environmental cleaning for ascs: aorn updated … cleaning for ascs: aorn updated guidance debbie...
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Environmental Cleaning for ASCs:
AORN Updated Guidance Debbie Hurst RN, BSN, CIC
Infection Preventionist Medford, Oregon
May 13, 2014
Oregon Patient Safety Commission Webinar
No conflicts of interest to disclose
Objectives
1. Describe the role of the environmental cleaning and
disinfection in the prevention of perioperative
healthcare associated infections (HAIs)
2. Discuss environmental cleaning updates for AORN
that apply to ambulatory surgery centers (ASCs)
3. Identify evidence-based methods and best practices
for environmental cleaning in ASCs
Role of the Environment and
HAIs
Now well documented in the scientific literature:
• Environmentally hardy HAI pathogens can be readily
cultured from near patient surfaces
• Patients have a 73% increased risk of acquiring the same
pathogen than patients not occupying such rooms
• Less than 40% of surfaces near patients are cleaned
according to hospital policies
Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May 2011
Mean = 32%
>110,000 Objects
Transmission Methods Involving the
Surface Environment
Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.
What about the ORs?
Probably not as good as we think…
• 25% mean cleaning rate for objects cleaned in the OR at 6
acute care hospitals Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the
operating room. AORN J. 2011;93(3):358-364.
Guidelines and Standards
Changes have occurred over past few years in recommendations
and standards as well as state laws relating to improving
environmental hygiene in health care settings
Including:
• CDC: 2003 recommended “high-touch” surfaces be cleaned,
monitored, supervised and inspected regarding cleaning
performance
• CMS 2007 required Infection Control to include appropriate
monitoring of environmental service housekeeping activities to
ensure that the hospital maintains a sanitary environment
• 2013 AORN revised Recommended Practices for Environmental
Cleaning for perioperative practice settings
Perioperative Environment
An increase in risk for spreading germs exists due to:
• common equipment used on every patient
• team members touch the patient, touch equipment, then
touch the patient again
• patient is at higher risk for infection because of surgery
• intense pressure to rapidly perform cleaning duties
between patients
• multiple people cleaning one area at same time
• staff involved in cleaning environmental areas are often
not trained specifically in basics of cleaning and
disinfection of environment
• minimal supervision, monitoring and inspection of
environmental cleaning activities in the OR areas
compared to acute side
AORN Revisions: 2013
New Scope: all perioperative areas including:
• Pre & Post OP Areas
• Operating suites and procedure rooms
• Semi-restricted areas
• Sterile Processing areas
AORN Revisions: 2013
New Concepts added:
• Multidisciplinary Teams
• High Touch Objects
• Enhanced Environmental Cleaning
• Cleaning Methodology
• Measurement of Cleanliness
AORN Standards revised in 2013 (Refer to: April 2013 AORN Journal)
• Recommendation I - Multidisciplinary Team
• Recommendation II - Provide clean/safe environment
• Recommendation III - Between Case Cleaning
• Recommendation IV - End of day…Terminal cleaning
• Recommendation V - Scheduled cleaning (beyond Terminal)
• Recommendation VI – Limit transmission: cleaning techniques
• Recommendation VII - Special cleaning Airborne/Contact
• Recommendation VIII – Education/Competency
• Recommendation IX - Policy/Procedure
• Recommendation X - Quality
Recommendation I
Recommendation I
Team Decisions:
• Cleaning solutions
• Cleaning materials, tools, equipment
• Cleaning frequencies
• Cleaning procedures
Recommendation II
Provide Clean/Safe Environment
Basics:
High Surfaces to Low…
Clean to Dirty,
Clockwise/Counter clockwise (systematic
approach)
Types of cleaning include:
Terminal (end of day),
between case,
scheduled.
Damp dusting
Why damp dust?
• removes dust from horizontal surfaces
• Do not use spray bottles for cleaning surfaces
• Use a clean, low-linting cloth moistened with EPA
registered hospital disinfectant
• For “first case”: damp dust first thing in the morning before
additional items or equipment are brought into the room.
