Recommended Practices for

Environmental Cleaning

Amber Wood, MSN, RN, CNOR, CIC, CPNNovember 13, 2013

Amber Wood is a Perioperative Nursing Specialist at AORN where she has

served as lead author for the AORN Recommended Practices for

Environmental Cleaning. Amber offers clinical information to members via the

AORN Consult Line and contributes regularly to the Clinical Issues column in

the AORN Journal. She serves as the staff liaison to the CDC Healthcare

Infection Control Practices Advisory Committee (HICPAC), as a member of

the Association for Professionals in Infection Control and Epidemiology

(APIC) and the Association for the Healthcare Environment (AHE). Amber’s

clinical experience includes infection prevention, pediatric perioperative

nursing, and clinical research. Amber completed her BSN and MSN in

Nursing Education at Texas Woman's University in Dallas, TX and she is

certified as a CNOR, infection prevention and control professional (CIC), and

pediatric nurse (CPN).

Amber Wood, MSN, RN, CNOR, CIC, CPN

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Speaker:

Amber Wood, MSN, RN, CNOR, CIC, CPN

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Perioperative Education Specialist, AORN

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Successful completion of this educational activity includes attendance at 90% of the webinar and completion of the

evaluation form.

1. Discuss recent revisions in AORN’s

recommended practices for environmental

cleaning.

2. Describe the evidence supporting the

recommended practices for environmental

cleaning.

Objectives

Purpose & Scope

Role of the Environment

• Possible infection transmission from

contaminated surfaces in the environment– Dancer SJ. The role of environmental cleaning in the control of hospital-

acquired infection. J Hosp Infect. 2009;73(4):378-385. [VB]

– Otter JA, Yezli S, French GL. The role played by contaminated surfaces

in the transmission of nosocomial pathogens. Infect Control Hosp

Epidemiol. 2011;32(7):687-699. [VA]

• High transmission risk in perioperative

setting– 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. [IIIA]

Cleaning in the OR

• May not be as good as we think it is…

– 25% mean cleaning rate for objects cleaned

in the OR at 6 acute care hospitals– Jefferson J, Whelan R, Dick B, Carling P. A novel technique for

identifying opportunities to improve environmental hygiene in the

operating room. AORN J. 2011;93(3):358-364. [IIIB]

Issues in Environmental Cleaning

• Many unanswered questions in the field– Carling PC, Huang SS. Improving healthcare environmental cleaning

and disinfection: current and evolving issues. Infect Control Hosp

Epidemiol. 2013;34(5):507-513. [VA]

New Scope

• All perioperative areas

– Pre- & Postoperative areas

– Operating and procedure rooms

– Semirestricted areas

– Sterile processing areas

Evidence Review

Modified Evidence Rating Model

New concepts added

• Multidisciplinary Teams

• High Touch Objects

• Enhanced Environmental Cleaning

• Cleaning Methodology

• Measurement of Cleanliness

Gaps in the Literature

• What is clean?

• Defined cleaning procedures

• Cleaning frequencies

Recommendation I

Multidisciplinary Teams

Multi-Disciplinary Team

Perioperative Nursing

Environmental Services

Infection Prevention

Sterile Processing

Havill NL. Best practices in disinfection of noncritical surfaces in

the health care setting: creating a bundle for success. Am J Infect

Control. 2013;41(5 Suppl):S26- S30. [VB]

Team Decisions

• Cleaning chemicals

• Cleaning materials, tools, equipment

• Cleaning frequencies

• Cleaning procedures

– Enhanced environmental cleaning

– Special situations (eg, C diff, airborne

precautions, CJD, construction, environmental

contamination)

High Touch Objects

• Determine which items are high touch

• Clean those items more frequently– Stiefel U, Cadnum JL, Eckstein BC, Guerrero 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. [IIIC]

Cleaning Responsibilities

• Missed items

Item to Clean Personnel

Anesthesia cart and equipment (eg, IV pole)

Nursing(Anesthesia Tech)

Anesthesia machine

Nursing(Anesthesia Tech)

Patient monitors Nursing

OR bed EnvironmentalServices

Reusable table strap

EnvironmentalServices

Dancer SJ. Hospital cleaning in the 21st century. Eur J

Clin Microbiol Infect Dis. 2011;30(12):1473-1481. [VA]

Recommendation II

Cleaning Basics

Damp dust

• Top to bottom

Practice Guidance for Healthcare Environmental Cleaning.

