Surface Disinfection Done Right

When it comes to the sequence of cleaning an OR, work from the dirtiest areas of the room to the cleanest and pay particular attention to areas where bodily fluids spilled and where patients touched the most. AORN has comprehensive training programs and toolkits on how to best clean ORs (osmag.net/Guideline). In general, you should clean rooms from the outside in and from top to bottom. Work either clockwise or counterclockwise the entire time to avoid cleaning the same area twice. You’re basically spot cleaning until the end of the day, when a deeper terminal cleaning can take place.
Fluorescent markers are excellent training tools for your staff. The gel or powder can’t be seen under regular light. In a training session, mark high-touch surfaces such as surgical lights, the side areas in the OR and the table on which you’re setting up your sterile field with the bioluminescent marking materials. Have your staff go in and clean the room. When they’re done, enter the room with the lights off and use a black light or some other type of UV light to reveal which parts of the room were adequately cleaned and which weren’t. If the areas you marked don’t glow, you know they’ve been thoroughly cleaned.

One of the best things about these products is that the staff members who clean ORs actually see the results, which makes it easier to understand what they missed. There’s something instructive about having simple, real, objective results in front of you that scream, “Hey, if there were bacteria on this surface instead of this fluorescent marker, the next patient would be exposed to infectious material.” Use of fluorescent markers can also help determine when to replace equipment. For example, the marks will remain in cracks or chips on a table you set up in the sterile field. When your staff tries to clean it again because the mark is still present, they’d realize it’s not cleanable because of the imperfection — and you’d know it’s time for a new table.

Adenosine triphosphate (ATP) testing is another way to check for gaps in your surface cleaning processes. It allows you to swab a small area after a surface clean and put the swab into a laminator machine, which tells you how much bacteria remain in the area. The potential problem with the teachability of using ATP testing is that it generates a reading based on relative light units (RLUs), which many frontline staff members view as a random number. RLU readings provide a probability of biofilm remaining on the surface and the threshold can be somewhat arbitrary. Plus, this technology doesn’t tell you the specific surface areas that staff missed during their cleaning, while fluorescent markers do.

The number one barrier to sound cleaning of OR surfaces between cases is time. I’ve done consulting work at a surgery center that used a disinfectant with clear instructions for use that said the product must stay on a surface for five minutes before being wiped off to get a germ kill. However, one of the center’s employees said the facility’s between-case turnover times were less than four minutes. Those kinds of situations aren’t safe for patients, aren’t likely to survive the scrutiny of a federal or state regulatory audit and, if the center was involved in litigation over a bad surgical outcome, would be very damning evidence about the surgery center’s priorities.

Obviously, this center could have switched to a disinfectant with a shorter required dwell time, but a fundamental change of culture is the better solution. In some cases, it just takes more time to safely prepare an OR for the next case than what you’re currently allocating to the task. I’ve also been in facilities that have rushed environmental services teams out of the OR because the next case allegedly had to begin right away. And yet, when the patient arrived, their hair had to be clipped because there wasn’t enough time to do it in the pre-op area.

It’s the responsibility of physicians and clinical leaders to ensure surface cleaning protocols contribute to reduced infection risks. These decisions may require adding a couple of additional steps to ensure patients move through their facilities safely and efficiently. OSM