1.
Recommended Practices for
Environmental Cleaning
Amber Wood, MSN, RN, CNOR, CIC, CPN
November 13, 2013

2.
Amber Wood, MSN, RN, CNOR, CIC, CPN
Amber Wood is a Perioperative Nursing Specialist at AORN where she has
served as lead author for the AORN Recommended Practices for
Environmental Cleaning. Amber offers clinical information to members via the
AORN Consult Line and contributes regularly to the Clinical Issues column in
the AORN Journal. She serves as the staff liaison to the CDC Healthcare
Infection Control Practices Advisory Committee (HICPAC), as a member of
the Association for Professionals in Infection Control and Epidemiology
(APIC) and the Association for the Healthcare Environment (AHE). Amber’s
clinical experience includes infection prevention, pediatric perioperative
nursing, and clinical research. Amber completed her BSN and MSN in
Nursing Education at Texas Woman's University in Dallas, TX and she is
certified as a CNOR, infection prevention and control professional (CIC), and
pediatric nurse (CPN).

3.
Disclosure Information
Speaker:
Planning Committee:
Amber Wood, MSN, RN, CNOR, CIC, CPN Ellice Mellinger MS, BSN, RN, CNOR
Disclose No Conflict
Perioperative Education Specialist, AORN
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4.
Objectives
1. Discuss recent revisions in AORN’s
recommended practices for environmental
cleaning.
2. Describe the evidence supporting the
recommended practices for environmental
cleaning.

5.
Purpose & Scope

6.
Role of the Environment
• Possible infection transmission from
contaminated surfaces in the environment
– Dancer SJ. The role of environmental cleaning in the control of hospitalacquired infection. J Hosp Infect. 2009;73(4):378-385. [VB]
– Otter JA, Yezli S, French GL. The role played by contaminated surfaces
in the transmission of nosocomial pathogens. Infect Control Hosp
Epidemiol. 2011;32(7):687-699. [VA]
• High transmission risk in perioperative
setting
– Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating
room environmental pathogen contamination through improved cleaning
practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. [IIIA]

7.
Cleaning in the OR
• May not be as good as we think it is…
– 25% mean cleaning rate for objects cleaned
in the OR at 6 acute care hospitals
– Jefferson J, Whelan R, Dick B, Carling P. A novel technique for
identifying opportunities to improve environmental hygiene in the
operating room. AORN J. 2011;93(3):358-364. [IIIB]

8.
Issues in Environmental Cleaning
• Many unanswered questions in the field
– Carling PC, Huang SS. Improving healthcare environmental cleaning
and disinfection: current and evolving issues. Infect Control Hosp
Epidemiol. 2013;34(5):507-513. [VA]

9.
New Scope
• All perioperative areas
– Pre- & Postoperative areas
– Operating and procedure rooms
– Semirestricted areas
– Sterile processing areas

10.
Evidence Review

11.
Modified Evidence Rating Model

12.
New concepts added
•
•
•
•
•
Multidisciplinary Teams
High Touch Objects
Enhanced Environmental Cleaning
Cleaning Methodology
Measurement of Cleanliness

13.
Gaps in the Literature
• What is clean?
• Defined cleaning procedures
• Cleaning frequencies

14.
Recommendation I
Multidisciplinary Teams

15.
Multi-Disciplinary Team
Perioperative
Nursing
Infection
Prevention
Environmental
Services
Sterile
Processing
Havill NL. Best practices in disinfection of noncritical surfaces in
the health care setting: creating a bundle for success. Am J Infect
Control. 2013;41(5 Suppl):S26- S30. [VB]

16.
Team Decisions
•
•
•
•
Cleaning chemicals
Cleaning materials, tools, equipment
Cleaning frequencies
Cleaning procedures
– Enhanced environmental cleaning
– Special situations (eg, C diff, airborne
precautions, CJD, construction, environmental
contamination)

17.
High Touch Objects
• Determine which items are high touch
• Clean those items more frequently
– Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM,Tima MA, Donskey
CJ. Contamination of hands with methicillin-resistant Staphylococcus
aureus after contact with environmental surfaces and after contact with
the skin of colonized patients. Infect Control Hosp Epidemiol.
2011;32(2):185-187. [IIIC]

18.
Cleaning Responsibilities
Item to Clean
• Missed items
Personnel
Anesthesia cart
and equipment
(eg, IV pole)
Nursing
(Anesthesia Tech)
Anesthesia
machine
Nursing
(Anesthesia Tech)
Patient monitors
Nursing
OR bed
Environmental
Services
Reusable table
strap
Environmental
Services
Dancer SJ. Hospital cleaning in the 21st century. Eur J
Clin Microbiol Infect Dis. 2011;30(12):1473-1481. [VA]

