SAFER SURGICAL SURFACES Interactions between patient body surfaces, hands and the OR environment play an important role in the transmission of bacteria.

When's the last time your OR floors, IV poles and OR entry-door handles were disinfected? I mean thoroughly disinfected. What about your bed control panels, anesthesia equipment and Mayo stands? If your facility's surface-cleaning practices are anything like my hospital's used to be, it's probably been a while, a long while, when it should happen between every case.

High-touch surfaces can harbor such infection-causing organisms as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridium difficile and Acinetobacter baumannii. Our recent observations of high-touch surfaces in the operating rooms at a large urban hospital showed that only 50% of surfaces were cleaned properly. The study also found that enhanced staff training and education yielded significant improvements. What did we learn? Two main lessons.

• What gets measured gets done. Education of your environmental services staff or turnover team combined with feedback using ultraviolet (UV) markers has been shown to improve the thoroughness of environmental cleaning. At the beginning of the study, we found that less than 50% of tested surfaces had been cleaned within 24 hours after target application. Ongoing performance feedback over the next 4 months led to an 82% increase in cleaning rates.
• Your ORs are probably dirty. Even though we assume and expect that our ORs will be sterile, surfaces are very rarely cleaned, especially between cases. The presence of UV material at 24 hours was considered to represent a lack of cleaning on the object tested. Removal of the UV marker was considered to be evidence of 1 or more episodes of cleaning of the monitored surfaces. Based on our findings and the existing literature, operating rooms might not be the clean settings that healthcare providers commonly believe them to be. Most of the high-touch surfaces we tested were neglected by the housekeeping staff's cleaning wipes and spray bottles: anesthesia-related equipment — keyboards, knobs, switches, oxygen reservoir bags and adjacent medication drawers — bed control panels, Mayo stands, intravenous poles, intravenous pumps, OR entry doors, overhead lamps and the floor. It's not a complete list, but it reflects most of the surfaces we checked for our study at our 1,500-bed teaching hospital, which has 42 ORs.

CLEANING RATES
Thoroughness Of Cleaning

After the study, the most striking improvement in cleaning rates was seen in anesthesia equipment, particularly in the cleaning of anesthesia machines. Here's how other objects fared.

Significant Improvement	No Clear Improvement
Bed control panels	Floors
Mayo stands	Intravenous poles
Overhead lamps	OR entry-door handles

Scratching the surface
Spotty surface cleaning is not an isolated problem at our hospital, but something that occurs in most ORs, as many studies besides ours have proven. Why does this happen? A couple reasons:

• Turnover pressures. Pressure to turn rooms over quickly could force environmental services techs to cut corners (or, in this case, gloss over surfaces).
• Staffing issues. Environmental services staff often don't receive adequate training to properly perform their jobs. Similarly, they might not receive adequate feedback or don't realize the critical role surface cleaning plays in preventing the transmission of disease. Our study demonstrated for them that improvements in the thoroughness of disinfection and cleaning in the OR can significantly decrease surface contamination. Let your turnover team members know cleaning expectations for specific objects. They could be neglecting to disinfect certain surfaces simply because they didn't know they were supposed to.

The biggest improvement during the study? Anesthesia machines were cleaned 150% more frequently as a result of the study. Rightly or wrongly, anesthesia providers have been shown to have low hand hygiene compliance while providing care in the OR, despite having high rates of interactions between patients, machines and medications. Researchers have shown a correlation between the contamination of anesthesia machines and contamination of IV stopcocks, as well as an association between hand contamination among anesthesia providers and contamination of IV stopcocks. If an anesthesia machine isn't adequately cleaned between cases, for example, the implications for the next patient could be serious.

Providers in the OR (circulating nurses, ancillary staff, anesthesia providers) often place objects that fall onto floors back on work surfaces or on patients themselves. For example, IV tubing frequently contacts the floor as it drapes between the patient and the IV pump. Keep in mind that the OR floor is often contaminated with hospital organisms; therefore, items that fall on the floor should not be put back on top of patients. The biggest change we made to decrease OR pathogen contamination was to make our anesthesia techs responsible for the cleaning of the anesthesia machine and associated equipment — including ECG leads, blood pressure cuffs, IV pumps, IV poles and oxygen reservoirs — between procedures.