust those bugs.

Last year, our hospital had 81 cases of hospital-acquired Clostridium difficile. We're on pace to have about one-third fewer hospital-acquired infections of all kinds this year, a decrease I attribute to the whole-room disinfection technologies we've added to our manual cleaning.

Here's how we approach the manual terminal clean in our ORs. At the end of a day or every 24 hours — whichever comes first — each OR undergoes a top-to-bottom, floor-to-ceiling, edge-to-center terminal clean. As opposed to the environmental cleaning we do between cases, which is a 5- to 7-minute process designed to remove accumulated bioburden from surfaces within a 10-foot diameter of the OR table, the terminal clean leaves no stone unturned.

Whole-room disinfection is an adjunct to your terminal clean, not a replacement and not a reason for your cleaning crew to take shortcuts during the manual clean. Here's the protocol we follow:

  • Start top to bottom, meaning the ceiling to the walls to the floor, and clean from the edge to the center; the center of the room is typically the dirtiest.
  • Use a checklist, and move in a uniform fashion — clockwise or counterclockwise — throughout the terminal clean to eliminate the potential for an oversight.
  • Use each disinfecting agent according to the manufacturer's instructions for use, being sure to leave adequate dwell time for proper disinfection. Some take 2 minutes, while others take as long as 10 minutes.
  • Disinfect every surface, including all wheels and casters and every nook of every vent.
  • Validate that the work has been effective before releasing the room. Tools such as adenosine triphosphate (ATP) bioluminescence can rapidly assess the level of cleanliness of disinfected surfaces.
  • Ensure that environmental services workers are properly educated about the transmission of disease, properly trained, equipped and afforded the necessary time to complete the job at hand.

Seeing the light
Our terminal cleaning crew is diligent about disinfecting every surface, but no terminal clean is immune to human error. To compound the challenge, many bacteria are highly resistant to cleaning agents and can survive on surfaces for months. For example, C. diff spores can live on surfaces for 70 to 90 days. This is where more specialized weapons come into play.

Our current terminal-cleaning protocol began as a call for more enhanced infection-control practices throughout our hospital. Our aim was to reduce HAIs — and the costs associated with them — caused by the likes of norovirus, MRSA and so on down the line. Our biggest target was C. diff.

Although proper cleaning and disinfection is a purposefully low-tech enterprise, we chose to supplement our approach with high-tech weaponry. At the time, our infection prevention team was in the early stages of evaluating the use of whole-room disinfection technology as an adjunct to our terminal cleaning. I wound up taking ownership of this project and spent the next 2 years reviewing technologies from vendors that use different kinds of disinfection — ultraviolet light (continuous and pulse), as well as hydrogen peroxide fog and ozone. Ultimately, we found one of the UV technologies to be the best fit for our needs.

The UV light kills C. diff, MRSA and other dangerous microbes by altering their DNA and rendering them unable to reproduce. Each unit delivers high-intensity UV light in short time periods to streamline room turnover. Each also has a built-in microprocessor designed to minimize human error and provide room-specific usage data.

During a 3-month trial of the technology on our 51-room med-surg floor, we experienced a significant downward trend in HAIs caused by C. diff. At the end of the trial, we purchased 3 UV robots, 1 for the OR and 2 for our isolation rooms. Now, as the manual portion of the terminal cleaning-process draws to a close, we roll in the device and bathe the room in germicidal UV light for 30 minutes. We treat each OR with UV light during a terminal clean at least once a week. Using them to clean select rooms throughout the day, and then disinfecting ORs at night after the day's surgeries are completed, hardly disrupts our schedule.

???Disinfection in an OR Light Fixture

continuously kill harmful bacteria BACTERIA-SLAYING LIGHTS Motion-activated overhead light fixtures combine white ambient light with 405 nanometers of indigo light in order to continuously kill harmful bacteria in the OR.

Do your overhead lights help prevent infection? Ours do. They look like regular fluorescent light fixtures, but the overhead lights we recently installed in our 2 joint replacement operating rooms emit high-intensity narrow-spectrum light that kills harmful bacteria in the air and on hard and soft surfaces below — providing continuous environmental disinfection regardless of whether the room is empty or in use.

Using occupancy sensors, the light-emitting diodes (LEDs) automatically change modes.

  • While the room is occupied, "white-disinfection mode" provides ambient lighting with a slight blue tint. A passing side effect: Everything appears more yellow for about 30 seconds after you leave the room as your eyes adjust to the regular fluorescent lighting.
  • When the room is not in use, a motion detector automatically selects "indigo-disinfection mode" to provide maximum continuous disinfection. In this mode, the 405-nanometer lights give off a deep purplish blue tint.

The light reflects off of walls and objects, providing 24/7 disinfection in areas not directly illuminated. The visible wave of white light contains a narrow spectrum of indigo-colored light. It's not ultraviolet light — the indigo color is just outside the UV spectrum.

Unlike whole-room disinfection systems that require a tech to wheel a device into the OR and activate it, overhead lights provide continuous environmental disinfection. You don't have to take the room out of service for 30 or 60 minutes. In a busy OR, whole-room disinfection could easily steal an hour from your day. Instead, I can get another case done.

The light fixtures install easily into the ceiling of any room. You simply remove the old lights in the ceiling and replace them with the same size lights. With LED lights, there's no bulb replacement and they're designed to last for 10 years. For a 10-light OR, it costs about $30,000.

Since we installed the LEDs, our own studies have shown a 70% reduction of bacterial burden. The lights also give our surgeons peace of mind that we're doing all we can to prevent surgical site infections in our patients.

— Mike Pankey, RN, MBA

Mr. Pankey ([email protected]) is the administrator of the Ambulatory Surgery Center of Spartanburg (S.C.).

Next-gen clean
We've found that whole-room disinfection devices can help in areas beyond terminal cleaning. One example: collecting gurneys, IV poles and other pieces of equipment known to be carriers of multidrug-resistant organisms in a room to bathe them in germicidal UV light.

We're also starting to see signs that ORs are making subtle design changes to accommodate the technology. As disinfection tools continue to evolve, we're starting to see ORs with permanently installed overhead lights that turn on automatically to disinfect the room when it's not in use (see "Disinfection in an OR Light Fixture"). Also, studies suggest painting rooms with UV-reflective paint ( may further enhance the technology's ability to battle multidrug-resistant organisms. We're considering this option as we build a new ICU tower.

The technology is also evolving into smaller and more portable devices. UV wands are already being used in foodservice and other industries, but it's inevitable that these kinds of devices will make their way into health care as a way to treat high-touch items like room curtains, which are among the biggest carriers of pathogens.

Feeling justified
Every time we have a patient readmitted with an HAI, it's on us, meaning it adds tens of thousands of unreimbursed dollars to the cost of care. It's also tying up the hospital, and we'd much rather have a new patient than a repeat patient who has been readmitted because of an infection. Each UV disinfection unit costs more than $100,000, but we justified the expense by preparing a pro forma to show our C-suite the savings we would experience by reducing HAIs by 30% per year. Based on our 2016 numbers, cutting HAIs by one-third should save more than $500,000 this year and more than $1.1 million in 2018.

It's a sizeable investment, but we anticipate a return in less than 4 months. I haven't seen a tool with this kind of game-changing potential in my 35 years in this field, as it addresses all the prongs that are important to every healthcare facility: reducing HAIs, curbing readmissions, driving patient satisfaction and making the hospital safer for everyone who walks through your door. It also gives us an assurance we've never had before, and it's tough to put a price on that. OSM

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