1. Environmental Hygiene
Debbie Hurst RN, BSN
Program Manager, Infection Prevention & Control
Rogue Valley Medical Center

2. Objectives
Explain why there is a need to maintain a clean environment to prevent the spread of infections
Discuss cleaning and disinfection requirements for ambulatory surgery centers
Utilize a set of tools designed to assure environmental hygiene quality

3. CMS Survey CMS will observe:
Operating rooms are cleaned and disinfected after each surgical or invasive procedure with an EPA-registered disinfectant
Operating rooms are terminally cleaned daily
High-touch surfaces in patient care areas are cleaned and disinfected with an EPA-registered disinfectant
ASC has a procedure in place to decontaminate gross spills of blood
Additional breaches in environmental cleaning not captured elsewhere in the survey

5. Contaminated Surfaces
VRE
MRSA
C. difficile
Bed Rails +
+++
Bed Table
++++++
Door Knobs ++
Doors
Call Button
Chair
Tray Table
Toilet Surface
++++
Sink Surface
Bedpan Cleaner
+ Amount of contamination
Source: Phillip Carling, MD, Boston University School of Medicine

6. Contaminated Surfaces
Table 1: Survival of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus and Clostridium difficile on dry inanimate objects 18
Copyright ©2009 Canadian Medical Association or its licensors
Matlow, A. G. et al. CMAJ 2009;180:

7. Places Where VRE has Been Cultured

8. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
HCW
HANDS
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS

9. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
HCW
HANDS
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS

10. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
HCW
HANDS
HAND HYGIENE
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS

11. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS ENVIRONMENTAL SURFACES
HCW
HANDS
HAND HYGIENE
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS
ENVIRONMENTAL SURFACES

12. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS ENVIRONMENTAL SURFACES
HCW
HANDS
HAND HYGIENE
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS
ENVIRONMENTAL SURFACES
DISINFECTION CLEANING

13. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS ENVIRONMENTAL SURFACES
HCW
HANDS
HAND HYGIENE
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS
ENVIRONMENTAL SURFACES
DISINFECTION CLEANING

14. ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS ENVIRONMENTAL SURFACES
HCW
HANDS
HAND HYGIENE
ISOLATION
ANTIBIOTIC RESISTANT PATHOGEN ON or IN PATIENTS
AT RISK
PATIENTS
ENVIRONMENTAL SURFACES
DISINFECTION CLEANING

15. EPA-registered Disinfectant
What is an EPA-registered disinfectant? How do I know that’s what I’m using?
Disinfectant bottles used for room turnover should not be refilled when empty unless they are washed with soap and water before refilling
Disinfectant kills while drying
Thoroughly wet surface and allow to dry for time listed on product label; staff should be able to verbalize dry time
Some equipment (e.g., gel pads) may need to be rinsed with water after drying

16. How Well Does Environmental Disinfecting Work?
Phenolic Compounds
Quaternary Ammonium compounds
Chlorine compounds
Idophors
Alcohol
Kill a wide range of microbial pathogens
Work rapidly
Work effectively in clinical settings
ALL

17. Frictional Cleaning
Cleaning requires the use of FRICTION to remove organisms contained in organic materials from surfaces
It’s important to use some “elbow grease” and “back and forth” movement when cleaning surfaces
Simply “touching and wetting” surfaces with a disinfectant is insufficient
No dry mopping or dusting allowed in the semi-restricted or restricted areas
Observe this process; there are frequent concerns
Do not re-dip used cloths in cleaning solutions

18. Microfiber Mops
Microfiber mop system has demonstrated superior microbial removal compared with cotton string mops when used with a detergent cleaner
Use of microfiber mops have also documented a reduction in occupational injuries as they are not as heavy to lift

19. Mop Heads and Cleaning Cloths
Mop heads, cleaning cloths, and cleaning solutions will be changed frequently; at a minimum, when visibly soiled
Mop heads and water are to be changed after each procedure
Use damp mopping or chemically treated mop for reduction of airborne dust areas
Spot clean soiled floors in between ALL cases as needed

20. Vacuums
Hepa-filtered vacuums should be used in patient care areas to reduce dust
Cleaning, buffing, and vacuuming should not be done during the day when procedures are being done

21. Cleaning Prior to First Procedure of Day in Room
Wipe the following with a cloth dampened with an EPA-registered disinfectant:
Horizontal surfaces
Operating/procedure room lights
Operating/procedure room furniture including the back table, prep table, ring stands, Mayo stands, and operating table

22. Before First Use of Room & Between Cases
Preparation of the room should include a visual inspection of the room for cleanliness before the case carts, supplies, and instrument sets are brought into the room

23. Cleaning Between Cases
All OR suites, procedure rooms, and the recovery area should be cleaned the same way between ALL cases
Remove linen and waste, including suction canisters and tubing
Disinfect all horizontal surfaces: operating/procedure room table, back table, Mayo stands, ring stands, X-ray view boxes, anesthesia cart, suction bovie
Disinfect other surfaces: furniture, computers and keyboards, overhead OR lights & handles, mattresses (both sides)

