CONTINUING EDUCATION Implementing AORN Recommended Practices for Environmental Cleaning GEORGE ALLEN, PhD, MS, BSN, RN, CNOR, CIC
2.0
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14517 Session: #0001 Fee: Members $16, Nonmembers $32
Conflict of Interest Disclosures
The CE contact hours for this article expire May 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to environmental cleaning and disinfection in the perioperative practice setting.
Objectives 1. Discuss the AORN recommended practices for environmental cleaning. 2. Describe risks associated with infectious pathogens. 3. Identify factors to consider when selecting cleaning products. 4. Discuss frequency for cleaning different surfaces. 5. Describe enhanced cleaning procedures.
George Allen, PhD, MS, BSN, RN, CNOR, CIC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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RECOMMENDED PRACTICES Implementing AORN Recommended Practices for Environmental Cleaning 2.0 GEORGE ALLEN, PhD, MS, BSN, RN, CNOR, CIC
www.aorn.org/CE
ABSTRACT In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health careeassociated infections. AORN’s “Recommended practices for environmental cleaning” is an evidence-based document that provides specific guidance for cleaning processes, for the selection of appropriate cleaning equipment and supplies, and for ongoing education and quality improvement. This updated recommended practices document has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support. Perioperative nurses, as the primary advocates for patients while they are being cared for in the perioperative setting, should help ensure that a safe, clean environment is reestablished after each surgical procedure. AORN J 99 (May 2014) 571-579. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.01.023 Key words: environmental cleaning, health careeassociated infections, pathogenic microorganisms, multidrug-resistant organisms, asepsis, disinfection.
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esearchers have linked the development of health careeassociated infections to external sources, such as environmental surfaces. The health care environment, including the perioperative setting, is now well documented as a primary source for infection.1-6 The accumulation of dust, debris, and other microbial contaminants on surfaces in health care settings is a potential source for health careeassociated
infections. The risk for the transmission of pathogenic microorganisms, including multidrugresistant organisms (MDROs), is related to the mere presence of pathogenic microorganisms on environmental surfaces, their capacity to survive for varying lengths of time on these surfaces, and their ability to be transferred to many different types of surfaces, including the hands of health care personnel.7
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Although principles of asepsis and aseptic techniques are the cornerstone of practice in the OR, procedures to prevent the development of surgical site and other infections depend on maintaining sanitary conditions. Consequently, health care providers should implement efficient and effective cleaning procedures to maintain a clean and healthy environment. Perioperative nurses, as the primary advocates for patients while they are being cared for in the perioperative setting, should help ensure that a safe, clean environment is reestablished after each surgical procedure. This article provides a brief review of AORN’s “Recommended practices for environmental cleaning,”8 an evidence-based document that can guide clinicians as they care for patients in the perioperative setting. WHAT IS NEW? The AORN Recommended Practices Advisory Board approved the updated “Recommended practices for environmental cleaning” in November 2013. The recommended practices (RP) document was revised based on a review of available evidence. A medical librarian conducted searches of the nationally and internationally recognized databases for English-language literature published between 2008 and 2013. The lead author, a master’s prepared perioperative nursing professional, together with the medical librarian also identified relevant guidelines from government and standardssetting bodies to develop the recommendations.8 The evidence was appraised by using the AORN Evidence Rating Model (Table 1) to assign evidence ratings: 1. 2. 3. 4. 5.
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Strong Evidence or Regulatory Requirement, Moderate Evidence, Limited Evidence, Benefits Balanced With Harm, or No Evidence.
Evidence rating has emerged as an issue of critical importance because of the growing demand that health care decisions be based on the best evidence available in the scientific literature.9 572 j AORN Journal
The scope of the RP document includes all perioperative areas, including the preoperative and postoperative areas, ORs and procedure rooms, and semirestricted areas, and the document now includes sterile processing areas as well. In addition to providing guidance for environmental cleaning and disinfection to minimize the exposure of surgical patients and health care personnel to potentially infectious pathogens, the updated document has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support. Recommendations relating to competency of personnel, policy and procedures, and quality improvement have been updated to incorporate the team approach. Other new content addresses high-touch objects, enhanced environmental cleaning, cleaning methods, and measurement of cleanliness. RATIONALE Historically, the perioperative environment has been viewed as the singular area in the health care setting where the highest degree of asepsis and adherence to sterile technique is practiced. However, MDROs, such as n n
n n n
methicillin-resistant Staphylococcus aureus, S aureus with resistance to vancomycin (ie, vancomycin-intermediate S aureus, vancomycinresistant S aureus), vancomycin-resistant enterococci, extended-spectrum b-lactamaseeproducing gram-negative bacilli, and Clostridium difficile,
have become more prevalent,10 stay in the environment longer, are difficult to control, and increase the incidence of both morbidity and mortality when they are transmitted to patients. Surfaces that health care providers frequently touch in the perioperative environment may present a high risk for these pathogens to be transmitted, so routine and effective cleaning is essential. Thorough cleaning and disinfection of perioperative areas can be facilitated
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TABLE 1. AORN Crosswalk: Appraisal Score to Evidence Rating Appraisal score Research
Non-research
AORN Evidence Rating Model Evidence rating
IA
IVA Regulatory
1: Strong Evidence 1: Regulatory Requirement
IB IIA, IIB IIIA, IIIB
IVB VA, VB
2: Moderate Evidence
IC IIC IIIC
IVC VC
3: Limited Evidence
4: Benefits Balanced With Harms
5: No Evidence
Evidence requirements Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews; rigorously developed clinical practice guidelines; or regulatory requirements n Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis n Supportive evidence from a single, well-conducted, randomized controlled trial n Guidelines developed by a panel of experts that derive from an explicit literature search methodology and include evidence appraisal and synthesis of the evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence” n Supportive evidence from a well-conducted research study n Guidelines developed by a panel of experts that are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence n Nonresearch evidence with consistent results and fairly definitive conclusions Interventions or activities for which there currently is insufficient evidence or evidence of inadequate quality n Supportive evidence from a poorly conducted research study n Evidence from nonexperimental studies with high potential for bias n Guidelines developed largely by consensus or expert opinion n Nonresearch evidence with insufficient evidence or inconsistent results n Conflicting evidence but where the preponderance of the evidence supports the recommendation Selected interventions or activities for which the AORN Recommended Practices Advisory Board is of the opinion that the desirable effects of following this recommendation outweigh the harms Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation n Consensus opinion
Reprinted with permission from “Introduction to the AORN recommended practices.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:46.
