IT'S A WASH Whether mopping the floor, cleaning keyboards or wiping down the OR table, user-friendliness is key to staff compliance.

Here at Olmsted Medical Center, we follow the standard surface disinfection guidelines, but we've also taken steps to use environmentally friendly products that increase the efficacy of our processes, all without losing sight of economizing.

Spick and span
Let's start with the basics: when to clean which areas. There are 4 types of surface disinfection — and countless items (see "Your Surface Disinfection Checklist" on page 70) — to concentrate on.

• Between-cases cleaning. Cleaning the OR is pretty standard — we follow AORN, CDC and Minnesota Department of Health guidelines. The general process is to start with the cleanest items and move to the dirtiest. So the OR lights are done first, and the turnover crew works its way down from there. All flat surfaces are cleaned with our chosen spray product and wiped down with disposable, single-use cloths or gone over with a microfiber mop. If the OR bed has blood or body fluids on it, it's done last.

• End-of-day cleaning. At 2:30 p.m., the evening custodian comes on and starts in on a deeper clean — going over all floors again, taking care of any spots that went unnoticed and doing visual inspection of the walls and ceilings.

• Terminal cleaning. Every 30 days, the ORs undergo an incredibly detailed cleaning. This includes shelves, cabinets, wheels on cautery machines, the nooks and crannies of the OR bed, Mayo stand wheels, walls and vents. The floors are buffed if warranted.

• As-needed. In pre-op, PACU, nurses' stations, the lobby and other "clean" patient areas, nurses primarily spot-clean between patients as needed. Similar to the OR, flat surfaces are wiped down and disinfected between patients, once a week, once a day — it all depends on the area. Keyboards and computers (daily), for example, aren't cleaned as often as the PACU stretchers (between patients). If a major incident occurs, we call housekeeping. Housekeeping also takes care of "clean" areas nightly, vacuuming and mopping floors, wiping down chairs and tables, and cleaning stretchers.

Product and practice
A few years ago, an intern from the Minnesota Technical Assistance Program reviewed our disinfection protocols and products. As a result of her work, we decided to start using concentrated cleaners in reusable bottles, and to use a cleaner that required less contact time to be effective. The project projected savings over $10,000 annually in our 5-OR, 2-endoscopy suite, 13-patient room facility.

During the conversion, our director of facilities kept us on track. We had 4 or 5 different cleaning sprays, 2 different metal cleaners — and it varied by department. So the director of facilities would come into our departments and have us pull all our fluid items and remind us that we weren't supposed to be using products X and Y. We all have our own order sheets, but they suddenly listed only the products we'd consolidated to, standardized for every department. In the end, we got down to 1 cleaning spray, an EPA-registered quaternary disinfectant cleaner. It's rinse-free, neutral-pH and has a contact time of 3 minutes. So it's easy to use, environmentally friendly and fast-acting.

I can't stress how important this is: If you want staff to do surface disinfection right, give them products that work with the fast pace of the OR and appeal to their sensibilities. We used to use a metal cleaner with an overpowering odor that, if it got on the floor, was very slippery. Staff presented the issue, so we changed products. If staff don't like something, they won't use it — or won't use it well.

We've also moved from standard cotton-loop mops to mops with washable microfiber heads. When you look at a bucket of dirty water that you're putting the mop in … well, it just seemed that maybe we weren't getting the floors as clean as we could. Reusable microfiber-head mops are also easier to use. You just pop the head on, squirt the quaternary disinfectant with the press of a button on the mop handle, and get down to business.

A small change in communication has been a big help: The overnight custodian's shift was moved to an evening shift starting at 2:30, to overlap with the OR staff, who leave at 3:30. During this time, they're able to give him notes on areas requiring special attention. This way, he knows to give the walls in OR 4 a thorough going-over, rather than only following the standard practices there.

Finally — and this is the most fun — we check for bioburden using a spot-tester. This is a great little kit that lets you swab a surface, any surface, put the swab in the tester, and find out how much bioburden is attached. There's no finger-pointing, it's just an entertaining exercise for the staff. (I admit, when we got the kit, I was swabbing everywhere — desks, toilet seats — just out of curiosity.) It reinforces the necessity of good surface disinfection, makes cleanliness visible to staff, and motivates them to do better or keep up the good work.

ARE YOU DOING IT RIGHT?
Your Surface Disinfection Checklist

The various levels of disinfection are defined by Spaulding's Classification. Surgical instruments, facility surfaces and other items are assigned to 1 of 3 categories:

• critical, which enter or penetrate sterile tissue, cavity or bloodstream (surgical instruments), and must be sterilized;
• semi-critical, which come into contact with intact non-sterile mucosa or non-intact skin (colonoscopes), and must be at least high-level disinfected; and
• non-critical, which have contact with intact skin (keyboards, surgical tables and floors), and must be cleaned or disinfected

Surface disinfection generally falls into this non-critical category. But don't let the name fool you. The tasks involved in general cleaning, whether in the OR, pre-op/PACU or waiting room, are every bit as important for reducing microbe levels in your facility. What's more, surface disinfection is done in the areas patients are most likely to see — important because, in hospitals at least, patient satisfaction with facility cleanliness is now tied partly to reimbursement.

Here's our facility's checklist of the areas and items you should be paying attention to, and the approach recommended according to Spaulding's Classification.

— Ben Riker, RN

CLEAN AND TIDY Surface disinfection may be "non-critical," but it's still key to infection control.

Pre-op/PACU — non-critical

Low-level disinfectant

• bed equipment
• blood pressure equipment
• IV stand
• keyboard
• light switches
• units on walls
• wheel chairs

Low-intermediate disinfection

• bed
• bed mattress
• bed rails

Neutral cleaner

All other surfaces, such as blinds, bed cords, chair/stretcher adjuster remote, floor, curtains, chairs, bedside table, food table, vents, walls, etc.

Operating room — non-critical
Neutral cleaner

• tile floor
• trash can
• valves on wall
• wall equipment
• walls
• window
• windowsill

Low-level disinfectant

• units on walls

Low-level disinfection or removal

• suction canisters

Operating room — semi-critical

Low to intermediate disinfectant

• surgical table

Waiting area — non-critical
Low-level disinfectant

• drawer handles
• keyboard
• light switches
• remote
• telephone and cord

Neutral cleaner

All other surfaces, such as plastic chairs, clock, coat rack, cords and tubes on the wall, television and DVD player, shelves, trash can, lights on ceilings, computer and monitor, etc.

Work stations — non-critical
Neutral cleaner

• tile floor
• trash can
• vents
• wall equipment
• walls
• windows
• windowsills

Low-level disinfectant

• stethoscopes
• keyboards
• ultrasound equipment
• units on walls

On the Web
Hospital and Clinic Cleaning Guidelines:
tinyurl.com/aau43xz