1. Guidelines for Environmental Cleaning
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

2. Developed and originally presented by 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 Guideline 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 as a member of 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).
These slides are taken from the webinar Recommended Practices for Environmental Cleaning, presented November 13, To listen to the webinar, visit These slides are made available for educational use. Slides may be personalized for your facility and presentation. HOWEVER, THE VIEWS EXPRESSED IN THESE SLIDES ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

3. Objectives
Discuss revisions in AORN’s guideline for environmental cleaning.
Describe the evidence supporting the guideline for environmental cleaning.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

4. Role of the Environment
Possible infection transmission from contaminated surfaces in the environment
Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 2009;73(4): [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): [VA]
High transmission risk in perioperative settings
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): [IIIA]
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5. 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): [IIIB]
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

6. 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): [VA]
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7. New Scope All perioperative areas Pre- & Postoperative areas
Operating and procedure rooms
Semi-restricted areas
Sterile processing areas
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8. New concepts added to the guideline
Multidisciplinary Teams
High-Touch Objects
Enhanced Environmental Cleaning
Cleaning Methodology
Measurement of Cleanliness
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9. Gaps in the Literature What is clean? Defined cleaning procedures
Cleaning frequencies
Cleanliness remains to be defined. The literature showed that no single method of assessing cleanliness was definitive. Rather, a combination of methods, including providing immediate feedback to cleaning personnel, was the most effective means to improve compliance with cleaning procedures.
Many of the studies reviewed during the process of updating the guideline isolated one cleaning procedure of interest and did not describe other cleaning procedures. For example, some studies of cleaning procedures for high-touch objects did not explain the cleaning materials, chemicals, or dilutions used.
Of the studies regarding cleaning in the OR, most evaluated terminal cleaning or cleaning of high-touch objects at the end of procedures. However, the studies did not define how often items should be cleaned, as this depends on many factors, including the frequency of touch and level of contamination.
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10. Multidisciplinary Teams
Recommendation I
Multidisciplinary Teams
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11. Multidisciplinary Team
Perioperative Nursing
Environmental Services
Infection Prevention
Sterile Processing
In a literature review, Havill recommended that multidisciplinary teams develop cleaning procedures as part of a bundle for best practice implementation for environmental cleaning.
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]
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12. 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)
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13. 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): [IIIC]
In an observational study, Stiefel et al found that surfaces contaminated with MRSA were just as likely to contaminate the hands of health care workers as touching the patient’s skin. This study shows that the environment can be a reservoir for pathogens to contaminate health care workers’ hands.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

