BY THE BOOK Following manufacturer's instructions for use is key to effective and efficient surface disinfection practices.

I'm an infection control consultant. During my onsite visits to surgical facilities, one of the areas I delve into deeply is surface disinfection, especially during room turnover, where I'm able to interact directly with staff members responsible for cleaning between patients. My method of figuring out how well you're disinfecting the environment is to begin a dialogue by asking a few questions of any employee in the facility who's responsible for room turnover, regardless of the location. I chat with staff in the operating rooms or procedure rooms, hallways, pre-op and PACU. Here are 10 questions I like to ask.

1 What is the dwell/wet/kill time of the product you're using to disinfect surfaces?
Answers vary depending on the facility and which staff members are chatting with me. Disinfectant products include manufacturer's instructions for use, or IFUs. Most, if not all, cleaning agents (particularly the disinfectant wipes) have the IFUs written on the outside of the container. While the print may be small, they're usually clear about the dwell times for surface disinfection. Liquid products may have the label imprinted on the bottle or a separate written IFU attached to the bottle when shipped to the facility. Many disinfectant wipes today have a "cheat code" on the outside of the container that includes a number contained within a circle. That number indicates the length of time that the product needs to remain wet on the surface. Given that there are many different products with different color containers and lids, always look at the labels on the containers. These products won't work effectively unless surfaces are allowed to remain wet for the required time.

2 How do you know that the surface has remained wet for the correct amount of time?
Once again, various answers are given, including "I don't know," "I wait until it looks dry" and "I estimate the time." I'll look around the room for a clock or look at my watch and that will usually elicit the response, "we need to time it." The introduction of disinfecting agents that require less of a dwell time helps staff achieve faster room turnover. For example, products that have a 1-minute dwell time are widely used and just as effective as the 3-minute products. I encourage facilities to simplify their processes by considering products with a shorter dwell time if possible, while ensuring that they're not compromising best practices.

DWELL TIME The number contained within a circle on your container of disinfectant wipes indicates the length of time that the product needs to remain wet on the surface.

3 What if the product dries in less time than the manufacturer stipulates?
The answer I'm looking for is, "We wet the surface again until we've reached the full time." Don't reset the timer. Rather, wet down the surface again. The concept of "surfaces remaining wet" becomes clearer as we delve into the importance of disinfection versus simply wiping a surface to "clean it."

4 If a surface hasn't been used in the OR (a Mayo stand, for example), should you disinfect it during room turnover?
Answers are mixed and I reiterate that surfaces in patient care areas should be disinfected after each case in the OR, as surfaces don't have to be physically touched to be contaminated. Aerosolization of blood and body fluids is not uncommon. In the pre-op and PACU, after the patient leaves the bay and is not returning, all environmental surfaces should be disinfected.

5 Does whole room disinfection replace traditional cleaning and disinfection?
The answer is no. Whole room disinfection is used as an adjunct to traditional environmental surface cleaning and disinfection. A relatively new concept, the goal for whole room disinfection, particularly when first introduced, was to terminally disinfect rooms — especially in hard-to-reach places. Patients need to be out of the room for whole room disinfection systems to be turned on. The 2 most common systems use either vaporized hydrogen peroxide or ultraviolet lights. Hydrogen peroxide systems are not practical for the perioperative environment due to the need for "airing the room" after use of the apparatus. Ultraviolet lights are becoming more "user-friendly" in operating rooms as companies design systems to better accommodate this setting. The idea of using UV lights is catching on in the surgical world and I'm watching this technology evolve with promising results.

What happens if the product dries in less time than the manufacturer stipulates?

6 After traditional cleaning, should you use an ultraviolet light or other whole room disinfection system between cases?
The answer at present is probably not, but companies are creating shorter-acting whole room models designed for room turnover. Several surgery centers have asked me about use of UV lights as a means of creating a cleaner environment between patients, but rapid turnover remains best served with traditional cleaning at this juncture. I expect this to change, but for now, UV light and other whole room disinfection models are best used as a terminal clean at day's end.

7 Do you monitor the terminal cleaning process by unannounced direct observation?
Most facilities that I interview don't have a system for unannounced visits by a staff member after hours when the cleaning company arrives to terminally clean/disinfect the facility. But facilities very often express concern that they don't feel the terminal clean is thorough so I suggest that the processes be monitored after hours. Several terminal cleaning checklists are available to monitor compliance. In addition, I suggest contacting the company and asking for its training/education program and its methods for monitoring compliance.

NO SKIPPED SURFACES Even if a surface wasn't physically touched during a case, you should still disinfect it during room turnover.