24. Cleaning Between Cases (cont.)
Keep IV tubing and other patient care items off the floor at all times
Spot clean walls and ceiling if needed
Remake litters with clean linen
Disinfect all shared patient equipment (BP cuffs, EKG leads, SCD tubing and pump, tourniquets & hoses); if heavily soiled, place in container and take to soiled utility room for decontamination and cleaning

25. Terminal Cleaning
All ORs should be terminally cleaned daily regardless of whether a procedure was performed during the regular work week
Move all removable equipment and furniture to the hallway or opposite side of room
Scrub all kick buckets, racks
Vacuum air duct grills/vents

26. Terminal Cleaning (cont.)
Clean all shelves, cabinets, handles, computers, keyboards, mouse, telephones, call lights, ceilings, shelves, cabinets, overhead lights, walls, furniture, equipment, wheels and casters, horizontal surfaces, sinks, items on walls, doors and door handles, light switches
Flood floor with disinfectant solution, machine scrub, pick up solution with vacuum

27. Cleaning Blood Spills
Use an EPA-registered disinfectant; gloves and other appropriate personal protective equipment (based on the specific situation) will be worn
First remove the blood, then disinfect the area
As an alternative, a fresh 1:10 dilution of bleach may be used
If using a blood spill kit, the manufacturer’s recommendations for cleaning and decontaminating will be followed; blood spill kits have expiration dates which must be monitored

28. Gloves
Don’t forget to follow Standard Precautions (gloves, wash hands, wear gowns) as needed
Remove gloves and wash hands before leaving the room!
Gloves are to be worn for the “dirty” task

29. But Hand Washing Isn’t 100%

30. CDC Guideline Requirements
Clean and disinfect HIGH TOUCH surfaces
Implement procedures that ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and likely to be touched by the patient and HCW
Evaluate the effectiveness of cleaning practices
Discussion: How can you monitor if the services are provided at night and you are only open in the daytime?

31. Environmental Hygiene Monitoring
New intervention for IPPs
Use monitoring tool, such as marking device (florescent gel, ATP, cultures) to evaluate the quality of cleaning
Focus on high-touch areas (door knobs, light handles and switches, phones, cords, etc.)
Studies report significantly improved practices after staff education, performance feedback, and remeasure; fold into QAPI program

32. Comparison of Environmental Quality Assurance
Healthy Facilities Institute, 2011

33. The Targeting Solution

34. Target After Marking

35. Target Enhanced

36. Marker removed 6 of 18 times after cleaning (33%)
Target Results
Pump On/Off Button
Marker removed 6 of 18 times after cleaning (33%)
Remote TV On/Off Button Marker removed 8 of 18 times after cleaning (44%)

37. Target Results Phone Marker removed 4 of 18 times after cleaning (22%)
Door Knob Marker removed 4 of 18 times after cleaning (22%)
Over Bed Table Marker removed 6 of 18 times after cleaning (33%)
Chair Arms Marker removed 6 of 18 times after cleaning (33%)

38. Target Results
O2 Flow Meter Knob Marker removed 2 of 18 times after cleaning (11%)
Sink Counter Marker removed 2 of 18 times after cleaning (11%)
Start Button Marker removed 3 of 18 times after cleaning (17%)

39. OR Environmental Hygiene Monitoring (using fluorescent marking)
12 OR rooms
Baseline (N=22)
F/U (N=22)
Main Light
  %
86%
Other Light
50% 
73%
Lg Side Table
  %
100% 
86% 
 91%
Sm Side Table
95%
 100%
77%
 77%
Bovie Control
 50%
 59%
Anesth. Machine
 86%
Anesth. Cart
 82%
Light Switch x 2
 68%
OR Door (2 sides)
 84%
 73%
Hallway Door (2 sides)
Cabinet Door Handle x 2
 48%
 52%
Telephone x 2
62% 
X-ray Machine Control Panel
23%
68% 
BP Cuffs
68%
Computer Keyboard
 25%
Oximeter
= Did not show improvement

40. Oregon Survey Findings
Dust noted in sterile equipment storage areas, dirty floors, buckled tiles; visible dirty materials around sink soap holders, drains, and floor drains
Fans should not be in ORs
Separate clean and dirty items and areas
Ensure everyone knows blood and body fluid exposure follow up policies and what to do for blood spills
Medical supplies kept on counter tops should be far away from sinks and faucets so that potential splash contamination of the packaging is not a risk

41. Contracted Services
Remember, you need documentation of your evaluation and oversight of contracted services (e.g., environmental services and linen)
Need to evaluate the safety and effectiveness of those services

42. Toolkit Contents ASC Environmental Cleaning Policy & Procedure (4.01)
Operating/Procedure Room Cleaning Checklist Audit Tool (4.02)
General Environmental Cleaning Checklist Audit Tool (4.03)
Web links to:
CDC standards and educational resources related to environmental cleaning

43. Remember
Providing a safe and healthful environment for all our patients and preventing infection spread by hand cleansing and good environmental cleaning are critical aspects of patient care.