Phyllis Wells, R N

“Confine and contain” approach to OR cleanup

The procedure for cleaning between surgical cases is a longneglected area that could benefit from reform. There is a sensible, practical approach that not only can simplify OR cleaning but also help eliminate bacterial contami- nation.

In 1968, Ginsberg introduced a

Phyllis Wells, RN, is marketing rep- resentative, textile fiber division, E I DuPont de Nemours and Co, Wil- mington, Del. Formerly OR supervisor at Boswell Memorial Hospital, Sun City, Ariz, she is a graduate of Good Samaritan Hospital School of Nursing, Phoenix.

From Proceedings: Hospital Infec- tion Control Program, Philadelphia, May 5-6, 1976. Copyright Association for Advancement of Medical Instru- mentation. Reprinted with permission.

simplified operating room cleaning procedure based on scientific princi- ples of microbiology.’ The basic prem- ise underlying this procedure is that cleanup should be easily executed yet comprehensive enough to provide a bacteriologically safe environment whether the surgical procedure is a “clean” or a “dirty” case. This proce- dure has subsequently had the support of leaders in infection controL2 In 1975, the Association of Operating Room Nurses (AORN) published stan- dards on OR sanitation3 similar to those introduced by Ginsberg.

The most frequently asked question in relation to OR cleanup is, How should we clean after a dirty case? With the idiosyncrasies of microbes, it is often difficult to determine whether a patient has an infection or not. Even in situations of gross contamination with purulent drainage, there can be a difference of opinion on whether the case should be considered dirty. Those who have worked in operating rooms have probably encountered the sur- geon who insists, ‘‘it’s only a sterile abscess.” With microorganisms as un- defined as viruses, as changeable as tuberculosis, or as secretly harbored as staphylococcus, we can never be cer- tain that a patient does not have some type of infection that will be harmful

60 AORN Journal, January 1977, Vol.25, No 1

f team has been diligent, I only small area needs cleaning between cases.

to the next patient or persons who come into that operating room. For this reason, every patient and every operation should be considered a pos- sible source of cross ~ontaminat ion.~

If we are to support this premise and still run the operating room schedule with efficiency, the clean-up procedure has to be comprehensive enough to be effective, simple enough to be carried out by everyone, and fast enough to keep change-over times to a minimum. These three requirements can be met with a logical “confine and contain” approach to cleaning. First, and prob- ably foremost, the operating room must be kept clean as the surgery progresses. The room should not be allowed to become such a disaster that it takes an hour to clean between cases. Clean up as the procedure goes along. The area of contamination should be confined to as small an area as possible. There is no need to spread contamination to the walls, ceilings, and the corners of the room. I t can be confined to an area close to the pa- tient.

Items that become contaminated must be contained to prevent cross contamination. Disposables are con- tained and discarded, reusables are contained for later decontamination. With containment of instruments, drapes, gowns, gloves, suction, anes- thesia equipment, and miscellaneous supplies from the operating room, the

room can be quickly rendered safe for the next patient with sensible house- keeping techniques.

This type of confine and contain method of control is better understood if i t is correlated to the ways microor- ganisms are transmitted. In the operating room, we are primarily con- cerned with two types of microor- ganism transmission: airborne and contact.

Microorganisms do not move around on their own. They have to ride along on something else, such as moisture droplets: the droplets that are spewed out when people talk, cough, sneeze, or laugh. This transmission can easily be controlled by requiring everyone who enters the operating room to wear a high filtration mask. If the patient has a local anesthetic, he should also wear a mask. If he has a general anesthetic, the anesthesia circuit is considered contaminated.6

Microbes will also move through the air on lint and dust particles. Whenever possible, low-linting mate- rials should be used for clothing, drapes, and packaging. Especially im- portant is a n effective air-handling system using high efficiency filters and an adequate amount of air circula- tion through the room. The latest rec- ommendations are 25 air changes per

Because dust settles on horizon- tal surfaces, proper cleaning of these surfaces will help to control airborne

AORN Journal, January 1977, Vol25, No I 61

microorganisms that travel on dust and lint.

