Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives | Page 18

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
18
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,
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