by the implementation of the practice recommendations in the RP document. Because these recommendations are based on the best available evidence and because perioperative personnel have long embraced patient safety and reduction
in surgical site infections into their culture, incorporating the practice recommendations into the routine policies and procedures of the organization can be accomplished with minimal disruptive culture shifts. AORN Journal j 573
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Concepts and processes from this RP document that are critical and that may be assessed by regulatory agencies include the following:
application of this recommendation. For example, when selecting a cleaning product, the team should evaluate the
n
n
There is a team and collaborative approach to cleaning the OR. n Cleaning procedures and schedules should be developed and available in writing, including the description of routine cleaning, enhanced environmental cleaning, and terminal cleaning. n Personnel safety and patient safety must be addressed during the cleaning process, with attention to the chemicals and detergents used, the handling and mixing of these chemicals, and the use of personal protective equipment (PPE) to prevent exposures to blood and body fluids11 and contact with chemicals. n Training, competency evaluation, and a quality improvement program are essential.
n n n n n n
Environmental Protection Agency (EPA) registration and rating as hospital grade; microorganisms affected; required contact time; manufacturers’ instructions for use; compatibility with surfaces, equipment, and cleaning materials; patient population (eg, neonates and pediatric patients, adults); and safety of the product.
DISCUSSION The updated RP document provides specific guidance for cleaning processes, for the selection of appropriate cleaning equipment and supplies, and for ongoing education and quality improvement. More information about several of the recommendations is discussed in this section. Readers are strongly encouraged to read the full RP document for a more complete understanding of all of the recommendations.
The team also should determine when enhanced environmental cleaning should be implemented and develop cleaning and disinfection procedures to use during construction, renovation, repair, demolition, or disaster recovery. It is important for the team to establish the appropriate use of chemicals and disinfectants. For example, personnel should not use high-level disinfectants or liquid chemical sterilants to clean and disinfect environmental surfaces because they are not intended for this use. Similarly, personnel should not use alcohol to disinfect large environmental surfaces because alcohol is not an EPA-registered disinfectant. Use of reusable or single-use cleaning materials, including mop heads and cloths, is acceptable.
Recommendation I Recommendation I, a new recommendation, states that a multidisciplinary team consisting of perioperative nurses and sterile processing, environmental services, and infection prevention personnel “should establish cleaning procedures and frequencies in the perioperative practice setting.”8(p256) This includes developing guidelines for the selection of cleaning detergents and chemicals, and for the frequency of cleaning, including for high-touch objects and surfaces. The document provides operational procedures for the multidisciplinary team to follow to facilitate
Recommendation II New to the recommendation that patients should be “provided a clean, safe environment”8(p258) is that personnel should consider floors in the perioperative practice setting to be contaminated at all times. Thus, personnel should consider items that touch the floor for any amount of time to be contaminated, and these should be disinfected before patient use. Noncritical equipment and surfaces that are difficult to clean or that cannot withstand disinfection (eg, computer keyboards) may be protected from contamination by use of a barrier cover. After each use, the barrier should be removed or cleaned
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RP IMPLEMENTATION GUIDE: ENVIRONMENTAL CLEANING and disinfected according to the manufacturer’s instructions for use. Recommendation III “A clean environment should be reestablished after the patient is transferred from the area.”8(p260) This requires the multidisciplinary team to establish procedures for cleaning reusable noncritical, nonporous surfaces (eg, mattress covers, pneumatic tourniquet cuffs, blood pressure cuffs, other patient equipment) after each individual patient use and according to the manufacturers’ recommendations. High-touch areas, including control panels, switches,
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knobs, work areas, and handles, should be cleaned, and the floor and walls of ORs and procedure rooms should be cleaned and disinfected after each surgical or invasive procedure if soiled or potentially soiled as evidenced by the presence of splash, splatter, or spray during the procedure. Examples of cleaning frequencies for ORs and procedure rooms are provided in Figure 1. Personnel should clean preoperative and postoperative patient care areas after each patient has left the area and clean and disinfect transport equipment and other mobile equipment, including suction regulators, medical gas regulators, imaging viewers, radiology
Figure 1. Example of cleaning frequencies: operating and procedures rooms. Reprinted with permission from “Recommended practices for environmental cleaning.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:261.
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equipment, and warming equipment, after each patient use. Recommendation VII The recommendation that procedures for environmental cleaning and disinfection and use of PPE should be established for circumstances that may require contact or airborne precautions has been expanded to include “circumstances that may require special cleaning procedures (ie, multidrugresistant organisms, C difficile, prion diseases, construction, environmental contamination).”8(p266) Enhanced environmental cleaning procedures should be implemented after the care of patients infected or colonized with MDROs. This involves cleaning all high-touch objects, in addition to other objects cleaned as part of routine cleaning, after the patient has left the area. Cleaning personnel should wear PPE (ie, gowns, gloves) when performing enhanced environmental cleaning. Personnel also should implement cleaning procedures to reduce dust and potential contamination during internal or external construction, repair, and renovation projects. Construction barriers should be assessed for effectiveness. Disaster remediation
ALLEN after a flood or other water-related emergency should include performing terminal cleaning of affected areas after water is removed.