Another vehicle on which microbes travel is skin shed. This can be con- trolled by proper hygiene of personnel in the operating room and proper at- tire. AORN has produced an excellent film on OR attire.8 Another considera- tion is the movement of people within the operating room. Studies show that the ratio of bacteria in the air is di- rectly related to the number of people in the operating room and the amount of activity in which they engage.s

The second method of transmission is by contact. Considering the patient as a source of contamination, every- thing that comes in contact with the patient is potentially contaminated and could be a source of cross con- tamination to any other person who comes in contact with those same items, eg, drapes, gowns, gloves, in- struments, sponges, suction, and the operating table. How they are handled between surgical cases is the basis of this clean-up procedure.

The procedure for cleaning the operating room is done in four phases. To facilitate the procedure, a cart con- taining an instrument washer tray, a supply of moisture-proof bags, dispos- able gloves, and detergent-germicide solution in a squirt bottle should be kept readily available along with dis- posable cleaning cloths.

Before surgery 0 Supplies and equipment are or-

ganized before the patient arrives to prevent unnecessary trips dur- ing surgery.

0 Proper OR attire including shoe covers are worn by all persons en- tering the operating room.

During surgery 0 Organic debris is immediately

cleaned up by the circulator, using phenolic solution and a dis-

posable cloth. The room is kept tidy; all used articles are con- tained in proper containers. Traf- fic is kept to a minimum.

0 When gown and gloves are not worn, handwashing is carried out following patient contact.

0 Used sponges are discarded into lined kick buckets. Sponges are sorted with a forcep (or the cir- culator may wear disposable gloves), counted, and placed into waterproof bags and sealed.

End of procedure 0 Drapes are rolled into small bun-

dles and placed into a trash hamper.

0 Surgeon’s gowns and gloves are removed inside-out and placed in the trash. Masks are removed and discarded upon leaving the room. Shoe covers are changed between procedures and removed when leaving the surgical suite.

0 Tape is applied to the dressing by the circulating nurse or the sur- geon after he removes his gown and gloves.

0 All dirty instruments are opened wide by the scrub person (still wearing gown and gloves) and placed into a washer tray con- tained in a large moisture-proof bag on the cart.

0 The specimen is placed in the specimen container, sealed, and delivered to pathology.

0 All unused instruments are placed in a washer tray contained in a moisture-proof bag and placed on the cart.

0 Solutions remaining on the back table are contained in the suction system. Basins are wiped clean and are placed in a washer tray.

0 Reusable articles that cannot be processed through the washer sterilizer are sealed in a

62 AORN Journal, January 1977, Vo l25 , No 1

leaning rituals have C to be reexamined for scientific soundness.

moisture-proof bag for later clean- ing and sterilization.

0 Any remaining solutions can be contained in the suction system. Basins are wiped clean and placed in a moisture-proof bag. The bag is placed on the cart.

0 Needles and knife blades are con- tained in a magnetic pad and dis- carded. Mayo stand cover and back table cover are rolled up with all re- maining articles to be disposed- suture bag, magnetic pad, sponges, etc-and discarded in the trash container. Scrub person’s gown and gloves are removed and discarded in the trash.

After the patient leaves the room Suction systems are emptied into a flush hopper, and the container is discarded in the trash.

0 Reusable anesthesia equipment is bagged and placed on the cart. Disposable items are discarded. The cart containing all contami- nated articles is removed to the clean-up area. The operating table, overhead light, and horizontal surfaces are cleaned with detergent-germicide. If other pieces of the furniture or equipment have been soiled, these are wiped clean.