2nd ed. Chicago, IL: Association for the Healthcare

Environment; 2012. [IVC]

Disinfectants

• Dwell times– Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory

Committee. Guideline for Disinfection and Sterilization in Healthcare

Facilities, 2008. Atlanta, GA: Centers for Disease Control and

Prevention; 2008. [IVA]

• Spraying and misting should not be used– 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. [IVA]

Dry methods of cleaning

• Should not be used in semirestricted &

restricted areas– Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria

and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):57-

65. [IIIB]

Floors

• The floor is always considered dirty– 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. [IIIA]

– Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria

and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):57-

65. [IIIB]

• Items that touch the floor are dirty

Recommendation III

Between Patient Cleaning

Operating or Procedure Room

• High touch objects

• Contaminated surfaces

• Trash removal

CMS & CDC Guidance

High Touch Objects in the OR

• Anesthesia cart and equipment (eg, IV

pole)

• Anesthesia machine

• Patient monitors

• OR bed

• Reusable table strap

High Touch Objects in the OR…(If used)

• OR bed attachments

• Positioning devices

• Patient transfer devices

• Overhead procedure lights

• Tables and Mayo Stand

• Equipment, mobile or fixed

Cleaning the OR…(If soiled)

• Floors

• Walls

Pre- & Postoperative Areas

• High touch objects

• Contaminated surfaces

CMS & CDC Guidance

High Touch Objects in

Pre- & Postoperative Areas

• Patient monitors

• Patient bed

• Overbed table

• Television remote control

• Call light

High Touch Objects in Pre&Postop…

(If used)

• Equipment, mobile or fixed

Cleaning Pre&Postop…(If soiled)

• Floors

• Walls

Recommendation IV

Terminal Cleaning

Operating or Procedure Room

• Daily when the area is being used

• Disinfect all exposed surfaces of all items,

including wheels and casters

• Mop or wet-vacuum the entire floor

CMS & CDC Guidance

Pre-&Postoperative Areas

• Daily when the area is being used

• Disinfect all exposed surfaces of all items,

including wheels and casters

• Mop or wet-vacuum the entire floor

• Trash removal

CMS & CDC Guidance

Sterile Processing

• Daily when the area is being used

• Disinfect work areas and high touch

objects

• Damp dust horizontal surfaces

• Mop or wet-vacuum the entire floor

• Trash removal

• Dirty work areas last

ANSI/AAMI ST79:2010 & A1:2010, & A2:2011, & A3:2012:

Comprehensive Guide to Steam Sterilization and Sterility

Assurance in Health Care Facilities. Arlington,VA: Association for

the Advancement of Medical Instrumentation; 2012. [IVC]

What about…

Perioperative Nursing

Environmental Services

Infection Prevention

Sterile Processing

Weekends?

Unused rooms

during the week?

We just did 1 case…

Semirestricted & Restricted Areas

• If the area is closed with no personnel

present, the team may determine that

terminal cleaning is unnecessary.

• If perioperative team members are present

in the area briefly, the team may determine

that the area may only need damp dusting

on horizontal surfaces.

cont.

• If perioperative team members are present

in the area for an extended amount of time

or are performing patient care activities,

the team may determine that thorough

terminal cleaning of the area is necessary.

Emerging Technologies

• Room Decontamination (eg, ozone,

peroxide vapor, ultraviolet light, saturated

steam)

• May enhance cleaning of perioperative

areas as an adjunct to terminal cleaning,

although further research is needed

• Evaluation by multidisciplinary team

Recommendation V

Scheduled Cleaning

Scheduled Clean

• Sinks

• Ventilation ducts & grilles

• Refrigerators & Ice machines

• Clean & Soiled storage areas

• Sterile storage areas

• Corridors, including stairwells and

elevators

• Privacy curtains

Scheduled Clean

• Walls and ceilings

• Pneumatic tubes and carriers

• Sterilizers

• Sterilizer service access rooms

• Unrestricted areas (eg, lounges, waiting

rooms, offices)

• Environmental services closets

Recommendation VI

Limiting Transmission

Cleaning Methodology

• Clean to dirty

• Top to bottom

• Clockwise or counter-clockwise

Practice Guidance for Healthcare Environmental Cleaning.