14. Cleaning Responsibilities
Item to Clean
Personnel
Anesthesia cart and equipment (eg, IV pole)
Nursing (Anesthesia Tech)
Anesthesia machine
Patient monitors
Nursing
OR bed
Environmental Services
Reusable table strap
Missed items
In a literature review, Dancer identified that assigning responsibility for cleaning items in the perioperative setting is important to avoid having items that are missed during cleaning procedures. The team should determine which department will clean items in the perioperative setting (EVS vs Nursing). The department accepting the assignment should be trained and confident in what they are cleaning to avoid failures of cleaning related to human factors.
Dancer SJ. Hospital cleaning in the 21st century. Eur J Clin Microbiol Infect Dis. 2011;30(12): [VA]
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15. Recommendation II Cleaning Basics
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16. Damp dust
Top to bottom
Before setting up for the first procedure of the day, the perioperative team should damp dust all horizontal surfaces to reduce the risk of dust that has accumulated overnight from being transferred to an open surgical wound. (Read slide)
Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: Association for the Healthcare Environment; [IVC]
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17. Spraying and misting should not be used
Disinfectants
Dwell times
Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, Atlanta, GA: Centers for Disease Control and Prevention; [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]
Dwell time is the amount of time required for contact of a chemical agent with a surface.
Cleaning solutions that are sprayed produce more aerosols than solutions that are poured or ready to use. Aerosols generated may contaminate the surgical wound, sterile supplies, or the sterile field, or may cause respiratory symptoms.
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18. 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): [IIIB]
Wet methods produce fewer aerosols than dry methods.
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19. 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): [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): [IIIB]
Items that touch the floor are dirty
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20. Between Patient Cleaning
Recommendation III
Between Patient Cleaning
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21. Operating or Procedure Room
High-touch objects
Contaminated surfaces
Trash removal
At the end of each procedure, the high-touch objects and contaminated surfaces should be disinfected. Visual inspection of surfaces, including under the OR bed, should occur during cleaning so that all visible soil is removed. (Read slide)
CMS & CDC Guidance
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22. High-Touch Objects in the OR
Anesthesia cart and equipment (eg, IV pole)
Anesthesia machine
Patient monitors
OR bed
Reusable table strap
These are the most common high-touch objects used during operative and other invasive procedures (Read slide).
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23. 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
These are also common high-touch objects in the OR. If these items are used, they should be cleaned. If these items are not used, as determined by the multidisciplinary team, they may not need to be cleaned. (Read slide)
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24. Cleaning the OR…(If soiled)
Floors
Walls
These items should be cleaned if soiled or if potentially soiled during the procedure (eg, by splash, splatter, spray). (Read Slide) The multidisciplinary team may choose to incorporate floor or wall cleaning as part of end of procedure cleaning, depending on the level of contamination of the room from certain procedures (eg, trauma).
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25. Examples of cleaning frequencies in Operating and Procedure Rooms.
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26. Pre- & Postoperative Areas
High-touch objects
Contaminated surfaces
After each patient leaves the area, the high-touch objects and contaminated surfaces in the room or bay area should be disinfected. (Read slide)
CMS & CDC Guidance
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27. High-Touch Objects in Pre- & Postoperative Areas
Patient monitors
Patient bed
Overbed table
Television remote control
Call light
These are the most common high-touch objects used in preoperative and postoperative areas (Read slide). The multidisciplinary team should be involved with the identification of high-touch objects to be cleaned in these areas.
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28. High-Touch Objects in Pre- & Postop… (If used)
Equipment, mobile or fixed
If any equipment is used in the preoperative and postoperative areas, it should be cleaned after each use. This includes suction regulators and oxygen gas regulators mounted to the wall.
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29. Cleaning Pre- & Postop…(If soiled)
Floors
Walls
These items should be cleaned if soiled, or if potentially soiled during patient care (eg, splash, splatter, spray). (Read Slide) The multidisciplinary team may choose to incorporate floor cleaning as part of cleaning after each patient has left the area, depending on the level of contamination of the room or area.
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30. Pre/post areas
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31. Recommendation IV Terminal Cleaning
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32. 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
All surfaces of items in the OR, including wheels and casters, should be cleaned as part of terminal cleaning. The floor should also be mopped or wet-vacuumed. Depending on the policy of your health care organization, flooding the entire floor is not essential, although it may be useful for cleaning the wheels of mobile equipment. Always remember to follow manufacturer’s instructions for disinfectant use, including dwell times. (Read slide)
CMS & CDC Guidance
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33. 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
All surfaces of items in the room or area, including wheels and casters, should be cleaned as part of terminal cleaning. The floor should also be mopped or wet-vacuumed. Always remember to follow manufacturer’s instructions for disinfectant use, including dwell times. (Read slide)
CMS & CDC Guidance
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34. 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
(Read slide) Take extreme caution when mopping or damp dusting near areas with sterile instruments and supplies. The dirty work areas of sterile processing, the decontamination area, should be cleaned last to prevent cross-contamination with the clean areas where items are prepared for sterilization. Also, cleaning should not take place when instruments are being actively decontaminated or packaged for sterilization. This may be very challenging to arrange in a busy sterile processing area that is operating 24/7. Collaborate with sterile processing to find the best time for terminal cleaning to occur.
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; [IVC]
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35. What about… Weekends? Unused rooms during the week?
Perioperative Nursing
Environmental Services
Infection Prevention