0 Bucket liners are discarded. Trash and linen bags are sealed and removed.

0 The floor is sprayed or flooded with detergent-germicide that is allowed to remain five minutes and vacuumed.

The entire cleanup can be ac- complished in ten minutes if the team is organized and the room has been picked up as the operation progressed. Terminal cleaning at the end of the day employs the same techniques listed above with the addition that all the furniture in the room is scrubbed down. The light and track are cleaned. The floor is flooded with detergent- germicide, scrubbed, and the cleaning solution is picked up with a wet vac- uum. Return air vents are cleaned weekly. Walls are spot cleaned as needed and completely washed down monthly.

Many items used in the modern operating room are single-use items such as drapes, sponges, solutions, needles, and suction systems. They can all be discarded after use. Sturdy, moisture-proof trash bags allow safe transport out of the hospital. Those items that are not disposable, such as blood pressure cuffs, instruments, some anesthesia equipment, and miscellaneous reusables must be contained in suitable moisture-proof containers until they reach the decon- tamination area.

What remains in the operating room for cleaning are those items that can- not be thrown away or sent to another area for decontamination-the floor,

AORN Journal, January 1977, Vo l25 , No I 63

furniture, and walls. If the surgical team has been diligent in its confine and contain approach, there will be only a small area within the operating room that needs cleaning between cases. This usually consists of the operating table, the overhead light, uncovered horizontal surfaces, and the floor. The task can be quickly com- pleted using effective cleaning solu- tions and modern cleaning equipment.

Unfortunately, OR personnel across the country have indicated that they do not have modern cleaning equip- ment. A hospital should not be accept- ing surgical patients if it does not have the basic equipment to carry out safe cleaning procedures in the operating room.

It is essential to have an effective way of decontaminating instruments. This can be accomplished (in a Rube Goldberg fashion) with a regular flash sterilizer, but a washer-sterilizer will prove more efficient and more con- venient. If instruments are processed shortly after surgery, there is usually no need for rinsing. The secret is to open the box locks of all instruments. The more complex instruments should be disassembled. An ultrasonic cleaner is essential for periodic “deep” clean- ing of all instruments except lensed instruments and instruments powered by air, electricity, or battery. These and many other items used in the OR cannot be processed through the washer-sterilizer or ultrasonic cleaner and should be carefully cleaned manu- ally in a designated area. Personnel should wear gloves. Once cleaned, these items should be wrapped and sterilized either by steam or ethylene oxide.

For floors, the mop and bucket of yesteryear have been replaced with the wet vacuum. Extensive studies have proven that covering a floor with

a broad-spectrum detergent-germicide, allowing five minutes contact and then removing all of the solution with a wet vacuum, leaves a floor virtually free of microorganisms.1° A watering can or low-pressured spray can may be used to dispense the liquid germicide. A more elaborate built-in system that automatically mixes correct propor- tions of germicide and water is being used in some hospitals in conjunction with a central vacuum system.

If we understand how microor- ganisms are transmitted and that contamination can be controlled by confining and containing, the danger of inadvertent contamination and the amount of time spent on cleaning can be greatly reduced. These measures, in conjunction with good housekeeping techniques, will provide a clean-up procedure that is effective for all situa- tions, whether the patient has gas gangrene, tuberculosis, or Pseudo- monas and whether the surgical procedure is a hemorrhoidectomy, thyroidectomy, or total hip replace- ment.

Now you can answer that age-old question of how to clean between cases. You no longer have to isolate a particular case as dirty or fog the OR after gas gangrene. You don’t have to put wet mats down at the door, wash the walls and ceilings after each pro- cedure, or soak instruments in disin- fectant solution. Cleaning rituals that have been performed for years need to be reexamined for scientific soundness. If they are not satisfactory, toss them out.

Instead, implement a clean-up pro- cedure that is effective and efficient. kour downtime between cases will be reduced, you will have more flexibility in scheduling, and you will take the guesswork out of OR cleanup. 0

64 AORN Journal, Janunry 1977, Vol25, No I

Notes 1. Francis Ginsberg, ". . . these fourteen

steps will make any OR safe," Modern Hospital (June 1968) 130.