• Damp dust from top to bottom
• Use damp dust method for floors as well; never dry sweep
or dry dust mop floors
Cleaning Tools and Equipment
The tools and equipment you will use to clean your facility
may vary based on what your facility provides
• reusable or single-use mops
• microfiber cloths
• single-use wipes
Recommendation III
Reestablish clean environment between cases
• Clean and disinfect reusable nonporous, surfaces
after each patient use. Includes mattress covers,
tourniquet cuffs
• High Touch objects cleaned after each patient
including switches, control panels, work areas
• Begin environmental cleaning including trash/laundry
removal after patient has left area
• Preop and postop areas must be cleaned after each
patient has left
• Patient transport vehicles cleaned after each use
Recommendation IV
Perioperative areas should be terminally cleaned
• Should be performed daily when areas are being
used
• Semi restricted and restricted areas should have
multidisciplinary team determine the frequency
and extent of cleaning required when area not
occupied (i.e. weekends, unused rooms)
• Includes sinks
• All floors should be disinfected in
perioperative and sterile processing areas.
Floors should always be considered “dirty”.
Floor Cleaning
• May use wet-vac or single use mop and disinfectant
• Use an EPA registered hospital disinfectant to mop floors
• Clean and disinfect the floor surfaces at the
• edge of the room first
• moving toward the center of the room (“clean to dirty”)
• Includes entire floor including areas under OR bed and
mobile equipment
Cleaning Chemicals
• Always follow the manufacturer’s directions for use when
using cleaning and disinfecting products in your facility.
• You will need to know and be able to tell others:
• if the chemical is approved for use at your facility
• what the “dwell time” is for the product
• how to mix the product (if needed)
• how long the chemical can be used before needing to be replaced
• how to label the chemical
Recommendation V Scheduled Cleaning
Recommendation VI
Limit Transmission
• Cleaning Methodology
• OSHA Regulations
• Handling of laundry/linen
Recommendation VII
Special Cleaning
• Enhanced Environmental Cleaning such as
with Contact Isolation for MRSA, C. difficile.
• Same as between case and then “High Touch
Objects” such as door handles, telephones,
computers, trash and linen, chairs (both in OR
and Pre & Postop) and privacy curtains. May
include different disinfectant.
Recommendation X
Recommendation X – Quality
• Qualitative and quantitative measures, Use multiple
measures, give feedback when possible, use checklists
and log sheets, facilitate communication among the team
when areas cleaned.
http://www.cdc.gov/hai/toolkits/evaluating-environmental-
cleaning.html
ATP: Adenosine triphosphate
Surface Swab Luminometer
28
New Methods for Monitoring Cleaning
Effectiveness:
Fluorescent Marker Technology
.Clean and refill the soap dispenser
A. Inspect soap dispensers to ensure that there is
an adequate supply of soap.
B. If a soap dispenser is a disposable unit and the
soap level is low, replace the unit.
.If a soap dispenser is a reusable unit, follow the
instructions for opening, cleaning, filling and
replacing the dispenser. Be sure to wash and dry
the inside of the dispenser before adding fresh
solution
D. Clean the exterior of the dispenser with a damp
cloth and disinfectant cleaner and dry it
completely.
.Report any broken or malfunctioning units to
maintenance or other appropriate person for
repairs.
12. Clean and refill the paper towel dispenser
.Open or unlock the dispenser. Be careful not to
let it fall open as it can scratch the wall or hurt you.
.Remove any paper towels and clean the inside
of the dispenser using a damp cloth and
disinfectant cleaner in order to remove loose
paper dust.
.Replace paper towels. For folded paper towels,
be sure to place them folded side down and
interleave the bottom of the new sheets with the
top of the existing sheets. Add as necessary in
order to fill the unit. Do not overfill as this will
make it difficult to pull the towels out. Check to be
sure the towels release easily.
.Close and lock the dispenser making sure it is
secure and will not fall open and hurt someone.
.Clean the outside of the dispenser with a damp
cloth and disinfectant cleaner and dry it
completely.
.Report any broken or malfunctioning units to
maintenance or other appropriate person for
repair.
.Clean and refill the soap dispenser
A. Inspect soap dispensers to ensure that there is
an adequate supply of soap.
B. If a soap dispenser is a disposable unit and the
soap level is low, replace the unit.
.If a soap dispenser is a reusable unit, follow the
instructions for opening, cleaning, filling and
replacing the dispenser. Be sure to wash and dry
the inside of the dispenser before adding fresh
solution
D. Clean the exterior of the dispenser with a damp
cloth and disinfectant cleaner and dry it
completely.
.Report any broken or malfunctioning units to
maintenance or other appropriate person for
repairs.
12. Clean and refill the paper towel dispenser
.Open or unlock the dispenser. Be careful not to
let it fall open as it can scratch the wall or hurt you.
.Remove any paper towels and clean the inside
of the dispenser using a damp cloth and
disinfectant cleaner in order to remove loose
paper dust.