The Final Three The final recommendations in each AORN RP document discuss education/competency, policies and procedures, and quality assurance/performance improvement, as applicable. These topics are integral to the implementation of AORN practice recommendations. Personnel should receive initial and ongoing education and competency validation as applicable to their roles. Implementing new and updated recommended practices affords an excellent opportunity to create or update competency materials and validation tools. AORN’s perioperative competencies team has developed the AORN Perioperative Competency Verification Tools and Job Descriptions12 to assist perioperative personnel in developing competency evaluation tools and position descriptions. Policies and procedures should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting. New or updated recommended practices may present an opEducational Resources portunity for collaborative efforts among nurses and n AORN Video Library: Environmental Sanitation, Terminal personnel from other deCleaning, and Disinfection [DVD]. http://cine-med.com/index partments within the facility .php?nav¼aorn&cat¼all. to develop organization-wide n AORN Video Library: Prevention of Transmissible Infections in policies and procedures that the Perioperative Practice Setting [DVD]. http://cine-med.com/ support the recommended index.php?nav¼aorn&cat¼all. practices. The AORN Policy n Recommended Practices for Environmental Cleaning [Webinar]. and Procedure Templates, AORN, Inc. http://www.aorn.org/Events/Webinars/Previously_ 3rd edition,13 provides a Recorded_Webinars.aspx#EnvironmentalCleaning. collection of 30 sample n Recommended practices for prevention of transmissible inpolicies and customizable fections in the perioperative practice setting. In: Perioperative templates based on AORN’s Standards and Recommended Practices. Denver, CO: AORN, Perioperative Standards Inc; 2014:385-417. and Recommended Practices.14 Regular quality Web site access verified March 13, 2014. improvement projects are
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RP IMPLEMENTATION GUIDE: ENVIRONMENTAL CLEANING necessary to improve patient safety and to help ensure safe, quality care. For details on the final three practice recommendations that are specific to the RP document discussed in this article, refer to the full text of the RP document.8
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complete the room turnover cleaning process. Reestablishing a clean environment after the patient leaves the room decreases the risk of crosscontamination and disease transmission. HOSPITAL PATIENT SCENARIO The perioperative team at Community Hospital is conducting a quality assurance and performance improvement activity “to improve understanding of and compliance with the principles and processes of environmental cleaning.”8(p270) After a surgical procedure, the infection preventionist marks hightouch areas with a fluorescent marker that is not visible to the environmental support (EVS) team members; subsequently, the efficacy of the cleaning can be qualitatively evaluated by using a fluorescent light. If the area is not adequately cleaned, then the marking is visible under the fluorescent light and the infection preventionist can give immediate feedback to the EVS team. Mr A, a 56-year-old black man who is obese and has a history of hypertension, diabetes mellitus, and coronary artery disease, is admitted for emergency
AMBULATORY PATIENT SCENARIO The first patient of the day at a busy free-standing ambulatory surgery center is scheduled to undergo repair of an inguinal hernia in OR #3 at 9 AM. The RN circulator assigned to the procedure assesses OR #3 to determine whether it is a clean and safe environment for the procedure. She confirms that all the ORs were terminally cleaned by the surgical team members after the last scheduled procedures were completed the previous day. The Centers for Disease Control and Prevention recommends that terminal cleaning and disinfection of the perioperative environment be performed after the last procedure has been completed to decrease the number of pathogens, dust, and debris in the room.15 The RN circulator and scrub person methodically damp dust all horizontal surfaces in the room (eg, furniture, surgical lights, booms, equipment) from top Resources for Implementation to bottom by using a clean, low-linting cloth moistened n AORN SyntegrityÒ Framework. AORN, Inc. http://www.aorn with an EPA-registered, .org/syntegrity. hospital-grade disinfectant. n ORNurseLinkTM. http://ornurselink.aorn.org. After the damp dusting is n Perioperative Competency Verification Tools and Job Decompleted, the scrub person scriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. http:// brings the case cart with the www.aorn.org/CompetencyTools. supplies for the procedure n Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, into the room, and the RN CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_ circulator and scrub perPublications/AORN_Publications/Policy_and_Procedure_ son begin to set up for the Templates.aspx. procedure. n The Roadmap to ASC Compliance [CD-ROM]. Denver, CO: The procedure is unAORN, Inc; 2012. http://www.aornbookstore.org//Product/ eventful, and after the product.asp?sku¼MAN543&dept_id¼1. anesthesia professional and RN circulator have transSyntegrity is a registered trademark and ORNurseLink is a tradeferred the patient to the mark of AORN, Inc, Denver, CO. postanesthesia care unit, Web site access verified March 13, 2014. the surgical team members
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surgery. Three weeks before, he was hospitalized with profuse diarrhea and was diagnosed with C difficile colitis. He was treated and discharged after being hospitalized for six days. Now Mr A has been readmitted with diarrhea and a suspected bowel perforation. Scheduling personnel notify the OR manager that Mr A is being treated with contact isolation precautions for C difficile. The perioperative team prepares OR #1, the designated emergency room for the day, for an exploratory laparotomy with potential bowel resection. The OR manager notifies all personnel, including the RN circulator, scrub person, OR transporter, resident, physician assistant, anesthesia professional, postanesthesia care unit nurses, and EVS personnel that the patient is being treated with isolation precautions for C difficile. When the room is ready, the OR transporter transfers Mr A directly to OR #1, adhering to isolation procedures. The RN circulator and the physician assistant wear isolation gowns and gloves while they transfer Mr A from the stretcher and secure him to the OR bed. After examining Mr A’s abdomen, the surgeon performs a bowel resection. When the procedure is complete, the RN circulator and anesthesia professional transfer Mr A to the isolation room in the postanesthesia care unit. Before EVS personnel are notified to clean the room, the infection preventionist tags several high-touch areas with the fluorescent marker. The EVS team dons isolation fluid-resistant gowns, gloves, and applicable PPE according to the institution’s approved policies and procedures for cleaning an isolation room and the Occupational Safety and Health Administration Bloodborne Pathogens Standard11 requirements for personnel safety. Because the pathogen has been identified as C difficile, the EVS team uses an EPAregistered cleaning agent that is effective against C difficile spores to clean the room.16 The EVS personnel use a checklist to ensure that all the critical equipment that requires cleaning is cleaned adequately. After the EVS team completes the room cleaning and the infection preventionist has 578 j AORN Journal
assessed the quality of cleaning with the fluorescent light, the OR manager verifies that a clean and safe environment has been reestablished and that the room is ready to be used for another procedure. As a way to further improve patient care and ensure a clean environment, the team at Community Hospital considers additional qualitative and quantitative measures, including culture and adenosine triphosphate testing, as tools that perioperative managers can use to implement quality improvement processes. The tests are particularly effective because adenosine triphosate is present in all living cells, so an adenosine triphosate monitoring system can detect the amount of organic matter that remains after cleaning has been completed. Such monitoring procedures would allow the infection preventionist to provide immediate feedback to EVS personnel and facilitate compliance with the approved cleaning policies and procedures of the institution.17 CONCLUSION In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health careeassociated infections, including surgical site infections, and the increasing prevalence of MDROs. The “Recommended practices for environmental cleaning” can be implemented in the many diverse settings in which perioperative nurses practice as part of the surgical team. Perioperative managers and leaders must work collaboratively with the environmental services leaders to promote a culture of safety through environmental cleanliness in health care settings. References 1. Stiefel U, Cadnum JL, Eckstein BC, Guerrrero DM, Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185-187. 2. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 2009;73(4):378-385. 3. Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial
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4.
