WIPE OUT Your staff might think they've got surface cleaning covered, but studies suggest most high-touch items aren't disinfected properly between cases.

Take a few minutes to watch your staff in action the next time they turn over ORs. Do they wipe down the keyboards and mice at nursing and anesthesia workstations? What about the beds, door handles and anesthesia workstations? Those are the high-touch items Terri Link, MPH, BSN, CNOR, CIC, a perioperative patient safety specialist at the University of Colorado Hospital in Aurora, Colo., identified in a study published in the American Journal of Infection Control (osmag.net/g8VdVY). If your turnover teams don't touch on those areas between cases, the surfaces in your ORs might not be as clean you think they are.

Unfortunately, that might be the rule rather than the exception. "On average, only about 40% of surfaces that need to be disinfected are being addressed," says Philip Carling, MD, MPH, a clinical professor of medicine at the Boston (Mass.) University School of Medicine. "Environmental cleaning is an underappreciated area of concern because surgical professionals assume surfaces are being cleaned properly."

In fact, it's best to assume the opposite and focus on making sure your staff does more than skim the surface when disinfecting ORs between cases.

Ms. Link suggests you gather representatives from infection control, anesthesia, radiology and surgery — any department that brings equipment into the OR — to determine who will be responsible for cleaning specific surfaces between cases. You should also develop a way to document that every surface in the OR has been wiped down between cases. "Establish enhanced cleaning protocols to ensure high-touch areas are addressed between cases," she says. "The OR surfaces stay the same, but the people who clean them varies."

Dr. Carling's widely referenced study published in the journal Infection Control & Hospital Epidemiology used transparent fluorescent gel to mark surfaces in 43 ORs of a major teaching hospital before the first case of the day (osmag.net/Z8RnHq). His research team then used a UV lamp to evaluate how many of the marks were removed 24 hours later. They also took environmental cultures in unused ORs that had been terminally cleaned the night before.

Contaminated objects included intravenous poles, operating room beds, Mayo stands and ?-?oors. Less than 50% of tested surfaces had been cleaned before the researchers conducted 4 months of ongoing performance feedback of the staff's cleaning practices. The educational efforts led to an 82% increase in cleaning of the test gel markers. In addition, when the hospital made anesthesia providers responsible for cleaning anesthesia machines' knobs, switches, keyboards, oxygen reservoir bags and medication carts, the percentage of negative culture samples obtained on that equipment rose from 11.3% to 33.3%.

The results show that having cleaning policies and procedures in place is only partly effective, according to Dr. Carling. He says you must also ensure your surgical team understands and is following directives designed to optimize surface disinfection.

"One of the biggest challenges staff face when turning over rooms is being efficient and effective," says Kathleen Pressimone, RN, CNOR, a perioperative patient safety nurse at Johns Hopkins Bayview Medical Center in Baltimore, Md. "Everyone wants faster room turnovers without sacrificing cleaning quality."

A study she co-authored in the American Journal of Infection Control compared the contamination levels on an OR light (a low-touch area) with other surfaces throughout the OR and found that high-touch areas were more contaminated than the surgical light (osmag.net/GCM2vt).

That's why Ms. Pressimone helped develop a cleaning checklist, which includes reminders to wipe down not-so-obvious high-touch surfaces like phones, door handles, light switches, monitor screens and keyboards. (Here's an idea: invest in water-resistant keyboards. Ms. Pressimone's hospital did, and her cleaning crew finds the surfaces easier to wipe down between cases). A laminated copy of the checklist is kept in each OR for easy reference by turnover teams. OR assistants assigned to specific rooms oversee the cleaning of surfaces and are responsible for ensuring each box on the checklist is marked.

AIRBORNE CONTAMINATION
To Lower Infection Risk, Keep the OR Doors Closed

TRAFFIC CONTROL Harmful bacteria can blow into the sterile field each time the OR door is opened. Eliminate unnecessary door openings in order to reduce the risk of OR contamination.

