Stepping Up to Keep ORs Clean

Infection Prevention

By: Joe Paone

Published: 4/8/2021

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High-tech solutions and plenty of elbow grease are needed in the intensified fight against surface contamination.


The pandemic has increased the importance of properly disinfecting ORs between cases, and facilities have maintained safe spaces for surgery with rigorous manual cleaning and the strategic use of disinfection technologies. Adding new protocols to room turnover routines on the fly and having to stock various cleaning products hasn't been easy.

"It's been difficult at times to acquire disinfectant wipes," says Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of infection prevention at University of Rochester (N.Y.) Medicine and president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC). Although she says the situation has stabilized as of late March, her facility has at times had to use whatever type of cleaning product was available — bleach, quaternary ammonium compounds, alcohol-based solutions.

Keeping them straight, including how they should be applied, is challenging. "The manufacturers' instructions for use vary depending on the active ingredient and the substrate chemical that's embedded," says Ms. Pettis.

Informing staff about that variability, especially regarding length of application times, is an issue Ms. Pettis and others have faced throughout the pandemic. "Contact times can vary from one to 10 minutes," she says. "If you're using an agent that's long-acting, and it dries before the required time, you need to reapply it, which means you actually need to time the application and drying process."

Ms. Pettis and her team came up with a low-tech solution to the "which disinfectant are we using today and what's its dry time?" problem. "When containers of disinfecting wipes come in, staff use a sharpie to mark the product's contact time in big lettering right on the front of the package," she says. "Now staff doesn't need to look at the tiny print on the container to see what it is."

Ms. Pettis reinforces this tactic with posters that remind workers to check contact times. "Little things like that can help get the message across," she says.

Monitoring compliance

It's one thing to have access to all the disinfectants you need. Ensuring they're being applied correctly is something else entirely. "When you're in a rush, it's easy to miss areas," says Ms. Pettis, who notes it's been difficult for facilities to audit compliance with cleaning protocols because resources have been stretched thin during the pandemic. However, tools to confirm compliance exist, such as ultraviolet light, which you can shine on surfaces staff just cleaned. Areas they missed will glow brightly.

Compliance is also important with soft surfaces like privacy curtains around pre- and post-op bays and upholstered waiting room furniture, which Ms. Pettis says require special soft surface disinfectants. Many outpatient facilities typically launder their privacy curtains twice a year. "Now we've all had to step up our game," she says. "Don't worry about cleaning the entire curtain every time a patient is moved from a bay, but you should disinfect the curtain's grab area."

Overall, Ms. Pettis suggests viewing your entire facility from the patient's perspective. "The most important point I've shared with staff, particularly at our ASCs, is that perception is reality," she says. "A lot of patients were afraid to come back to our facilities after the elective surgery shutdown. We've had to think long and hard about how we get the message to the public and our patients that our facilities are safe. We've had to rethink our cleaning protocols and make sure every surface looks spick-and-span, down to the carpeting in the waiting room. We need to continue looking at our practices with a new eye."

Clean looks

TIMING IS EVERYTHING ?Refer to a disinfectant's recommended contact time to ensure it stays on surfaces long enough to effectively treat the area.   |  Pamela Bevelhymer

The performative aspect of cleaning has been important for Nadine Calloway Reese, BSN, CCRN, TNCC, clinical operations manager and assistant director of Kona Ambulatory Surgery Center in Kailua-Kona, Hawaii. "As part of the check-in process, we give patients a flyer that says their care might take a little longer due to the extra effort and attention we're giving to our enhanced surface cleaning protocols."

Kona ASC, which closed for eight weeks at the beginning of the pandemic, used the downtime to implement other changes to its already high level of disinfection efforts. All equipment in the facility, from the phones to the ortho monitors, is wiped down regularly.

"We changed the way we clean," says Ms. Reese. "In our waiting room, the housekeeping staff immediately clean where each patient sat and wipe down the counter after they check in. We used to clean the bathroom periodically throughout the day. Now it's cleaned after each use."

