Using Checklists to Ensure a 24/7 Safer Operating Room Environment

by J. Darrel Hicks, BA, REH, CHESP

The original checklists used by pilots and co-pilots were developed to make sure that everything was done, and that nothing was overlooked or forgotten – to eliminate accidents and incidents. Similarly, new “best-practice” checklists developed specifically for OR processing are paving the way to a safer operating room environment, especially in those scenarios involving several infection prevention modes of practice.

In his pioneering book, “The Checklist Manifesto: How to Get Things Right,” surgeon and writer Atul Gawande makes clear the reasons why checklists are an absolute necessity in life if we are to get things done right. Gawande cites architects and pilots – and physicians and surgeons – among the professionals who recognize that checklists are essential if they are to succeed and perform safely.

I would argue that Gawande might say that processing the operating room today has entered its “B-17 phase.”

That is to say, in today’s environment, the checklist should soon become a mandatory tool for ensuring the quality of cleaning and disinfection of the OR in the same way the checklist was first developed in the 1930s for the new and complicated B-17 aircraft: To make sure in complex situations that everything is done, that nothing is overlooked or forgotten; to eliminate accidents and incidents.

Fortunately, new checklists that are focused specifically on OR processing best practices are now available and are being embraced by those clinicians who have recognized their value to ensuring patient safety.

These new checklists come at a critical time. Patients must be provided a clean, safe environment. Healthcare-associated infections (HAIs) have been linked to external sources, which can include environmental surfaces. The risk of infection from pathogenic organisms on environmental surfaces is due not only to their presence but to their ability to survive on and be transferred to many surfaces.

In order to prevent surgical wound infections, a multimodal approach is necessary. There are many disciplines involved in protecting the health and safety of surgical patients and staff. Here is an essential inventory of some of the key infection prevention modes of practice:

  • Employee health
  • Surgical draping
  • Surgical environments – floors, walls, ceilings and the absence of floor drains; all vinyl coverings on mattresses, stools, chair arms, etc. should be free of tears and splits;
  • Temperature and humidity
  • Airborne contamination and ventilation systems
  • Traffic control
  • Handling of infectious waste, linen and sharps
  • Intra-operative infection control-responsibilities of both the circulator and scrub tech
  • Housekeeping requirements

Sanitation protocols for cleaning and disinfection are required before, during and after each procedure. Environmental cleaning is the framework and basis for all aseptic practices. This is why I believe the time has come for a checklist that covers the 24/7 clean-and-ready condition of the surgical suite. This checklist will aid those who are responsible for processing the OR on a regular basis. (The term “process” as used includes cleaning and disinfecting an item or area using a clean micro-denier cloth or flat mop, as appropriate and an EPA-registered disinfectant.)

In one instance of the kind of checklist I’m talking about, the Association of periOperative Registered Nurses (AORN) recently awarded its AORN Seal of Recognition™ to the PerfectCLEAN® Operating Room program developed by UMF Corp., a manufacturer and innovator of infection prevention products.

UMF Corp. broke down the processing of the surgical suite into the same four segments identified in the “Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:243-254.” Those segments (and the four separate checklists) are:

  • OR 24-Hour Idle Processing Unused rooms should be processed once every 24 hours to ensure their readiness for surgery in an emergency situation where the room is needed immediately.
  • OR Pre-First Procedure Processing Includes removing unnecessary equipment based upon direction of the charge nurse and arranges remaining equipment as directed; process overhead surgical lights, all horizontal (upward facing) surfaces including tables, countertops, equipment and floors.
  • OR Between Procedure Processing Due to the heavy surgical schedule, room turnover has to be performed by several people working in concert. Once nursing and the anesthesia techs have performed their necessary duties, the room must be processed by the cleaning staff all within a 10- to 15-minute window (some processing may take up to an hour depending on the size of the room, the amount of equipment to be processed and the excessive soiling of the area). This is truly “team cleaning.”
  • OR Terminal (End-of-the-Day) Processing This is performed in each individual operating room when the last case of the day is finished; is usually done only once in a 24-hour period. The decontamination process begins at the highest level (light tracks, ceiling fixtures) and progresses downward (floors and baseboards) with an eye for blood or other potentially infectious material (e.g., flesh, bone, etc.). Using a clean micro-denier cloth and appropriate disinfectant, thoroughly wipe down all furniture and furnishing paying particular attention to the surgical table and the area/equipment within 5 feet of the table. There may be items that the anesthesia tech or OR orderly is responsible for cleaning and disinfecting; make sure they are using a micro-denier cloth and appropriate disinfectant when performing these tasks. Wet scrub the entire floor, wall-to-wall, moving and replacing furniture as you go.

Each of these four newly available checklists is laminated. These “best-practice” checklists provide the “cleaning task description” with separate boxes for the cleaner’s initials and the inspector’s initials and is able to be wet cleaned and disinfected. Realizing that wall space is a precious commodity in the OR, one should have a prominent and consistent spot where these checklists are displayed. The checklists provide a visible reminder of processing tasks and hold the appropriate staff member responsible and accountable for performing them.

Just like the checklists used by B-17 pilots and co-pilots that prevented loss of life and valuable military assets, the implementation of these four checklists helps ensure that patients are provided a safe and clean surgical environment. After all, the sanitation of the surgical theatre is among the key approaches to the prevention of surgical site infections.

J. Darrel Hicks has more than 30 years of experience providing safe and clean hospital ORs.