62%
lack of a monitoring and feedback
process, poor workflow, and ineffective
of between- cleaning tools.
Roles and responsibilities for cleaning
case cleaning
the
operating room varies from hospital
is completed by
to hospital. To better understand who
operating clinical
actually cleans the operating room,
room staff,
Ecolab surveyed 250 hospital operating
are completed by room directors across the country. The
a combination of results showed that 62 percent of
between-case cleaning is completed
operating room by operating clinical room staff, 19
clinical staff and percent are completed by a combination
environmental of operating room clinical staff and
services staff, and environmental services staff, and 19
percent are cleaned by environmental
are cleaned services staff alone. 7 And while they
by environmental may be experts at aseptic technique
services staff and the importance of preventing
alone. 7 cross-contamination, most operating
room clinical staff would probably
tell you that they have had minimal
training on OR-specific cleaning and
disinfection practices.
Of course, workflow is very important for efficiency as
well. It may seem like having more people helping in room
turnover would improve efficiency, but as part of a lean six
sigma project, one study found that efficiency and effectiveness
actually decrease when more than two people are involved in
cleaning an OR between cases. 8 In addition to the number of
people cleaning, the way in which the room is cleaned can
also lead to inefficiency. A clearly defined and communicated
workflow or cleaning process is key to ensuring that cleaning
is done both thoroughly and quickly.
OR staff are used to working with many complex medical
devices in the operating room, and yet we often use the same
tired tools to clean and disinfect a room between cases that
we’ve used for decades: dusty whisk brooms, open mop
buckets, string mops, and cotton linens. Whisk brooms
are not to be used in operating rooms because they can
aerosolize dust and debris and are impossible to disinfect. The
disinfectant used in open mop buckets must be changed out
regularly, but often isn’t which can cause splashes and spills.
String mops have been shown to be less effective at picking
up soil and debris than microfiber mops, and cotton linens
sometimes appear with stains, hair or other quality issues.
In fact, in a survey of 50 nurses across the United States, it
was reported that anywhere from one (33 percent) to 10 (7
percent) sheets per day were found to be unusable due to
stains, slowing turnover efficiency as they had to take time to
replace the linen. In the same study, just 24 percent of nurses
responded that they never had stained linen that could not
be used, suggesting this is a widespread issue. 9
Change is hard, and clearly there are many things that can
prevent hospitals from achieving the OR turnover efficiency
that they desire. As we work to implement new processes,
training and tools, we must find a way to measure our
success and keep people engaged in the right behaviors.
Multiple studies have shown that one of the most effective
19%
19%
24
ways to drive improvement in thoroughness of cleaning is
to perform process monitoring and provide performance
feedback. 10 This is not a new idea. In 2010, The Centers
for Disease Control and Prevention (CDC) published a
toolkit, “Options for Evaluating Environmental Cleaning,”
that outlines how to develop programs to optimize the
thoroughness of high-touch surface cleaning. 11 In this
toolkit, the CDC describes the methods currently available
to monitor environmental hygiene and recommend that
all hospitals develop a program to monitor environmental
hygiene. In general, the CDC recommends the following:
Focus on identifying and cleaning high-touch
objects (HTOs)
Use an objective method to monitor the thoroughness
of disinfection cleaning of HTOs
Provide continuous feedback that drives
continuous improvement
Develop reports documenting progress to share with
staff, leadership and surveyors
Financial Benefits of Effective and Efficient Between-
Case Cleaning and Disinfection
Last but certainly not least, there is a financial incentive
to perform effective and efficient cleaning and disinfection
between patients. As mentioned above, the cost of health-
care-associated infections in the United States is as high as
$10 billion annually. To make that number more meaningful in
the perioperative setting, 17 percent of patients will develop
a surgical site infection each year 1 and the average cost of
a surgical site infection is $34,000.2 If you perform 15,000
surgical procedures per year, and 2.5 percent of patients
acquire a surgical site infection, the cost is an astounding
$12.5 million, and that excludes the added cost of outpatient
follow up treatment of the infection or its sequelae.
In addition, cost studies have shown that the average
cost of operating room time ranges from $22 to $133 per
minute depending on the methods used to calculate it. 13 For
healthcare facilities, time is money — and that is especially
true in the operating room.
A Programmatic Approach is Needed
It isn’t enough to introduce a new product or tool
alone and expect it to have an impact on the effectiveness
and efficiency of between-case cleaning. Optimizing
between-case cleaning requires a multi-pronged approach.
A multi-center, randomized trial conducted in 11 acute-care
hospitals demonstrated that a programmatic approach
improves cleaning and may reduce healthcare associated
infections.14 Their programmatic approach introduced a
cleaning bundle for routine cleaning, focusing on:
Optimizing product use
Technique
Staff training
Auditing with feedback
Communication
In a study evaluating the use of an OR environmental
hygiene program to improve thoroughness of cleaning
and reduce between-case turnover time, researcher
demonstrated that they could improve clinical, operational
and financial metrics. 15
march 2020 • www.healthcarehygienemagazine.com