.Replace paper towels. For folded paper towels,
be sure to place them folded side down and
interleave the bottom of the new sheets with the
top of the existing sheets. Add as necessary in
order to fill the unit. Do not overfill as this will
make it difficult to pull the towels out. Check to be
sure the towels release easily.
.Close and lock the dispenser making sure it is
secure and will not fall open and hurt someone.
.Clean the outside of the dispenser with a damp
cloth and disinfectant cleaner and dry it
completely.
.Report any broken or malfunctioning units to
maintenance or other appropriate person for
repair.
Qualitative Measuring Ideas…
Resources available to you…
AORN Environmental Cleaning Tool Kit
• The purpose of the Environmental Cleaning Toolkit is to educate all team members about the recommended practices
on cleaning the perioperative environment, promote patient safety and prevent the spread of infection in the
perioperative environment.
Leaning Objectives:
1. Describe the importance of a clean perioperative environment.
2. Define the common terminology associated with recommended practices for cleaning the perioperative
environment.
3. Explain the recommended steps for cleaning the perioperative areas and the sterile processing areas.
4. State the recommended practices for using chemicals, tools, and equipment for cleaning in the perioperative areas.
Components
Begin with the webinar to review the Recommended Practices for Environmental Cleaning
Teach the recommended practices for environmental cleaning to all perioperative team members with these
PowerPoint presentations:
Module 1 Environmental Cleaning: Basics
Module 2 Environmental Cleaning: Preoperative and Postoperative Areas
Module 3 Environmental Cleaning: OR and Procedure Rooms
Module 4 Environmental Cleaning: Sterile Processing Areas
Module 5 Special Cleaning Procedures
Module 6 Quality and Process Improvement
www.aorn.org
search for: Environmental Tool Kit
www.aorn.org
search for: Environmental Tool Kit
• Sample Documents
Definitions related to Environmental Cleaning
Cleaning Checklists
1. Sample Cleaning Checklist: includes OR and Preoperative and Postoperative Areas
Sample Cleaning Checklist: includes OR and Preoperative and Postoperative Areas (TEMPLATE)
2. Sample Cleaning Checklist: Special Conditions
Sample Cleaning Checklist: Special Conditions (TEMPLATE)
3. Sample Cleaning Checklist: Sterile processing areas
Sample Cleaning Checklist: Sterile processing areas (TEMPLATE)
Resources
Posters
Poster 1 Clean Your Hands and Clean the Environment
Poster 2 Environmental Cleaning: It’s Important!
Poster 3 Keep it Clean! OR
Poster 4 Keep it Clean! Preoperative and Postoperative Areas
Poster 5 Keep it Clean! Sterile Processing Area
Funded through the AORN Foundation and supported by a grant from Ecolab.
•
Posters from AORN Toolkit
Summary
• Important to establish your multidisciplinary group to
review processes and establish schedules and task
assignments
• More evidence now available to drive practice changes in
environmental cleaning
• High touched surfaces emphasized
• Educational tools “turn key” now available from AORN, all
staff need to have education that provide environmental
cleaning
• New technology for monitoring environmental cleaning
effectiveness of high touch surfaces are being used
• IC oversight of cleaning processes is requirement
References
1. AORN Environmental Cleaning Toolkit: www.AORN.org
2. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Centers for
Disease Control and Prevention (CDC), Rutala, W. Weber, D and Healthcare Infection
Control Practices Advisory Committee HICPAC www.cdc.gov
3. AORN 2014 Standards: Recommended Practices RP Summary: Recommended
Practices for Environmental Cleaning. AORN Journal May 2014;Vol 99, No.5.
4. Dr. Rutala’s website: http://disinfectionandsterilization.org/
5. Guidelines for Environmental Infection Control in Health-Care Facilities-CDC, 2003
www.cdc.gov
6. Carling, P. Bartley, J. Evaluating hygienic cleaning in health care settings: What you do
not know can harm your patients. AJIC June 2010;S41-S49.
7. Weber, D. Rutala, W. Understanding and Preventing Transmission of Healthcare-
Associated Pathogens Due to the Contaminated Hospital Environment. Infection
Control and Hospital Epidemiology May 2013;Vol.34,No.5.
8. Centers for Disease Control and Prevention: Options for Evaluating Environmental
Cleaning Website: http://www.cdc.gov/hai/toolkits/evaluating-environmental-
cleaning.html
Participation Code
• The 5 digit confirmation code for this webinar is: 58413
• You will be asked to enter this in the survey