Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives | Page 12

medical director of infection control and epidemiology at
the University of Nebraska Medical Center, and colleagues,
who conducted a more extensive survey to test the premise
that a positive deviance or “optimum outlier” model for
improving cleaning might be possible. The researchers
sought to ascertain whether a subgroup of housekeepers
could be identified as role models in an optimum outlier
improvement model.
Rupp says this 2014 study confirmed their original
observations; however, they were able to document the
presence of a small group of housekeepers who perform
faster and better than others.
Rupp emphasizes that they termed these workers
“optimum outliers” (instead of using the term “positive
deviance”). “We hypothesized that we could study their
habits and procedures and learn,” Rupp says, adding that
he’d like to see the term “optimum outlier” achieve more
traction within the infection prevention community.
The study was conducted in three patient-care units (a
burn unit, a telemetry unit, and a medical surgical unit)
from April 2011 to August 2011 at a 689-bed academic
medical center. Following routine terminal cleaning by EVS
personnel, a convenience sample of rooms was assessed
during regular work hours by measuring ATP levels on 18
designated surfaces (exterior door handle, bed rail, nurse call
button, bedside table, toilet flush handle, bathroom door
handle, toilet seat, bedside chair, light switch, mattress, sink
light switch, sink faucet handle, stethoscope, soap dispenser,
and telephone). A consistent surface area was sampled for
each surface. A composite cleanliness score was calculated
on the basis of the percentage of surfaces that were below
a cutoff point of 250 relative light units (RLUs)
The amount of housekeeper time spent cleaning a room
was documented through use of an automated system which
required personnel to document by telephone when they
arrived at the room and when room cleaning was complete.
Researchers estimated the cleaning effectiveness rate (as
measured by ATP detection) for each housekeeper and then
compared the rate of effectiveness of each housekeeper to
all other housekeepers. Analysis of variance was used to
compare the efficiency of cleaning (average time to clean
a room) between housekeepers, and pairwise comparisons
were performed. The association between effectiveness and
efficiency was analyzed by plotting the median time to clean
hospital rooms versus the median percentage of surfaces
graded as clean per housekeeper.
Seventeen housekeepers (labeled A–O) performed routine
terminal cleaning of 292 hospital rooms at patient discharge.
Housekeeper cleaning effectiveness ranged from 46 percent
to 79 percent. Pairwise comparisons placed housekeepers
into three groups. Housekeepers in group 1 (A–G) had
similar rates of cleaning effectiveness compared with one
another but were statistically less effective than the more
effective housekeepers in group 3 (K–Q). Housekeepers
in group 2 (H–J) were of intermediate effectiveness. The
average time to clean a room for the 17 housekeepers ranged
from 24 minutes to 47 minutes. For each housekeeper,
the average effectiveness of cleaning versus the median
efficiency of cleaning was plotted; the researchers found that
housekeepers M, O and Q cleaned rooms more effectively
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want the most “throughput” with the least cost,
whereas the surgeon wants first case of the day
block time, rapid turnover, low cancellation rate, and
on-time starts. Nurse managers may focus more on
flexibility to move cases around, disposable supply
costs/case, the percentage of cases in compliance
with flash sterilization policy and having adequate
reserve capacity for add-on cases or emergency
cases. Risk management, on the other hand, will
want to know the percentage of patients without
injury (e.g., wrong-side surgery).”
“The main challenge of turnover between
cases is time, as pressure from both surgeon and
administration to begin next case as soon as possible
is continually at the forefront,” acknowledges Karen
deKay, MSN, RN, CNOR, CIC, perioperative practice
specialist at AORN). “However, a clean and safe
environment for our patients should be first and
foremost. Performing qualitative and quantitative
monitoring methods to evaluate the thoroughness of
cleaning, as well as a gap analysis to determine com-
pliance with guidelines and policies and procedures
can provide documentation of any shortcomings that
may be a result of the time pressure. These findings
should then be shared with environmental, infection
prevention, and perioperative administration for
development of an improvement plan that includes
continued monitoring.”
The great many pieces of equipment and the
numerous OR personnel rushing around can pose
significant challenges to EVS personnel who are
trying to follow AORN and AHE guidance on
operating suite hygiene.
“Irregular surfaces, such as knobs and dials,
components of the OR bed specifically beneath the
mattresses, and complex pieces of equipment such
as a robot, imaging devices and microscope,” deKay
says. “Most often, EVS personnel converge all at once
to clean/turnover a room and these items may be
missed or quickly swiped over. In an organizational
experience to improve between case cleaning,
Pedereson, et al. found that when a ‘pit crew’ concept
was introduced that assigned personnel specific
tasks, the overall compliance with cleaning protocol
increased from 79 percent to 93 percent. I have also
heard of facilities dividing the room into zones and
a team captain assigning zones before entering the
room to clean. Additionally, establishing a cleaning
schedule for those items used less frequently that
clearly outlines how, when and the person responsible
for cleaning them is key. Initial training and annual
competencies, along with supplementary education
when new products or equipment are introduced are
also vital components for success.”
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