Healthcare Hygiene magazine March 2020 | Page 22

The Benefits of Optimizing Between-Case Cleaning in the Operating Room By Linda Homan, RN, BSN, CIC S urgical room turnover is a quick, complicated dance that takes place between surgical procedures and is intended to ensure that everything is ready for the next patient. At a high level, the goals for this process are to ensure that the room is disinfected, that all instruments and equipment needed are in the room and ready to go, and that the patient and staff are prepared for the procedure. There are constant time and cost pressures on this critical, but often under-appreciated step. The between-case cleaning portion of surgical room turnover is often considered less important than the more directly patient focused activities by clinicians; however, if done properly, it can provide great value to hospitals. In truth, there are important clinical, operational and financial benefits to be realized if the room is cleaned and disinfected effectively and efficiently between cases. Clinical Benefits of Effective Between-case Cleaning and Disinfection Healthcare-associated infections (HAIs) affect 2 percent to 5 percent of all surgical patients, and result in substantial morbidity, poor surgical outcomes, and total healthcare costs.1 In the U.S. alone, it has been estimated that more than 500,000 surgical site infections (SSIs) occur annually, with a direct cost of as much as $10 billion. 3 In addition, a surgical site infection increases the length of stay by 4.9 days, which can have a significant impact on both patient outcomes as well as hospital costs. 1 The environment has long been considered a vector for the transmission of HAIs. In 2015, the Agency for Healthcare Research and Quality (AHRQ) published a technical bulletin titled “Environmental Cleaning for the Prevention of Healthcare-associated Infections.” The first sentence of this document states what many of us have long known, “The cleaning of hard surfaces in hospital rooms is essential for reducing the risk of healthcare-associated infections.” 3 To reduce the risk of surgical site infections, operating rooms have practiced strict aseptic technique at least since 1865, when Lister discovered the benefits of antiseptics to sterilize instruments and clean wounds in surgery. Additional measures to ensure asepsis include surgical scrub, patient skin antisepsis, maintenance of the sterile field and specialized air handling. Cleaning practices in the OR are increasingly in focus as perhaps the last-frontier OR practices to prevent SSIs. In 2017, Yezli published a review article summarizing the 22 published studies supporting the role of the environment on the transmission of healthcare-associated pathogens via the hands of healthcare workers in the OR. He concluded that, “It is clear that the inanimate environment of the OR, including medical equipment, can become contaminated with pathogens that cause SSIs despite infection control measures such as standard environmental cleaning.” 4 The key phrase here is “standard environmental cleaning” because in a multicenter study published by Jefferson, et al. in 2011, they too found that only 25 percent of high-touch objects in the OR were cleaned when standard cleaning meth- ods were used. 5   What does this suggest? That standardized cleaning alone isn’t enough. In 2012, Munoz-Price showed that a combination of training, monitoring and feedback on the thoroughness of cleaning of high-touch objects in the OR was successful in decreasing the presence of gram negative bacilli in the environment. 6 So, while standard cleaning practices alone may not help reduce the risk of SSIs, standardized processes combined with thorough cleaning and disinfection, training, monitoring and feedback on cleaning best practices can in fact help reduce the contamination in the environment, thereby reducing the risk of infection and contributing to positive patient outcomes. Operational Benefits of Efficient Between-Case Cleaning and Disinfection While thorough cleaning and disinfection is critical to support patient outcomes, it is equally important that the work be accomplished efficiently so that procedures can start on-time. Operating rooms often feel a lot of pressure for quick turnover times to help increase the surgical volume in the department (often a source of revenue for the hospital). Many hospitals have a goal of 20 to 30 minutes total to turn a room over from wheels out to wheels in. A lot has to happen in that short period of time, including: removing the case cart, bagging trash and linen, cleaning and setting up anesthesia equipment, cleaning and disinfecting high-touch objects, mopping the floor, making the bed, opening for the next case, interviewing the patient, preparing medications for the next case, and counting and prepping. As important as it is, the cleaning and disinfecting portion of room turnover is only one small part of the activity that must take place during that time frame. As a result, it must be done as efficiently as possible. There are several factors that can hinder efficiency during room turnovers including poorly defined roles and responsibilities, inadequate training, march 2020 • www.healthcarehygienemagazine.com