8 Do you monitor room turnover cleaning with checklists?
Some facilities conduct routine monitoring during the process, some conduct random monitoring during the process and some don't monitor at all. Points to consider when monitoring room turnover disinfection include how experienced the observer is to undertake this monitoring, type of monitoring tools, feedback to committees and staff, and action steps to improve processes.

9 How do you verify that a room is clean?
Verification of cleaning is a relatively new concept and the 2 most common processes include fluorescent gel markers and adenosine triphosphate (ATP) testing. Fluorescent marker technique includes placement of gel or powder on surfaces in patient care areas before the room or area is cleaned and disinfected. Once the area is cleaned, a special light, sometimes referred to as a blacklight, is used to look for traces of the marker that were left behind. If the light identifies the marker, this confirms that surface areas weren't adequately cleaned and disinfected. This system is more labor intensive and more subjective than use of ATP. The detection of ATP, the universal unit of energy in all living cells, immediately determines if surfaces and reusable medical equipment are truly clean. It provides an objective numeric measurement of organic material that is left behind on a surface. Both systems are slowly being integrated into monitoring practices, providing important feedback to staff and helping to improve cleaning practices.

10 Do you provide committee feedback regarding environmental services and cleaning processes?
It is imperative that environmental services in the perioperative environment comply with guidelines and standards. The purpose of monitoring these processes is to identify trends in practice that may need to be improved upon. The purpose of a committee is to receive feedback and to guide the facility with respect to remediating issues if they are identified and/or to assist with improving practices on an ongoing basis.

For patients and staff
Surface cleaning and disinfection plays a key role in the multi-disciplinary approach to keeping patients and staff infection-free. Following manufacturer's instructions for use is the key to ensuring that practices are done correctly and efficiently. Monitoring for compliance is another factor that enhances practices. Finally, verifying that cleaning and disinfection is undertaken appropriately with subsequent follow-up is recommended as part of a complete infection prevention program in the perioperative setting. OSM

HAND WASHING
7 Creative Ways to Improve Hand Hygiene Compliance

MAKE IT EASY Increase the number of locations where staff can clean their hands. Staff shouldn't have to walk more than a couple steps to find a dispenser.

1. Product placement. How far does your staff need to walk to find a hand sanitizer dispenser? The Grand Rapids (Mich.) Ophthalmology Surgical Care Center increased the number of locations where staff can clean their hands. They have hand sanitizer all around the facility, including the nurse's station, staff lounge, patient waiting area and each bed station. "It's about location and availability," says Kris Kilgore, RN, BSN, the administrative director. "You want it in their face."

2. Involve the staff. The type of hand sanitizing solution matters as much as the location. "There's nothing worse than having a product and nobody uses it because it's so harsh on their hands," says Ms. Kilgore. "You need to involve your staff. As a manager, you can't be the only one determining what everyone will use."

3. Have a code word. You don't want to embarrass your nurses for forgetting once or twice, but it's critical to maintain proper hand hygiene at your facility. To achieve both goals, create a code word for when one staff member notices another not complying. "We got the idea from 'Meet the Fockers,'" says Michael Pankey, RN, MBA, the former administrator of the Ambulatory Surgery Center of Spartanburg (S.C). (In the Ben Stiller comedy, the code word "muskrat" tips Robert De Niro's character that he needs to lighten up.) "We didn't like muskrat, so we went with 'squirrel.' It's just a random word that clicks in nurses' heads that they didn't wash their hands."

4. Create a healthy competition. Ms. Kilgore has found positive reinforcement always works better than negative, so she occasionally will put together a hand hygiene "competition" with the nurses in pre-op, recovery and the OR. She'll tally and graph compliance among the groups, and the one that performs the best might receive something like a paid half-day off or a free lunch.

5. Use secret surveillance. Start a mystery shopper-like program where a randomly assigned person will observe employees to maintain ongoing hand hygiene surveillance. Prizes of movie passes or a gas card go to those who comply, says Ms. Kilgore. "It's like with your kids: Bribery works."

6. Sign of the times. By every hand rub and soap dispenser, Ms. Kilgore has posted laminated posters from the Centers for Disease Control and Prevention or World Health Organization (WHO) showing proper hand hygiene measures, including the length of time needed and reminders not to forget between the fingers (a common misstep). She also puts the WHO's "Five Moments of Hand Hygiene" in each patient bay and sprinkles around some lighter signs, like a play on the ubiquitous "keep calm" motto, that still hit the point home.

7. Survey patients post-discharge. Patients might be a little less than forthright about their care while still in the surgery center. "They think nurses will get mad at them," says Mr. Pankey. His facility implements a follow-up phone survey with patients following the procedure, asking about the providers' hand hygiene. He believes they will be a bit more honest this way.

— Mike Bederka