5.
6.
7.
8.
9.
10.
11.
pathogens. Infect Control Hosp Epidemiol. 2011;32(7): 687-699. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. Rutala WA, Weber DJ; the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disin fection_Nov_2008.pdf. Accessed March 12, 2014. Faires MC, Pearl DL, Berke O, Reid-Smith RJ, Weese JS. The identification and epidemiology of methicillinresistant Staphylococcus aureus and Clostridium difficile in patient rooms and the ward environment. BMC Infect Dis. 2013;13:342. http://www.biomedcentral.com/1471 -2334/13/342. Accessed March 12, 2014. Cozad A, Jones RD. Disinfection and the prevention of infectious disease. Am J Infect Control. 2003;31(4): 243-254. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-276. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. Allen G. Managing patients with multidrug-resistant organisms: implementing isolation precaution procedures in the perioperative setting. Perioper Nurs Clin. 2010; 5(4):419-426. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule. Fed Regist. 1991;56:64003-64182 (29 CFR x1910.1030).
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12. Perioperative Competency Verification Tools and Job Descriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. 13. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. 14. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014. 15. Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. 16. Frequently asked questions about Clostridium difficile for healthcare providers. Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/organisms/cdiff/ Cdiff_faqs_HCP.html. Accessed March 12, 2014. 17. Guh A, Carling P; Environmental Evaluation Workgroup. Options for evaluating environmental cleaning. 2010. Centers for Disease Control and Prevention. http:// www.cdc.gov/HAI/toolkits/Evaluating-Environmental -Cleaning.html. Accessed March 12, 2014.
George Allen, PhD, MS, BSN, RN, CNOR, CIC, is the director, infection control, at Downstate Medical Center and a clinical assistant professor at SUNY College of Health Related Professions, Brooklyn, NY. Dr Allen has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION
2.0
CONTINUING EDUCATION
Implementing AORN Recommended www.aorn.org/CE Practices for Environmental Cleaning PURPOSE/GOAL To provide the learner with knowledge specific to environmental cleaning and disinfection in the perioperative practice setting.
OBJECTIVES 1. 2. 3. 4. 5.
Discuss the AORN recommended practices for environmental cleaning. Describe risks associated with infectious pathogens. Identify factors to consider when selecting cleaning products. Discuss frequency for cleaning different surfaces. Describe enhanced cleaning procedures.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
The risk for the transmission of pathogenic microorganisms on environmental surfaces is related to their 1. ability to be transferred to many different types of surfaces. 2. ability to be transferred to the hands of health care personnel. 3. capacity to survive for varying lengths of time on surfaces. 4. mere presence. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4 The updated AORN “Recommended practices for environmental cleaning” has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough
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cleanliness in a culture of safety and mutual support. a. true b. false 3.
Multidrug-resistant organisms 1. are difficult to control. 2. have become less prevalent. 3. increase the incidence of morbidity in infected patients. 4. stay in the environment longer. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
4.
When selecting a cleaning product, some factors a multidisciplinary team should evaluate include its 1. Environmental Protection Agency registration. 2. compatibility with surfaces, equipment, and cleaning materials. 3. manufacturer’s instructions for use.
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CE EXAMINATION 4.
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required contact time. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
5.
Personnel should use alcohol to disinfect large environmental surfaces. a. true b. false
6.
Items that touch the floor for _________ should be considered contaminated and should be disinfected before patient use. a. any amount of time b. 5 seconds c. 10 seconds d. 15 seconds
7.
Based on the information in Figure 1, walls should be cleaned a. after every patient. b. after every patient, if used. c. when enhanced cleaning is indicated. d. if soiled.
8.
Based on the information in Figure 1, _________ should be cleaned after every patient.
1. 2. 3. 4. 5.
anesthesia machine IV poles OR bed strap Mayo stand trash containers a. 1 and 2 b. 1, 2, and 3 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
9.
Based on the information in Figure 1, footstools should be cleaned a. after every patient. b. after every patient, if used. c. when enhanced cleaning is indicated. d. if soiled.
10.
Special cleaning procedures may be required in the presence of 1. construction. 2. environmental contamination. 3. prion diseases. 4. multidrug-resistant organisms. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION
2.0
CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended www.aorn.org/CE Practices for Environmental Cleaning
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the AORN recommended practices for environmental cleaning. Low 1. 2. 3. 4. 5. High 2. Describe risks associated with infectious pathogens. Low 1. 2. 3. 4. 5. High 3. Identify factors to consider when selecting cleaning products. Low 1. 2. 3. 4. 5. High 4. Discuss frequency for cleaning different surfaces. Low 1. 2. 3. 4. 5. High 5. Describe enhanced cleaning procedures. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 10. Our accrediting body requires that we verify the time you needed to complete the 2.0 continuing education contact hour (120-minute) program: _________________________________
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2.0
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14517 Session: #0001 Fee: Members $16, Nonmembers $32
Conflict of Interest Disclosures
The CE contact hours for this article expire May 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to environmental cleaning and disinfection in the perioperative practice setting.
