By Don Sadler
The worldwide COVID-19 pandemic has reinforced the need for everyone to practice effective personal hygiene, such as washing hands frequently and not touching one’s face. Cleanliness and hygiene are also important in the health care setting – especially in operating rooms and ambulatory surgery centers (ASCs).
“Maintaining a clean and sterile OR environment is integral to patient safety,” says Jan Martin MSN, RN, CIC, interim manager, infection prevention at WellStar Atlanta Medical Center.
Preventing Adverse Outcomes
Martin points out that all nationally recognized evidence-based standards point to maintaining a clean and sterile operating room (OR) environment as one of the most important steps in preventing adverse outcomes in that specific setting.
“It’s just the right thing to do,” says Martin. “No one would want anyone close to them to undergo a procedure at a hospital or ASC that did not abide by all nationally recognized guidelines for maintaining a clean and sterile operating environment.”
David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC, says that the consequences of failure to maintain a clean OR environment “can be devastating and have a life-altering impact on patients. Nobody goes into surgery thinking they are going to become infected because the OR leadership fails to maintain their department.”
According to Karen deKay, MSN, RN, CNOR, CIC, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN), the environment is the third component in the epidemiological triangle.
“The triangle represents the elements required for disease transmission: a susceptible host, an agent or viable pathogen, and an environment that facilitates transmission,” says deKay. “If we can perform measures to reduce pathogens on environmental surfaces and patient care devices, we can assist in interrupting the infectious process or decreasing transmission.”
deKay stresses that the OR environment itself cannot be sterilized. “Instead, it is cleaned and disinfected,” she says. “This eliminates the bioburden and microorganisms found on surfaces. Supplies such as drapes and sutures and instruments are sterilized using specially designed machines that remove all microorganisms, including spores. Sterile technique is then utilized to maintain their sterility.”
SSIs Promote Other Problems
Poor infection control practices can result in increased incidences of surgical site infections (SSIs) that in turn lead to a host of problems, says Taylor. These include increased length of patient stay, financial burdens for additional care, physical disability and even death.
“The best way to avoid these problems is to implement a robust preoperative assessment testing (PAT) program to ensure each patient is worked up medically before their procedure,” says Taylor. “A patient who is medically stable – or optimized – for surgery can provide opportunities to improve outcomes and reduce length of stay and SSI rates.”
Another benefit of a robust PAT program is fewer scheduling conflicts, delays and day of surgery cancellations, Taylor adds.
deKay points to research that investigated the transmission of pathogens within the anesthesia workspace. “These studies not only demonstrated intraoperative transmission of pathogens, but also found that virulent and antibiotic-resistant bacterial strains were often the transmissible agents,” she says.
In the hundreds of assessments he has performed on operating rooms across the country, Taylor says he has found OR cleanliness and infection prevention practices to be lacking.
“Perioperative leaders are not maintaining their ORs to the standard they should be,” he says. “And the statistics are evidence of this – SSIs are occurring in hundreds of thousands of patients annually and costing hospitals as much as $10 billion a year.”
Martin has also observed shortcomings when it comes to maintaining a clean operating room environment. She attributes them to a wide range of factors including:
- A lack of staff training
- Long dwell times of cleaning products
- A lack of accountability among leadership for strict adherence to maintaining a clean and sterile OR environment
- Quick OR turnarounds that are expected in order to maintain patient flow
- The fact that infection prevention often does not maintain a presence in the OR and conduct regular rounds
“I frequently observe products drying well before the required dwell time without application of additional product,” says Martin. “I personally believe that hospitals should use products with the shortest dwell time and the highest kill capability. Products with 10-minute dwell times may not be the best for disinfection.”
In her personal observations, deKay says that surfaces are not always cleaned as thoroughly as they should be due to expectations for quick OR turnover. “Additionally, clear designation of who was cleaning what item did not always occur, so items were missed or cleaned twice. This led to cross-contamination as team members would clean in the cleanest area of a room, move to a dirtier area and then return to a cleaner area.”
deKay points to studies that found compliance with OR cleaning protocols was low. In one of them, the mean overall thoroughness of cleaning was just 25% of 946 objects evaluated.
Unfortunately, there are some obstacles that can make it difficult for health care facilities to improve their infection control practices. “These can include personal opinion and bias as well as facilities not providing the training needed to understand the recommended practice standards and how they should be incorporated into daily practice,” says Taylor.
The good news is that there are some exciting technology solutions that are making it easier for hospitals and ASCs to create and maintain a clean and sterile operating environment. One of these is Needlepoint Bipolar Air Ionization, also known as NPBI. Taylor explains how it works.“The NPBI produces a high concentration of positive and negative ions which allows similarly charged particles to combine, making it easier for them to be filtered in the HVAC system more effectively. As the ions travel within the air stream, they attach to pathogens, particles and gas molecules, breaking them down and rendering them ineffective.”
Ultraviolet light (or UV-C) technology is also being used to help maintain a clean OR environment. “It works by using UV-C band wavelength to degrade organic material and inactivate microorganisms and pathogens,” says Taylor. “UV-C technology has been used more extensively during the COVID-19 pandemic.”
“Using UV-C for mask disinfection has been especially beneficial during the pandemic,” adds Martin.
deKay stresses that these technologies should be considered adjuncts to environmental cleaning and disinfection in the operating room.
“Physically cleaning surfaces is the first step in environmental cleaning, followed by the application of EPA-registered, hospital-grade disinfectant for the designated contact time. UV-C technology could possibly be used after the environmental cleaning process to kill any residual germs left behind on surfaces,” deKay adds. “But since this technology is in addition to normal cleaning and disinfection, it is important to consider the implications of adding it to your environmental cleaning process.”
deKay believes that further research is needed to determine clinical benefit of this technology in the prevention of SSIs and the potential harm of using these devices in the OR, including their effect on sterile supplies and environmental parameters like temperature and humidity.
“If more training and resources were spent on manual cleaning processes and personnel instead, could this help reduce the spread of infections?” deKay wonders.
Meanwhile, Taylor points out some limitations regarding the use of UV-C technology to maintain a clean OR environment. “Because UV exposure is hazardous to humans, it is typically only used in certain configurations,” he says. “These include in unoccupied room disinfection, upper room disinfection, air handler unit surface disinfection and air handler surface airstream disinfection.”
“However, this technology has been thoroughly vetted and has a proven track record,” says Taylor.