19.
Recommendation II
Cleaning Basics

20.
Damp dust
• Top to bottom
Practice Guidance for Healthcare Environmental Cleaning.
2nd ed. Chicago, IL: Association for the Healthcare
Environment; 2012. [IVC]

21.
Disinfectants
• Dwell times
– Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory
Committee. Guideline for Disinfection and Sterilization in Healthcare
Facilities, 2008. Atlanta, GA: Centers for Disease Control and
Prevention; 2008. [IVA]
• Spraying and misting should not be used
– Sehulster L, Chinn RY; CDC, HICPAC. Guidelines for environmental
infection control in health-care facilities. Recommendations of CDC and
the Healthcare Infection Control Practices Advisory Committee
(HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. [IVA]

22.
Dry methods of cleaning
• Should not be used in semirestricted &
restricted areas
– Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria
and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):5765. [IIIB]

23.
Floors
• The floor is always considered dirty
– Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating
room environmental pathogen contamination through improved cleaning
practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. [IIIA]
– Andersen BM, Rasch M, Kvist J, et al. Floor cleaning: effect on bacteria
and organic materials in hospital rooms. J Hosp Infect. 2009;71(1):5765. [IIIB]
• Items that touch the floor are dirty

24.
Recommendation III
Between Patient Cleaning

25.
Operating or Procedure Room
• High touch objects
• Contaminated surfaces
• Trash removal
CMS & CDC Guidance

26.
High Touch Objects in the OR
• Anesthesia cart and equipment (eg, IV
pole)
• Anesthesia machine
• Patient monitors
• OR bed
• Reusable table strap

27.
High Touch Objects in the OR…(If used)
•
•
•
•
•
•
OR bed attachments
Positioning devices
Patient transfer devices
Overhead procedure lights
Tables and Mayo Stand
Equipment, mobile or fixed

28.
Cleaning the OR…(If soiled)
• Floors
• Walls

29.
Pre- & Postoperative Areas
• High touch objects
• Contaminated surfaces
CMS & CDC Guidance

30.
High Touch Objects in
Pre- & Postoperative Areas
•
•
•
•
•
Patient monitors
Patient bed
Overbed table
Television remote control
Call light

31.
High Touch Objects in Pre&Postop…
(If used)
• Equipment, mobile or fixed

32.
Cleaning Pre&Postop…(If soiled)
• Floors
• Walls

33.
Recommendation IV
Terminal Cleaning

34.
Operating or Procedure Room
• Daily when the area is being used
• Disinfect all exposed surfaces of all items,
including wheels and casters
• Mop or wet-vacuum the entire floor
CMS & CDC Guidance

35.
Pre-&Postoperative Areas
• Daily when the area is being used
• Disinfect all exposed surfaces of all items,
including wheels and casters
• Mop or wet-vacuum the entire floor
• Trash removal
CMS & CDC Guidance

36.
Sterile Processing
• Daily when the area is being used
• Disinfect work areas and high touch
objects
• Damp dust horizontal surfaces
• Mop or wet-vacuum the entire floor
• Trash removal
• Dirty work areas last
ANSI/AAMI ST79:2010 & A1:2010, & A2:2011, & A3:2012:
Comprehensive Guide to Steam Sterilization and Sterility
Assurance in Health Care Facilities. Arlington,VA: Association for
the Advancement of Medical Instrumentation; 2012. [IVC]

37.
What about…
Weekends?
Perioperative
Nursing
Unused rooms
during the week?
Infection
Prevention
We just did 1 case…
Environmental
Services
Sterile
Processing

38.
Semirestricted & Restricted Areas
• If the area is closed with no personnel
present, the team may determine that
terminal cleaning is unnecessary.
• If perioperative team members are present
in the area briefly, the team may determine
that the area may only need damp dusting
on horizontal surfaces.

39.
cont.
• If perioperative team members are present
in the area for an extended amount of time
or are performing patient care activities,
the team may determine that thorough
terminal cleaning of the area is necessary.

40.
Emerging Technologies
• Room Decontamination (eg, ozone,
peroxide vapor, ultraviolet light, saturated
steam)
• May enhance cleaning of perioperative
areas as an adjunct to terminal cleaning,
although further research is needed
• Evaluation by multidisciplinary team

41.
Recommendation V
Scheduled Cleaning

42.
Scheduled Clean
•
•
•
•
•
•
Sinks
Ventilation ducts & grilles
Refrigerators & Ice machines
Clean & Soiled storage areas
Sterile storage areas
Corridors, including stairwells and
elevators
• Privacy curtains

43.
Scheduled Clean
•
•
•
•
•
Walls and ceilings
Pneumatic tubes and carriers
Sterilizers
Sterilizer service access rooms
Unrestricted areas (eg, lounges, waiting
rooms, offices)
• Environmental services closets