Objectives 1. Discuss the AORN recommended practices for environmental cleaning. 2. Describe risks associated with infectious pathogens. 3. Identify factors to consider when selecting cleaning products. 4. Discuss frequency for cleaning different surfaces. 5. Describe enhanced cleaning procedures.
George Allen, PhD, MS, BSN, RN, CNOR, CIC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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RECOMMENDED PRACTICES Implementing AORN Recommended Practices for Environmental Cleaning 2.0 GEORGE ALLEN, PhD, MS, BSN, RN, CNOR, CIC
www.aorn.org/CE
ABSTRACT In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health careeassociated infections. AORN’s “Recommended practices for environmental cleaning” is an evidence-based document that provides specific guidance for cleaning processes, for the selection of appropriate cleaning equipment and supplies, and for ongoing education and quality improvement. This updated recommended practices document has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support. Perioperative nurses, as the primary advocates for patients while they are being cared for in the perioperative setting, should help ensure that a safe, clean environment is reestablished after each surgical procedure. AORN J 99 (May 2014) 571-579. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.01.023 Key words: environmental cleaning, health careeassociated infections, pathogenic microorganisms, multidrug-resistant organisms, asepsis, disinfection.
R
esearchers have linked the development of health careeassociated infections to external sources, such as environmental surfaces. The health care environment, including the perioperative setting, is now well documented as a primary source for infection.1-6 The accumulation of dust, debris, and other microbial contaminants on surfaces in health care settings is a potential source for health careeassociated
infections. The risk for the transmission of pathogenic microorganisms, including multidrugresistant organisms (MDROs), is related to the mere presence of pathogenic microorganisms on environmental surfaces, their capacity to survive for varying lengths of time on these surfaces, and their ability to be transferred to many different types of surfaces, including the hands of health care personnel.7
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Although principles of asepsis and aseptic techniques are the cornerstone of practice in the OR, procedures to prevent the development of surgical site and other infections depend on maintaining sanitary conditions. Consequently, health care providers should implement efficient and effective cleaning procedures to maintain a clean and healthy environment. Perioperative nurses, as the primary advocates for patients while they are being cared for in the perioperative setting, should help ensure that a safe, clean environment is reestablished after each surgical procedure. This article provides a brief review of AORN’s “Recommended practices for environmental cleaning,”8 an evidence-based document that can guide clinicians as they care for patients in the perioperative setting. WHAT IS NEW? The AORN Recommended Practices Advisory Board approved the updated “Recommended practices for environmental cleaning” in November 2013. The recommended practices (RP) document was revised based on a review of available evidence. A medical librarian conducted searches of the nationally and internationally recognized databases for English-language literature published between 2008 and 2013. The lead author, a master’s prepared perioperative nursing professional, together with the medical librarian also identified relevant guidelines from government and standardssetting bodies to develop the recommendations.8 The evidence was appraised by using the AORN Evidence Rating Model (Table 1) to assign evidence ratings: 1. 2. 3. 4. 5.
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Strong Evidence or Regulatory Requirement, Moderate Evidence, Limited Evidence, Benefits Balanced With Harm, or No Evidence.
Evidence rating has emerged as an issue of critical importance because of the growing demand that health care decisions be based on the best evidence available in the scientific literature.9 572 j AORN Journal
The scope of the RP document includes all perioperative areas, including the preoperative and postoperative areas, ORs and procedure rooms, and semirestricted areas, and the document now includes sterile processing areas as well. In addition to providing guidance for environmental cleaning and disinfection to minimize the exposure of surgical patients and health care personnel to potentially infectious pathogens, the updated document has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support. Recommendations relating to competency of personnel, policy and procedures, and quality improvement have been updated to incorporate the team approach. Other new content addresses high-touch objects, enhanced environmental cleaning, cleaning methods, and measurement of cleanliness. RATIONALE Historically, the perioperative environment has been viewed as the singular area in the health care setting where the highest degree of asepsis and adherence to sterile technique is practiced. However, MDROs, such as n n
n n n
methicillin-resistant Staphylococcus aureus, S aureus with resistance to vancomycin (ie, vancomycin-intermediate S aureus, vancomycinresistant S aureus), vancomycin-resistant enterococci, extended-spectrum b-lactamaseeproducing gram-negative bacilli, and Clostridium difficile,
have become more prevalent,10 stay in the environment longer, are difficult to control, and increase the incidence of both morbidity and mortality when they are transmitted to patients. Surfaces that health care providers frequently touch in the perioperative environment may present a high risk for these pathogens to be transmitted, so routine and effective cleaning is essential. Thorough cleaning and disinfection of perioperative areas can be facilitated
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TABLE 1. AORN Crosswalk: Appraisal Score to Evidence Rating Appraisal score Research
Non-research
AORN Evidence Rating Model Evidence rating
IA
IVA Regulatory
1: Strong Evidence 1: Regulatory Requirement
IB IIA, IIB IIIA, IIIB
IVB VA, VB
2: Moderate Evidence
IC IIC IIIC
IVC VC
3: Limited Evidence
4: Benefits Balanced With Harms
5: No Evidence
Evidence requirements Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews; rigorously developed clinical practice guidelines; or regulatory requirements n Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis n Supportive evidence from a single, well-conducted, randomized controlled trial n Guidelines developed by a panel of experts that derive from an explicit literature search methodology and include evidence appraisal and synthesis of the evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence” n Supportive evidence from a well-conducted research study n Guidelines developed by a panel of experts that are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence n Nonresearch evidence with consistent results and fairly definitive conclusions Interventions or activities for which there currently is insufficient evidence or evidence of inadequate quality n Supportive evidence from a poorly conducted research study n Evidence from nonexperimental studies with high potential for bias n Guidelines developed largely by consensus or expert opinion n Nonresearch evidence with insufficient evidence or inconsistent results n Conflicting evidence but where the preponderance of the evidence supports the recommendation Selected interventions or activities for which the AORN Recommended Practices Advisory Board is of the opinion that the desirable effects of following this recommendation outweigh the harms Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation n Consensus opinion
Reprinted with permission from “Introduction to the AORN recommended practices.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:46.