Sterile Processing
Weekends?
Unused rooms during the week?
We just did 1 case…
(Read slide)
The answers to these questions is a team decision. Here are some ideas that may guide your team, which are based on the concept that the presence of personnel generates dust from shedding skin squames, which can harbor bacteria.
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36. 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.
Pre- & Postop
The traffic and level of contamination in the pre- and postoperative areas may guide terminal cleaning procedures in these situations (ASC vs trauma center). If the departments are closed with no patients present, terminal cleaning is not necessary. If the preoperative areas are closed outside the regular work week, terminal cleaning may only need to occur in the postoperative areas when used for patient care.
SPD
Collaborate with sterile processing to determine activity in the area for these situations (ASC vs trauma). In some facilities, the perioperative personnel perform decontamination only and then call the sterile processing team to come in off-shift if they need items sterilized. For this scenario, the decontamination area may need terminal cleaning daily, whereas the clean side of sterile processing may only need damp dusting on the weekends.
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37. (continued)
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.
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38. 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
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39. Recommendation V Scheduled Cleaning
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40. Scheduled Cleaning Sinks Ventilation ducts & grilles
Refrigerators & ice machines
Clean & soiled storage areas
Sterile storage areas
Corridors, including stairwells and elevators
Privacy curtains
The multidisciplinary team should also determine when to clean items on a scheduled basis (eg, weekly, monthly). (Read slide)
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41. Scheduled Cleaning Walls and ceilings Pneumatic tubes and carriers
Sterilizers
Sterilizer service access rooms
Unrestricted areas (eg, lounges, waiting rooms, offices)
Environmental services closets
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42. Limiting Transmission
Recommendation VI
Limiting Transmission
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43. 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; [IVC]
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44. OSHA Regulations Standard precautions
Cleaning blood, body fluids, or other potentially infectious materials
Waste
Sharps
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45. Recommendation VII Special Cleaning
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46. Enhanced Environmental Cleaning
Multidrug-resistant organisms (MDROs)
Enhanced cleaning may reduce MRSA* and VRE** contamination & risk of transmission from the previous 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): [IIB].
*Methicillin-resistant Staphylococcus aureus
**Vancomycin-resistant Enterococci
Definition of Enhanced Environmental Cleaning:
Environmental cleaning practices implemented to prevent the spread of infections or outbreaks; enhanced cleaning practices promote consistent and standardized cleaning procedures that extend beyond routine cleaning.
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; [IVA]
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47. (continued)
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): [IA]
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48. (continued)
Environmental contamination with MDROs was most likely to contaminate worker’s clothing, gowns, and 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): [IIIA]
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49. 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
These common high-touch objects in the OR may not be deemed necessary to clean after each procedure by the multidisciplinary team. However, the team should consider that enhanced environmental cleaning has been demonstrated as an effective means to control transmission of multi-drug resistant organisms, such as MRSA and VRE. Enhanced environmental cleaning may also be a useful approach for controlling outbreak situations or cases in which an environmental surface has been epidemiologically linked to disease transmission. (Read slide)
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50. 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
These common high-touch objects in the preoperative and postoperative areas may not be deemed necessary to clean after each patient by the multidisciplinary team. However, the team should consider that enhanced environmental cleaning has been demonstrated as an effective means to control transmission of multi-drug resistant organisms, such as MRSA and VRE. Enhanced environmental cleaning may also be a useful approach for controlling outbreak situations or cases in which an environmental surface has been epidemiologically linked to disease transmission. (Read slide) Curtain changes or cleaning may be accomplished in many ways, and the discussion of how to clean or launder textiles is outside the scope of this document. Your team should decide how to manage curtains as part of enhanced environmental cleaning procedures.
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51. 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): [IVA]
Patients and personnel entering a room that has transmissible disease particles in the air are at risk for contracting the disease.
Personnel entering the room before a complete air exchange occurs must wear respirator protection (eg, an N95 respirator).
After the air has exchanged by 99%, personnel may proceed with environmental cleaning without respiratory protection.
Special cleaning procedures should be used if environmental contamination with high-risk tissue (ie, brain, spinal cord, eye tissue) from a patient who is diagnosed with or suspected of having CJD.
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52. 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]
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53. Recommendation X Quality
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54. 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 Centers for Disease Control and Prevention. Accessed September 30, [VC]
Use multiple measures
Give immediate feedback when possible
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55. Checklists & Log Sheets
Reduces chance of missing items during cleaning
Facilitate communication among the team when items are cleaned
Terminal cleaning
Scheduled cleaning
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56. Frequently Asked Questions (FAQs)
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57. FAQs
Use various methods to pick up 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.
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58. FAQs
You can mop at terminal cleaning in the OR; you are not required to wet-vacuum.
Wait to clean until after the patient is gone.
Pour cleaning chemicals rather than spray.
People generate dust.
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59. FAQs No time limit between terminal cleaning and damp dusting.
Risk-Benefit-Cost Analysis
The floor is dirty.
Use common sense.
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60. Questions & Answers
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