44.
Recommendation VI
Limiting Transmission

45.
Cleaning Methodology
• Clean to dirty
• Top to bottom
• Clockwise or counter-clockwise
Practice Guidance for Healthcare Environmental Cleaning.
2nd ed. Chicago, IL: Association for the Healthcare
Environment; 2012. [IVC]

46.
OSHA Regulations
• Standard Precautions
• Cleaning blood, body fluids, or other
potentially infectious materials
• Waste
• Sharps

47.
Recommendation VII
Special Cleaning

48.
Enhanced Environmental Cleaning
• Multidrug-resistant organisms (MDRO)
– Enhanced cleaning may reduce MRSA* and
VRE** contamination & risk of transmission
from prior room occupant
– Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning
intervention and risk of acquiring multidrugresistant organisms from
prior room occupants. Arch Intern Med. 2011;171(6):491-494. [IIB].
*Methicillin Resistant Staphylococcus Aureus
**Vancomycin Resistant Enterococci
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection
Control Practices Advisory Committee. Management of MultidrugResistant Organisms in Healthcare Settings. Atlanta, GA: Centers for
Disease Control and Prevention; 2006. [IVA]

49.
cont.
• Enhanced cleaning in ICU did not reduce
contamination of worker’s gowns & gloves
– Hess AS, Shardell M, Johnson JK, et al. A randomized controlled trial of
enhanced cleaning to reduce contamination of healthcare worker gowns
and gloves with multidrug-resistant bacteria. Infect Control Hosp
Epidemiol. 2013;34(5):487-493. [IA]

50.
cont.
• Environmental contamination with MDROs
was most likely to contaminate worker’s
clothing, gowns, & gloves
– Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant
bacteria to healthcare workers’ gloves and gowns after patient contact
increases with environmental contamination. Crit Care Med.
2012;40(4):1045-1051. [IIIA]

51.
High Touch Objects in the OR…
(Enhanced)
•
•
•
•
•
•
•
Storage cabinets, supply carts, furniture
Light switches
Door handles or push plates
Telephones and mobile devices
Computer
Chairs, stools, step stools
Trash and linen receptacles

52.
High Touch Objects in Pre&Postop…
(Enhanced)
• Storage cabinets, supply carts, furniture
• Light switches
• Door handles or push plates
• Telephones and mobile devices
• Computer
• Chairs
• Trash and linen receptacles
• Privacy curtains

53.
Updated
• C difficile
– EPA-registered product
– Effective against C diff spores
• Airborne diseases & Aerosolized droplet
transmissible infections
– Restrict room access
• Creutzfeldt-Jakob disease (CJD)
– Rutala WA, Weber DJ, Society for Healthcare Epidemiology of America.
Guideline for disinfection and sterilization of prion-contaminated medical
instruments. Infect Control Hosp Epidemiol. 2010;31(2):107-117. [IVA]

54.
Expanded
• Construction cleaning
– Clean dust & assess barriers
– Terminal clean when it’s done
– Clean when the environment is contaminated
• Water damage, condensation, air contamination
Sehulster L, Chinn RY; CDC, HICPAC. Guidelines for environmental
infection control in health-care facilities. Recommendations of CDC
and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42. [IVA]

55.
Recommendation VIII
Education
Recommendation IX
Policies & Procedures

56.
Recommendation X
Quality

57.
Measuring Clean
• Qualitative (eg, visual, fluorescent
marking) & quantitative measures (eg,
culture, adenosine triphosphate [ATP]
monitoring)
– Guh A, Carling P; Environmental Evaluation Workgroup. CDC toolkit:
options for evaluating environmental cleaning. 2010. Centers for
Disease Control and Prevention.
http://www.cdc.gov/HAI/toolkits/Evaluating-EnvironmentalCleaning.html. Accessed September 30, 2012. [VC]
• Use multiple measures
• Give immediate feedback when possible

58.
Checklists & Log Sheets
• Reduces chance of missing items during
cleaning
• Facilitate communication among the team
when items are cleaned
– Terminal cleaning
– Scheduled cleaning

59.
Frequently Asked Questions
(FAQs)

60.
FAQs
• Use various methods to pickup debris, but
don’t sweep the OR with a broom
• At a minimum, mop the floor between
cases if it’s visibly soiled
• Move the OR bed when you mop or if
something falls under the bed

61.
FAQs
• You can mop at terminal clean in the OR,
not required to use wet-vacuum
• Wait to clean until after the patient is gone
• Pour cleaning chemicals rather than spray
• People generate dust

62.
FAQs
• No time limit between terminal cleaning
and damp dusting
• Risk-Benefit-Cost Analysis
• The floor is dirty
• Use common sense

63.
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