2. Bertha Yank Litsky, "Simple steps to OR asepsis," Medical-Surgical Review (April-May 1971) 20-24; J G Peers, "Clean-up techniques in the operating room," Archives of Surgery 107 (Oc- tober 1973); P Dineen, "Prevention of infection in the operating room." Bulletin of the American Col- lege of Surgeons 55 (1 970) 18-21.

3. "AORN standards for OR sanitation," AORN Journal 21 (June 1975) 1228-1231.

4. Peers, "Clean-up techniques in the operat- ing room," 596.

5. Mabel Crawford. "Infection control in the OR," AORN Journal (May 1970) 54.

6. G E Dryden, "Sources of infection in the surgical patient," AORN Journal (May 1971)

7. American College of Surgeons, Manual on 67-69.

Control of infection in Surgical Patients (Philadel- phia: J P Lippincott, 1976) 118.

8. "AORN standards OR wearing apparel, draping and gowning materials," AORN Journal 21 (March 1975) 594; Judy Pfister, "Proper operating room attire," 1975, a 16 mm sound film, Davis + Geck Film Library, DG 1209.

9. J A Ulrich, "Surgical team remains prime source of organisms contaminating OR air," Hospi- tal Topics 49 (October 1971) 81; Harold Laufman, "Operating room environment," Hospitals 4 (Jan 1, 1971) 55; V W Greene et al, "Microbiological con- tamination of hospital air," Applied microbiology 10 (1962) 561.

10. A K Pryor, "Cleaning procedures for the operating room," Executive Housekeeper 17 (1 970) 14-20; "A cooperative microbiological evaluation of floor cleaning procedures in hospital patient rooms," Health Laboratory Science 7 (Oc- tober 1970).

Pediatric chest trauma correlated to age A group of Chicago physicians has correlated types of pediatric chest trauma with a child's age. Thomas G Baffes, MD, Mt Sinai Medical Center, Chicago, reported that three groups of incidence can be distinguished: (1) at birth, (2) from the first year of life until puberty, and (3) after puberty.

Results of a survey taken in hospitals in metropolitan Chicago were presented to the American College of Surgeons October Clinical Congress in Chicago.

Birth injuries include broken collar bones resulting from prolonged labor or difficulties in extracting the child from the birth canal. A large number of injuries resulted from necessary attempts to resuscitate newborns with respiratory distress or with instrumentation injuries. Most responded to conservative treatment.

After the first year, aspiration of foreign bodies is a common injury. These instances are usually due to the child's lack of comprehension that small objects can be aspirated if placed in the mouth. It may also indicate a parent's failure to supervise and instruct the child, Dr Baffes said. Research also indicated a high incidence of child abuse cases in this age group.

As the child emerges from puberty, he indulges in a number of vigorous physical activities. Many injuries in this age group stem from automobile and sports accidents, Dr Baffes observed. "It is usually difficult for parents and other supervisory adults to control the hazards that these items produce to children since, as they emerge into adulthood, they have an exaggerated opinion of their physical and mental prowess."

Dr Baffes noted, "There was a fairly equal distribution in most injuries that were studied." In the 434 cases accumulated, injuries associated with birth amounted to 21.89%; aspiration of.foreign bodies, 28.8%; blunt trauma to the chest, 21.43%; penetrating injuries to the thorax, 17.74%; chest burns, 7.1%; and compression fractures of the vertebral column, 3%.

had either gunshot wounds or stab wounds of the chest-an indication of the savage environment in which many children in the metropolitan Chicago area have to live," said Dr Baffes.

Christianson, MD, Joanne Levitan, MD, and Elliot Kroger, BS.

"There were 77 children in the series who

Coauthors of the report were Paul

AORN Journal, January 1977, Vol25, No 1 65