by the implementation of the practice recommendations in the RP document. Because these recommendations are based on the best available evidence and because perioperative personnel have long embraced patient safety and reduction
in surgical site infections into their culture, incorporating the practice recommendations into the routine policies and procedures of the organization can be accomplished with minimal disruptive culture shifts. AORN Journal j 573
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Concepts and processes from this RP document that are critical and that may be assessed by regulatory agencies include the following:
application of this recommendation. For example, when selecting a cleaning product, the team should evaluate the
n
n
There is a team and collaborative approach to cleaning the OR. n Cleaning procedures and schedules should be developed and available in writing, including the description of routine cleaning, enhanced environmental cleaning, and terminal cleaning. n Personnel safety and patient safety must be addressed during the cleaning process, with attention to the chemicals and detergents used, the handling and mixing of these chemicals, and the use of personal protective equipment (PPE) to prevent exposures to blood and body fluids11 and contact with chemicals. n Training, competency evaluation, and a quality improvement program are essential.
n n n n n n
Environmental Protection Agency (EPA) registration and rating as hospital grade; microorganisms affected; required contact time; manufacturers’ instructions for use; compatibility with surfaces, equipment, and cleaning materials; patient population (eg, neonates and pediatric patients, adults); and safety of the product.
DISCUSSION The updated RP document provides specific guidance for cleaning processes, for the selection of appropriate cleaning equipment and supplies, and for ongoing education and quality improvement. More information about several of the recommendations is discussed in this section. Readers are strongly encouraged to read the full RP document for a more complete understanding of all of the recommendations.
The team also should determine when enhanced environmental cleaning should be implemented and develop cleaning and disinfection procedures to use during construction, renovation, repair, demolition, or disaster recovery. It is important for the team to establish the appropriate use of chemicals and disinfectants. For example, personnel should not use high-level disinfectants or liquid chemical sterilants to clean and disinfect environmental surfaces because they are not intended for this use. Similarly, personnel should not use alcohol to disinfect large environmental surfaces because alcohol is not an EPA-registered disinfectant. Use of reusable or single-use cleaning materials, including mop heads and cloths, is acceptable.
Recommendation I Recommendation I, a new recommendation, states that a multidisciplinary team consisting of perioperative nurses and sterile processing, environmental services, and infection prevention personnel “should establish cleaning procedures and frequencies in the perioperative practice setting.”8(p256) This includes developing guidelines for the selection of cleaning detergents and chemicals, and for the frequency of cleaning, including for high-touch objects and surfaces. The document provides operational procedures for the multidisciplinary team to follow to facilitate
Recommendation II New to the recommendation that patients should be “provided a clean, safe environment”8(p258) is that personnel should consider floors in the perioperative practice setting to be contaminated at all times. Thus, personnel should consider items that touch the floor for any amount of time to be contaminated, and these should be disinfected before patient use. Noncritical equipment and surfaces that are difficult to clean or that cannot withstand disinfection (eg, computer keyboards) may be protected from contamination by use of a barrier cover. After each use, the barrier should be removed or cleaned
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RP IMPLEMENTATION GUIDE: ENVIRONMENTAL CLEANING and disinfected according to the manufacturer’s instructions for use. Recommendation III “A clean environment should be reestablished after the patient is transferred from the area.”8(p260) This requires the multidisciplinary team to establish procedures for cleaning reusable noncritical, nonporous surfaces (eg, mattress covers, pneumatic tourniquet cuffs, blood pressure cuffs, other patient equipment) after each individual patient use and according to the manufacturers’ recommendations. High-touch areas, including control panels, switches,
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knobs, work areas, and handles, should be cleaned, and the floor and walls of ORs and procedure rooms should be cleaned and disinfected after each surgical or invasive procedure if soiled or potentially soiled as evidenced by the presence of splash, splatter, or spray during the procedure. Examples of cleaning frequencies for ORs and procedure rooms are provided in Figure 1. Personnel should clean preoperative and postoperative patient care areas after each patient has left the area and clean and disinfect transport equipment and other mobile equipment, including suction regulators, medical gas regulators, imaging viewers, radiology
Figure 1. Example of cleaning frequencies: operating and procedures rooms. Reprinted with permission from “Recommended practices for environmental cleaning.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:261.
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equipment, and warming equipment, after each patient use. Recommendation VII The recommendation that procedures for environmental cleaning and disinfection and use of PPE should be established for circumstances that may require contact or airborne precautions has been expanded to include “circumstances that may require special cleaning procedures (ie, multidrugresistant organisms, C difficile, prion diseases, construction, environmental contamination).”8(p266) Enhanced environmental cleaning procedures should be implemented after the care of patients infected or colonized with MDROs. This involves cleaning all high-touch objects, in addition to other objects cleaned as part of routine cleaning, after the patient has left the area. Cleaning personnel should wear PPE (ie, gowns, gloves) when performing enhanced environmental cleaning. Personnel also should implement cleaning procedures to reduce dust and potential contamination during internal or external construction, repair, and renovation projects. Construction barriers should be assessed for effectiveness. Disaster remediation
ALLEN after a flood or other water-related emergency should include performing terminal cleaning of affected areas after water is removed.