If so many people are coming and going during cases that your OR doors are more like turnstiles, you could be risking airborne contamination of the sterile field, according to a study in the journal Orthopedics (osmag.net/9PxYaR). The study says installing an alarm that sounds whenever the OR doors are opened is a great way to lighten traffic.

It's important to limit foot traffic into and out of ORs when surgeries are in progress because every time you open the OR door, you alter airflow, which could lead to airborne contamination of the sterile field, says Terri Link, MPH, BSN, CNOR, CIC, a perioperative patient safety specialist at the University of Colorado Hospital in Aurora, Colo.

Ms. Link conducted research to determine which OR surfaces are touched most often and therefore need to be cleaned with care. She also discovered that an "alarming" number of people were in rooms during short procedures — an average of 14 people were in outpatient ORs during cases that lasted about 69 minutes.

The authors of the Orthopedics study installed an alarm that sounded a 2-tone chime every time an OR door was opened and repeated the chime every 3 seconds until the door was closed. During 50 consecutive joint replacement surgeries without the alarm, the door was opened an average of 88 times per case and remained open for 14 minutes per procedure. During the 50 cases with the alarm installed, the number of door openings dropped to 69 and the door remained open for 10 minutes per surgery.

— Daniel Cook

Beyond the surface
The latest in "no-touch" surface disinfection technologies and cleaning supplies improve your staff's performance and provide back-up coverage for spots they might miss.

Focus on the floor. Before beginning his study, Dr. Carling had seen surgical team members grab objects that had fallen onto the floor and place them back on work stations or patients. In the study, he notes that IV tubing often touches the floor as it drapes between the patient and the IV pump. Anesthesia providers, who often touch the tubing, can therefore spread contamination to patients during routine care.

That's why Dr. Carling emphasizes the importance of cleaning floors properly between cases. Microfiber mops have been shown to be more efficacious at removing bacteria from surfaces than cotton mops, but their durability and effectiveness can be compromised by laundering and drying between uses, according to a report published in the journal Antimicrobial Resistance & Infection Control (osmag.net/N8QuUd). More research is needed to draw definitive conclusions about the relative advantages of microfiber mops and cloths to cotton alternatives, says the report.

Consider whole-room disinfection. "No-touch" surface disinfecting options include aerosol and vaporized hydrogen peroxide, mobile units that emit continuous ultraviolet light and pulsed-xenon UV light, and use of high-intensity narrow-spectrum (405 ?nm) light. The Antimicrobial Resistance & Infection Control report says these technologies have been shown to reduce bacterial contamination of surfaces, but further independent research is needed that directly compares the newer methods to traditional disinfecting methods. Dr. Carling says current studies that tout the efficacy of whole-room disinfection systems are quasi-experimental in that they're based on the experience of single facilities that employed the technology, but did not control for confounding factors.

"They likely have some efficacy in decreasing surface bioburden in areas that are not well cleaned," he says, "but there is no scientific reason to believe they add anything to areas that are addressed with reasonable disinfectants. If a surface hasn't been touched by a disinfectant, the technology won't work very well."

What about wipes? Newer hydrogen-peroxide-based liquid surface disinfectants and a peracetic-acid-hydrogen-peroxide combination product are effective disinfectants, but what's the best way to apply them?

Most single-use, pre-moistened wipes are packaged with the proper ratio of soaked-in disinfectant, according to a study in the American Journal of Infection Control (osmag.net/5tEYXu). The key, says the study, is to make sure they remain that way by closing containers between uses, storing the containers according to manufacturers' directives and to not use wipes past their shelf life.

Ms. Pressimone says her staff has had issues with pre-moistened wipes drying before they've had the chance to apply the proper amount to surface areas. They now have the option to use pre-moistened wipes or a lint-free or microfiber cloth moistened with a detergent/disinfectant and water.

"Alcohol is the critical aspect of wipe chemistry," adds Dr. Carling. "Oftentimes the alcohol is rendered ineffective if the containers are left open and the wipes dry out."

Remember this rule, he says, when wiping down surfaces: one wipe, one direction, one time. OSM