Clean Up After Yourself

When we experienced an uncharacteristic increase in SSIs starting in August 2018 — 9 infections over the next 6 months — we assumed the spike was related to opening too many peel packs to piecemeal instrument sets for our fledgling spine program. But then the SSIs started spiking in mastectomies, lumpectomies and hernias, procedures we've been performing for years. We were dumbfounded and worried.

After consulting with our hospital system's infection prevention nurse, we realized we were no longer the center that specialized in cataracts and knee scopes. We'd evolved into doing total joints, bariatrics and spine fusions — more intense, complicated and bloodier cases. The change in procedures brought with them a change in patient population; older and more obese individuals with comorbidities that put them at a greater risk for infection.

The stakes were clearly raised for how well we cleaned every inch our clinical space. We've made changes to our environmental cleaning practices throughout our surgical department and stepped up enforcement on how we turn over ORs during the day and clean them overnight. We think the following new cleaning efforts are a big part of why we've significantly reduced our facility's infection rate in recent months.

• Pick the right product. Make sure the cleaners you're using are formulated for the areas you're applying them to and strong enough to disinfect the treated surfaces. We switched from a general-purpose cleaner to a quaternary ammonium chloride-based disinfectant cleaner concentrate ?for use on floors and a quaternary-based, heavy-duty alkaline cleaner and disinfectant concentrate for use on walls. We also changed the product we use to clean flat surfaces, switching from germicidal wipes to wipes that employ hydrogen peroxide to kill pathogens.
• Hit trouble spots. Be sure staff hit the high-touch surface areas in ORs during room turnovers. When we were falling out of compliance with wiping down all the surfaces in our 4 ORs, we assigned the day's earliest arriving staff member to go into each room 30 minutes before the first case start time to wipe down all horizontal surfaces. The staff member then hangs a laminated sign in rooms she hits that says, "Wipe down completed." If the sign is present when the OR team arrives to open its case, the surgery can proceed. If the sign's not up, the team knows that they have to wipe down surfaces before starting the case.

Regularly clean the curtains that separate pre- and post-op bays and wipe down the surfaces in those patient care areas. Also consider using a mobile robot unit that bathes the bays in ultraviolet light to further ensure all surfaces are disinfected.

• Wipe down electronics. Think about how many personal devices and facility-issued screens circulate through your surgical department. Now think about how many times they're cleaned.

One of our highly respected physicians noticed the number of electronic devices that are regularly in our ORs: cell phones, iPads, in-house mobile phones and walkie-talkies used to communicate internally with the pre- and post-op units. The surgeon suggested we disinfect the devices daily, and we agreed.

We looked into using a tabletop ultraviolet light disinfecting unit, but the physician's own research found that alcohol-based sanitizing wipes are just as effective. Now sanitizing wipes are located throughout the facility, and a staff member is charged with disinfecting all of the devices each day. Members of the OR team and other staff wipe down their personal phones before they enter the ORs.

• Stay vigilant. Monitoring the cleaning practices is as important as the practices themselves. Terminal cleaning is unheralded, almost a behind-the-scenes activity, but is so very important. We don't know that we would be on the contracted staff so hard had we not had this uptick in infections. We do know that if we don't consistently audit them, there will be inconsistencies in their practices.

Members of an outside cleaning service need to be just as educated as your frontline staff on mandatory infection prevention measures, and why your facility's cleaning protocols are so important to follow. We got permission from the owner of the company that terminally cleans our ORs to do just that.

At the end of the day and after terminal cleaning is complete, have a staff member or representative from the outside cleaning firm you work with conduct a final walkthrough of the ORs to make sure the areas have been properly cleaned and have them submit a daily report. If all the ORs are clean in our hospital, the staff member who completed the inspection puts a checkmark on the box for each room. If something was missed, they'll make a note on the report sheet — suture on floor or floor unmopped — to help us identify and address areas of needed improvement.

Validate your staff's work after training them on new cleaning protocols or reinforcing the importance of established methods. Approach staff members for impromptu spot checks of their cleaning practices. Ask them which cleaning products they're using on the floors, walls and flat surfaces. Watch how they clean an OR, making sure they start at the room's perimeter and work toward the table. Perform these real-time, random audits every 2 weeks, or at least monthly, to make sure team members are hitting every square inch of your facility. OSM