The Final Three The final recommendations in each AORN RP document discuss education/competency, policies and procedures, and quality assurance/performance improvement, as applicable. These topics are integral to the implementation of AORN practice recommendations. Personnel should receive initial and ongoing education and competency validation as applicable to their roles. Implementing new and updated recommended practices affords an excellent opportunity to create or update competency materials and validation tools. AORN’s perioperative competencies team has developed the AORN Perioperative Competency Verification Tools and Job Descriptions12 to assist perioperative personnel in developing competency evaluation tools and position descriptions. Policies and procedures should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting. New or updated recommended practices may present an opEducational Resources portunity for collaborative efforts among nurses and n AORN Video Library: Environmental Sanitation, Terminal personnel from other deCleaning, and Disinfection [DVD]. http://cine-med.com/index partments within the facility .php?nav¼aorn&cat¼all. to develop organization-wide n AORN Video Library: Prevention of Transmissible Infections in policies and procedures that the Perioperative Practice Setting [DVD]. http://cine-med.com/ support the recommended index.php?nav¼aorn&cat¼all. practices. The AORN Policy n Recommended Practices for Environmental Cleaning [Webinar]. and Procedure Templates, AORN, Inc. http://www.aorn.org/Events/Webinars/Previously_ 3rd edition,13 provides a Recorded_Webinars.aspx#EnvironmentalCleaning. collection of 30 sample n Recommended practices for prevention of transmissible inpolicies and customizable fections in the perioperative practice setting. In: Perioperative templates based on AORN’s Standards and Recommended Practices. Denver, CO: AORN, Perioperative Standards Inc; 2014:385-417. and Recommended Practices.14 Regular quality Web site access verified March 13, 2014. improvement projects are
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RP IMPLEMENTATION GUIDE: ENVIRONMENTAL CLEANING necessary to improve patient safety and to help ensure safe, quality care. For details on the final three practice recommendations that are specific to the RP document discussed in this article, refer to the full text of the RP document.8
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complete the room turnover cleaning process. Reestablishing a clean environment after the patient leaves the room decreases the risk of crosscontamination and disease transmission. HOSPITAL PATIENT SCENARIO The perioperative team at Community Hospital is conducting a quality assurance and performance improvement activity “to improve understanding of and compliance with the principles and processes of environmental cleaning.”8(p270) After a surgical procedure, the infection preventionist marks hightouch areas with a fluorescent marker that is not visible to the environmental support (EVS) team members; subsequently, the efficacy of the cleaning can be qualitatively evaluated by using a fluorescent light. If the area is not adequately cleaned, then the marking is visible under the fluorescent light and the infection preventionist can give immediate feedback to the EVS team. Mr A, a 56-year-old black man who is obese and has a history of hypertension, diabetes mellitus, and coronary artery disease, is admitted for emergency
AMBULATORY PATIENT SCENARIO The first patient of the day at a busy free-standing ambulatory surgery center is scheduled to undergo repair of an inguinal hernia in OR #3 at 9 AM. The RN circulator assigned to the procedure assesses OR #3 to determine whether it is a clean and safe environment for the procedure. She confirms that all the ORs were terminally cleaned by the surgical team members after the last scheduled procedures were completed the previous day. The Centers for Disease Control and Prevention recommends that terminal cleaning and disinfection of the perioperative environment be performed after the last procedure has been completed to decrease the number of pathogens, dust, and debris in the room.15 The RN circulator and scrub person methodically damp dust all horizontal surfaces in the room (eg, furniture, surgical lights, booms, equipment) from top Resources for Implementation to bottom by using a clean, low-linting cloth moistened n AORN SyntegrityÒ Framework. AORN, Inc. http://www.aorn with an EPA-registered, .org/syntegrity. hospital-grade disinfectant. n ORNurseLinkTM. http://ornurselink.aorn.org. After the damp dusting is n Perioperative Competency Verification Tools and Job Decompleted, the scrub person scriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. http:// brings the case cart with the www.aorn.org/CompetencyTools. supplies for the procedure n Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, into the room, and the RN CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_ circulator and scrub perPublications/AORN_Publications/Policy_and_Procedure_ son begin to set up for the Templates.aspx. procedure. n The Roadmap to ASC Compliance [CD-ROM]. Denver, CO: The procedure is unAORN, Inc; 2012. http://www.aornbookstore.org//Product/ eventful, and after the product.asp?sku¼MAN543&dept_id¼1. anesthesia professional and RN circulator have transSyntegrity is a registered trademark and ORNurseLink is a tradeferred the patient to the mark of AORN, Inc, Denver, CO. postanesthesia care unit, Web site access verified March 13, 2014. the surgical team members
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surgery. Three weeks before, he was hospitalized with profuse diarrhea and was diagnosed with C difficile colitis. He was treated and discharged after being hospitalized for six days. Now Mr A has been readmitted with diarrhea and a suspected bowel perforation. Scheduling personnel notify the OR manager that Mr A is being treated with contact isolation precautions for C difficile. The perioperative team prepares OR #1, the designated emergency room for the day, for an exploratory laparotomy with potential bowel resection. The OR manager notifies all personnel, including the RN circulator, scrub person, OR transporter, resident, physician assistant, anesthesia professional, postanesthesia care unit nurses, and EVS personnel that the patient is being treated with isolation precautions for C difficile. When the room is ready, the OR transporter transfers Mr A directly to OR #1, adhering to isolation procedures. The RN circulator and the physician assistant wear isolation gowns and gloves while they transfer Mr A from the stretcher and secure him to the OR bed. After examining Mr A’s abdomen, the surgeon performs a bowel resection. When the procedure is complete, the RN circulator and anesthesia professional transfer Mr A to the isolation room in the postanesthesia care unit. Before EVS personnel are notified to clean the room, the infection preventionist tags several high-touch areas with the fluorescent marker. The EVS team dons isolation fluid-resistant gowns, gloves, and applicable PPE according to the institution’s approved policies and procedures for cleaning an isolation room and the Occupational Safety and Health Administration Bloodborne Pathogens Standard11 requirements for personnel safety. Because the pathogen has been identified as C difficile, the EVS team uses an EPAregistered cleaning agent that is effective against C difficile spores to clean the room.16 The EVS personnel use a checklist to ensure that all the critical equipment that requires cleaning is cleaned adequately. After the EVS team completes the room cleaning and the infection preventionist has 578 j AORN Journal
assessed the quality of cleaning with the fluorescent light, the OR manager verifies that a clean and safe environment has been reestablished and that the room is ready to be used for another procedure. As a way to further improve patient care and ensure a clean environment, the team at Community Hospital considers additional qualitative and quantitative measures, including culture and adenosine triphosphate testing, as tools that perioperative managers can use to implement quality improvement processes. The tests are particularly effective because adenosine triphosate is present in all living cells, so an adenosine triphosate monitoring system can detect the amount of organic matter that remains after cleaning has been completed. Such monitoring procedures would allow the infection preventionist to provide immediate feedback to EVS personnel and facilitate compliance with the approved cleaning policies and procedures of the institution.17 CONCLUSION In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health careeassociated infections, including surgical site infections, and the increasing prevalence of MDROs. The “Recommended practices for environmental cleaning” can be implemented in the many diverse settings in which perioperative nurses practice as part of the surgical team. Perioperative managers and leaders must work collaboratively with the environmental services leaders to promote a culture of safety through environmental cleanliness in health care settings. References 1. Stiefel U, Cadnum JL, Eckstein BC, Guerrrero DM, Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185-187. 2. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 2009;73(4):378-385. 3. Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial
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4.
