Environmental surveillance in the operating room

AORN Journal,  July, 2005  by Janice A. Neil,  Pamela F. Nye,  Lisa Ann Toven

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Perioperative nurses have an ethical obligation to provide patients with safe, effective care during surgical interventions. (1) A guiding principle of perioperative nursing care is surgical asepsis. Regulatory agencies monitor and evaluate OR environments, and AORN's "Recommended practices for environmental cleaning in the surgical practice setting" provide guidelines for a safe, visibly clean environment to minimize patients' and health care workers' exposure to potentially infectious microorganisms. (2) These recommendations state that, ultimately, it is the responsibility of perioperative RNs to ensure that the surgical environment is clean and eliminate environmental hazards to reduce the risk of surgical site infections that may be related to environmental contamination. (2) This article describes the results of a pilot test of an instrument that was developed to help nurses conduct environmental surveillance of ORs after terminal cleaning has been performed, identify problem areas, and correct deficiencies before patient care is affected adversely.

TERMINAL CLEANING

Terminal cleaning of ORs should be performed once every 24 hours even if no procedure has been performed in the room. (2) Registered nurses should monitor the OR environment to ensure that terminal cleaning processes have been carried out effectively according to the Centers for Disease Control and Prevention infection control guidelines. (3)

Terminal cleaning is performed in surgical procedure rooms and scrub and utility areas at the completion of daily surgery schedules. It includes cleaning

* surgical lights and external tracks;

* fixed and ceiling-mounted equipment;

* all furniture, including wheels and casters;

* equipment;

* handles of cabinets and push plates;

* ventilation faceplates;

* horizontal surfaces (eg, countertops, autoclaves, fixed shelving);

* the entire floor;

* kick buckets; and

* scrub sinks.

Both ongoing and terminal cleaning are extremely important because they not only decrease microorganisms and contamination risks but also may contribute to control and prevention of infection in patients. Cleaning solutions used for terminal cleaning are institution-specific but must be bacteriocidal. This is of paramount importance because of the virulence of some organisms, including those that are medication resistant. An instrument that allows perioperative nurses to monitor the OR environment may contribute to patient safety and positive outcomes and, ultimately, may contribute to a reduction in surgical infection rates.

SURVEILLANCE INSTRUMENT

The environmental surveillance monitor is a checklist of surfaces found in every OR (Table 1). The OR quality coordinator in one facility developed this instrument to track and trend terminal cleaning of the OR suite based on her observations of a general lack of attention to detail in terminal cleaning processes. A score of one is assigned for each contamination event (ie, dust, paper, suture, blood spatter) found in a room, and the total is noted for each room each day. Data obtained from the instrument can be used to identify and correct problem areas, and, in collaboration with environmental services personnel, improve terminal cleaning processes.

PILOT TEST

A pilot test of the instrument was conducted at a large academic medical center serving patients from 27 rural counties in a southeastern state. The interior of 22 operating suites currently in use at the medical center served as the setting. A nonexperimental, descriptive design was used to compare the number of contamination events in rooms and on room surfaces daily during a six-month period.

Data collection was performed by an RN and the environmental services team leader or a designee on a daily basis Monday through Friday between 6 AM and 6:45 AM, using the following procedure.

* The entire room was inspected from the door.

* Monitors, booms, hanging equipment, ledges above cabinets, white boards and doors, light fixtures, casings holding monitors, desks, radios, shelves, overhangs, doors, counters, telephones, and floors were inspected individually.

* If dust or debris was found, it was removed immediately using the hospital approved cleaner and cloth, and this action was noted on the environmental surveillance monitor.

* Personnel coming into the room were notified and educated about the deficiencies noted in the room.

* A log was completed for each room, and a total score was calculated for each room.

* A daily report was submitted to relevant nursing, infection control, plant operations and environmental services managers.

Data were coded, and frequency distributions, means, and standard deviations were calculated for each item.

RESULTS

Figure 1 shows the total number of events by month. In January, the total number of dust, suture, blood, and paper events noted in all rooms was 1,217. In February, there was a 4% (54event) increase over January. This increase may have occurred because of personnel changes in the environmental services department and the data collectors' increased familiarity with the instrument.