Q We've recently had a problem with flies getting into the OR suite. We don't have any direct access to the outside, except the doorway, but they're sneaking in somehow. What are your recommendations for dealing with this?

A The first thing I'd do is hire a professional insect-control company to assess the situation. Such a company may be familiar with insect problems in your area and may be able to solve the problem quickly and easily. Professionals should be able to find likely ports of entry and/or living spaces in your building, as well as recommend solutions.

The fact that your problem is recent leads me to believe that something has changed within your facility that has attracted the flies. I'd look in the immediate area for sources of attraction.

• Are there any places where moisture is allowed to collect and stagnate? Check all your floor drains.
• A leading cause of insect infestation is the OR staff lounge, where food often is not cleaned up after every use. Nothing will attract insects as fast as an open can of soda or spilled cookie crumbs.
• We all like to be environmentally responsible, but look to the areas where you may be recycling cans, plastics or paper. These can all be breeding grounds.
• Are your trash bins covered and not allowed to overflow?
• How are you collecting, storing and transporting bloody and soiled linens?

Q The humidity in our ORs is usually less than 40 percent, and you can get really thirsty during procedures. Is it acceptable to have a drink in the OR if it's not near the sterile field?

A My answer needs to be qualified with an "it depends." Of course, the rule has always been that there should be no food or drink in the OR, and for very good reasons. To begin with, the OR is not a place for eating or drinking. Either the food or drink can contaminate an at-risk patient, or the patient can contaminate the food or drink. This all depends on the type of case: how bloody, how long, how many attendants. Ask those who are promoting this if they'd eat or drink in decontam or in the women's washroom. Also, is the procedure so long that the person can't wait another 30 or more minutes for a drink? Allowing it is setting a bad precedent: If it's okay to have a drink of water, is it also okay to have a soda, or maybe a hot dog?

There may or may not be any direct problem associated with an occasional drink from an enclosed container. It is just bad practice because of what it could lead to. Also, I highly recommend that you get your environmental services department to regulate the humidity in the OR at the recommended 50 percent to 65 percent. There are many problems associated with low humidity beyond just the comfort of those in the room.

Q A recent compliance directive from OSHA says: "Removing the needles and reusing blood tube holders can expose workers to multiple hazards: We want to make it very clear that this practice is prohibited in order to protect workers from being exposed to contaminated needles." Is our purchasing department correct when it claims this OSHA regulation pertains only to the single-use units and not the reusable ones?

A The issue is not single-use versus reusable blood-tube holders. OSHA's Bloodborne Pathogens Standard [29 CFR1910.1030, paragraph (d)(2)(vii)(A)] mandates that "Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure." More specifically, OSHA's new compliance directive, CPL 2-2.69 at XIII.D.5, states, "removing the needle from a used blood-drawing/phlebotomy device is rarely, if ever, required by a medical procedure. Because such devices involve the use of a double-ended needle, such removal clearly exposes employees to additional risk, as does the increased manipulation of a contaminated device."

Therefore, to prevent potential worker exposure to the contaminated hollow bore needle at both the front and back ends, immediately discard all blood-tube holders, with needles attached, in an accessible sharps container after the safety feature has been activated. Removing contaminated needles from and subsequently reusing blood-tube holders poses multiple potential hazards. The increased manipulation required to remove a contaminated needle from a blood-tube holder is unnecessary and may result in a needlestick from either the front or back end of the needle.

Q One of our cardiac surgeons complained to our OR director about bowel cases' being done in the same room as CABG procedures (we are not large enough to have a room dedicated only to heart procedures). I have heard that some hospitals have been cited for doing contaminated cases in the same room as cardiac cases. Are there any regulations or procedural recommendations about restricting certain ORs to "clean" cases only?

A I am not aware of any regulations requiring this type of separation but common sense would tell you that scheduling a total hip replacement, followed by a bowel resection, followed by a CABG would be poor scheduling unless extraordinary cleaning were also scheduled between cases.

The ideal situation would be to have an OR dedicated to open-heart procedures, another for orthopedic and another for colon/urinary/rectal. But this is not always possible. All procedures are considered dirty, it's just that some are more dirty than others, and you must accommodate those differences through scheduling and cleaning practices. It would make sense, for example, to schedule the so-called clean cases first in the day and dirty cases at the end of the day if they are all going to be done in the same room. A thorough cleaning would then prepare the room for the next day's clean case.

If you must mix these types of cases in the same room, I would recommend that you document supporting evidence that your between-cases cleaning is exemplary.