5.
6.
7.
8.
9.
10.
11.
pathogens. Infect Control Hosp Epidemiol. 2011;32(7): 687-699. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. Rutala WA, Weber DJ; the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disin fection_Nov_2008.pdf. Accessed March 12, 2014. Faires MC, Pearl DL, Berke O, Reid-Smith RJ, Weese JS. The identification and epidemiology of methicillinresistant Staphylococcus aureus and Clostridium difficile in patient rooms and the ward environment. BMC Infect Dis. 2013;13:342. http://www.biomedcentral.com/1471 -2334/13/342. Accessed March 12, 2014. Cozad A, Jones RD. Disinfection and the prevention of infectious disease. Am J Infect Control. 2003;31(4): 243-254. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-276. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. Allen G. Managing patients with multidrug-resistant organisms: implementing isolation precaution procedures in the perioperative setting. Perioper Nurs Clin. 2010; 5(4):419-426. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule. Fed Regist. 1991;56:64003-64182 (29 CFR x1910.1030).
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12. Perioperative Competency Verification Tools and Job Descriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. 13. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. 14. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014. 15. Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. 16. Frequently asked questions about Clostridium difficile for healthcare providers. Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/organisms/cdiff/ Cdiff_faqs_HCP.html. Accessed March 12, 2014. 17. Guh A, Carling P; Environmental Evaluation Workgroup. Options for evaluating environmental cleaning. 2010. Centers for Disease Control and Prevention. http:// www.cdc.gov/HAI/toolkits/Evaluating-Environmental -Cleaning.html. Accessed March 12, 2014.
George Allen, PhD, MS, BSN, RN, CNOR, CIC, is the director, infection control, at Downstate Medical Center and a clinical assistant professor at SUNY College of Health Related Professions, Brooklyn, NY. Dr Allen has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION
2.0
CONTINUING EDUCATION
Implementing AORN Recommended www.aorn.org/CE Practices for Environmental Cleaning PURPOSE/GOAL To provide the learner with knowledge specific to environmental cleaning and disinfection in the perioperative practice setting.
OBJECTIVES 1. 2. 3. 4. 5.
Discuss the AORN recommended practices for environmental cleaning. Describe risks associated with infectious pathogens. Identify factors to consider when selecting cleaning products. Discuss frequency for cleaning different surfaces. Describe enhanced cleaning procedures.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
The risk for the transmission of pathogenic microorganisms on environmental surfaces is related to their 1. ability to be transferred to many different types of surfaces. 2. ability to be transferred to the hands of health care personnel. 3. capacity to survive for varying lengths of time on surfaces. 4. mere presence. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4 The updated AORN “Recommended practices for environmental cleaning” has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough
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cleanliness in a culture of safety and mutual support. a. true b. false 3.
Multidrug-resistant organisms 1. are difficult to control. 2. have become less prevalent. 3. increase the incidence of morbidity in infected patients. 4. stay in the environment longer. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
4.
When selecting a cleaning product, some factors a multidisciplinary team should evaluate include its 1. Environmental Protection Agency registration. 2. compatibility with surfaces, equipment, and cleaning materials. 3. manufacturer’s instructions for use.
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CE EXAMINATION 4.
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required contact time. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
5.
Personnel should use alcohol to disinfect large environmental surfaces. a. true b. false
6.
Items that touch the floor for _________ should be considered contaminated and should be disinfected before patient use. a. any amount of time b. 5 seconds c. 10 seconds d. 15 seconds
7.
Based on the information in Figure 1, walls should be cleaned a. after every patient. b. after every patient, if used. c. when enhanced cleaning is indicated. d. if soiled.
8.
Based on the information in Figure 1, _________ should be cleaned after every patient.
1. 2. 3. 4. 5.
anesthesia machine IV poles OR bed strap Mayo stand trash containers a. 1 and 2 b. 1, 2, and 3 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
9.
Based on the information in Figure 1, footstools should be cleaned a. after every patient. b. after every patient, if used. c. when enhanced cleaning is indicated. d. if soiled.
10.
Special cleaning procedures may be required in the presence of 1. construction. 2. environmental contamination. 3. prion diseases. 4. multidrug-resistant organisms. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION
2.0
CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended www.aorn.org/CE Practices for Environmental Cleaning
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the AORN recommended practices for environmental cleaning. Low 1. 2. 3. 4. 5. High 2. Describe risks associated with infectious pathogens. Low 1. 2. 3. 4. 5. High 3. Identify factors to consider when selecting cleaning products. Low 1. 2. 3. 4. 5. High 4. Discuss frequency for cleaning different surfaces. Low 1. 2. 3. 4. 5. High 5. Describe enhanced cleaning procedures. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 10. Our accrediting body requires that we verify the time you needed to complete the 2.0 continuing education contact hour (120-minute) program: _________________________________
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