This hyper-cleaning regimen during the pandemic has taken the ASC from contracting one cleaning professional for part of the day and another for terminal cleaning in the evenings to hiring three full-time staff cleaners. "We needed more value, and needed them to be more available," says Ms. Reese.

In Kona ASC's ORs, post-procedure protocols have become more in-depth. At the height of the pandemic, after terminal manual cleaning, the OR doors were closed for 20 minutes for air to circulate through HEPA filters and disinfecting UV lights built into the air exchange system — an approach Ms. Reese was proud to learn the CDC subsequently recommended.

Ms. Reese has also thought of ways to reduce the cleaning load in her ORs. In the past, staff would move equipment that was unnecessary for a procedure against the wall and cover it. "Now we take everything out that isn't needed, which eliminates a lot of equipment that has to be cleaned, because everything in the room needs to wiped down whether or not it's used," she says.

These strategies have worked for Kona ASC. "In satisfaction surveys, many patients comment on how clean the facility looks, that they notice surfaces being wiped down and that they appreciate the cleanliness of our care areas," says Ms. Reese. "They've been truly grateful, and I think that's contributed to our increase in post-COVID case volumes. Patients see we're taking extra steps to keep them safe, and they're letting other people know about it."

ERGONOMICS
Feeling the Strain During Room Turnovers
ACHES AND PAINS Surgical team members who have been forced to wipe down surfaces more often than usual are suffering repetitive strain injuries.

Rigorous surface disinfection during the pandemic is taking a toll on surgical professionals. "Because the frequency of cleaning has changed so dramatically, some of our staff members are suffering repetitive motion injuries," says Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of infection prevention at University of Rochester (N.Y.) Medicine. Although ergonomic injuries have primarily been a problem among environmental services staff in her large health system, Ms. Pettis notes that nurses and techs do most of the cleaning in ASCs and have suffered similar injuries.

"It's been very difficult to try to figure out how to help them," she says. "Friction is such an important first step in order to achieve disinfection. Manual cleaning puts stress on your joints, and parts of your anatomy get overtaxed for a while before these injuries show up."

If this is a problem at your facility, Ms. Pettis suggests consulting an ergonomic expert who can recommend mitigation and injury prevention strategies.

— Joe Paone

High-tech help

Surface disinfection technologies such as short-wave ultraviolet light (UV-C) and hydrogen peroxide mist have attracted increased attention during the pandemic, and for good reason. They effectively augment rigorous manual cleaning and provide a level of assurance that ORs are clean.

UV-C lights built into ORs, as well as portable UV-C robots, have been increasing in use for several years in outpatient facilities. UV-C attacks the DNA and RNA cellular material of bacteria and viruses, stops them from replicating and leaves them non-infectious. When a UV-C robot is used in an OR, the room must be cleared as it disinfects and performs multiple cycles to ensure the entire room is treated.

Patients see we're taking extra steps to keep them safe, and they're letting other people know about it.
— Nadine Calloway Reese, BSN, CCRN, TNCC

Hydrogen peroxide mist systems continue to gain supporters. "We've been successfully using hydrogen peroxide sanitizers before and during the pandemic," says Ms. Pettis. The systems employ one of three types of fogging technologies: dry vapor, which turns liquid disinfectant into gas; micro-condensation, which produces microscopic aerosols; and activated or ionized, vaporized aerosols that are electrically charged before they're sprayed.

Although technology is undeniably helpful, Ms. Pettis and Ms. Reese both stress that it's no substitute for effective manual cleaning. The important thing is to employ everything at your disposal to clean your surfaces, and to make sure your patients and staff know about it.

Ms. Reese points to the process improvements her ASC has made during the pandemic as a positive development. "Some of the things that have come out of it are probably things we should have been doing all along," she says. OSM

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