2nd ed. Chicago, IL: Association for the Healthcare

Environment; 2012. [IVC]

OSHA Regulations

• Standard Precautions

• Cleaning blood, body fluids, or other

potentially infectious materials

• Waste

• Sharps

Recommendation VII

Special Cleaning

Enhanced Environmental Cleaning

• Multidrug-resistant organisms (MDRO)

– Enhanced cleaning may reduce MRSA* and

VRE** contamination & risk of transmission

from prior room occupant– Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning

intervention and risk of acquiring multidrugresistant organisms from

prior room occupants. Arch Intern Med. 2011;171(6):491-494. [IIB].

*Methicillin Resistant Staphylococcus Aureus

**Vancomycin Resistant Enterococci

Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection

Control Practices Advisory Committee. Management of Multidrug-

Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for

Disease Control and Prevention; 2006. [IVA]

cont.

• Enhanced cleaning in ICU did not reduce

contamination of worker’s gowns & gloves– Hess AS, Shardell M, Johnson JK, et al. A randomized controlled trial of

enhanced cleaning to reduce contamination of healthcare worker gowns

and gloves with multidrug-resistant bacteria. Infect Control Hosp

Epidemiol. 2013;34(5):487-493. [IA]

cont.

• Environmental contamination with MDROs

was most likely to contaminate worker’s

clothing, gowns, & gloves– Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant

bacteria to healthcare workers’ gloves and gowns after patient contact

increases with environmental contamination. Crit Care Med.

2012;40(4):1045-1051. [IIIA]

High Touch Objects in the OR…

(Enhanced)

• Storage cabinets, supply carts, furniture

• Light switches

• Door handles or push plates

• Telephones and mobile devices

• Computer

• Chairs, stools, step stools

• Trash and linen receptacles

High Touch Objects in Pre&Postop…

(Enhanced)

• Storage cabinets, supply carts, furniture

• Light switches

• Door handles or push plates

• Telephones and mobile devices

• Computer

• Chairs

• Trash and linen receptacles

• Privacy curtains

Updated

• C difficile

– EPA-registered product

– Effective against C diff spores

• Airborne diseases & Aerosolized droplet

transmissible infections

– Restrict room access

• Creutzfeldt-Jakob disease (CJD)– Rutala WA, Weber DJ, Society for Healthcare Epidemiology of America.

Guideline for disinfection and sterilization of prion-contaminated medical

instruments. Infect Control Hosp Epidemiol. 2010;31(2):107-117. [IVA]

Expanded

• Construction cleaning

– Clean dust & assess barriers

– Terminal clean when it’s done

– Clean when the environment is contaminated

• Water damage, condensation, air contamination

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. [IVA]

Recommendation VIII

Education

Recommendation IX

Policies & Procedures

Recommendation X

Quality

Measuring Clean

• Qualitative (eg, visual, fluorescent

marking) & quantitative measures (eg,

culture, adenosine triphosphate [ATP]

monitoring)– Guh A, Carling P; Environmental Evaluation Workgroup. CDC toolkit:

options for evaluating environmental cleaning. 2010. Centers for

Disease Control and Prevention.

http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-

Cleaning.html. Accessed September 30, 2012. [VC]

• Use multiple measures

• Give immediate feedback when possible

Checklists & Log Sheets

• Reduces chance of missing items during

cleaning

• Facilitate communication among the team

when items are cleaned

– Terminal cleaning

– Scheduled cleaning

Frequently Asked Questions

(FAQs)

FAQs

• Use various methods to pickup debris, but

don’t sweep the OR with a broom

• At a minimum, mop the floor between

cases if it’s visibly soiled

• Move the OR bed when you mop or if

something falls under the bed

FAQs

• You can mop at terminal clean in the OR,

not required to use wet-vacuum

• Wait to clean until after the patient is gone

• Pour cleaning chemicals rather than spray

• People generate dust

FAQs

• No time limit between terminal cleaning

and damp dusting

• Risk-Benefit-Cost Analysis

• The floor is dirty

• Use common sense

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