Controlling CDI — OR room turn-over cleaning

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Objectives

Review WHY the need to improve cleaning in the OR

Review HOW to use the Allina disinfectant products

Review WHAT surfaces to touch between every case

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WHY is surface disinfection so important??

Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multi-drug resistant gram negative bacteria (MDR-GNB) can survive in the environment for weeks

MDR-GNB hospital acquired infections on the rise

New types of MDR-GNB resistant to ALL commonly used antibiotics

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Clostridium difficile

Spores can exist in environment for months

Most often presents as diarrhea, can cause pseudomembranous colitis and progress to toxic megacolon, sepsis, and death• Infection recurrence is common

Spread is fecal-oral (you EAT it)

Hospital-acquired C. difficile became publicly reportable in 2013

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One patient’s story

Cost of CDI:• Lost his colon• 9 readmissions• 143 days in the hospital• OVER 1.2 MILLION in

healthcare costs

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C. difficile in the U.S.

From 2000 to 2009, the number of hospitalized patients with any CDI discharge diagnoses more than doubled, from approximately 139,000 to 336,600

The number with a primary CDI diagnosis has more than tripled, from 33,000 to 111,000

Patients with no past healthcare exposure presenting with C. difficile

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Definitions you need to know

Room turn-over

• Between case cleaning done by OR staff Terminal clean

• End of the day cleaning done by Environmental Service staff

Cycle cleaning

• Periodic deep cleaning, (e.g.,walls and ceiling) done by Environmental Service staff

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Low-level disinfection

Destroys vegetative bacteria, some fungi and viruses, not mycobacteria or spores.

Most commonly used in healthcare for cleaning and disinfection of noncritical patient care equipment and surfaces (bedside table).

Non-critical items: those that contact intact skin but not mucous membranes.

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Disinfection process

Effective cleaning is critical. • The processes are more important than products

o Need to touch the “right” surfaces consistently Disinfectants may vary by facility

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Disinfection

Adequate amount

• Enough chemical to keep surface wet for required contact time

Adequate contact time

• Amount of kill time required • Determined by testing by the U.S. EPA

Friction

• Wiping the surface removes bugs Saturation

• Having enough disinfectant on a cloth to ensure that enough chemical gets to the surface for the right amount of time.

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Quat and microfiber (preferred)

Microfiber technology

“Captures” more debris from the environment

Helps to remove microbes

Reduces cross-contamination

Change cloths when not delivering enough solution to the surface

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Using AF or bleach wipes:

1)Use friction2)If a surface is visibly soiled, it must first be

cleaned and then another wipe must be used to disinfect (use 2 wipes)

3)Don’t overuse a wipe – use more for larger surface areas (e.g., 5-6 wipes per surgical bed)

4)Do NOT dispose of them in the toilets!

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Wet Contact Time Requirements

Increased attention by surveyors on staff knowledge of and adherence to disinfectant wet contact time • HB 3M Quat – 10 minutes • AF wipes – 3 minutes • Bleach wipes – 4 minutes

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Key recommendations for the OR

Dedicate cleaning equipment to the OR Use small bucket system with microfiber

cloths Dip cloths into disinfectant just before use. Do

not store cloths in bucket. Get a clean cloth when needed - never re-dip

a used (dirty) cloth into the cleaning solution Follow EPA approved contact time for

disinfectants

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Recommended cleaning procedures

Before first case of the day Between cases Terminal clean after the last case of the day

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Before first case

Verify date and time of last terminal clean Prior to bringing case cart into OR, visually

inspect the OR for cleanliness Spot clean as necessary or not completed

within last 24 hours, damp dust horizontal surfaces

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Last Case of the day

Remove instruments, basins, trays, to appropriate locations for reprocessing. Place all sharps in appropriate containers.

Clean and disinfect as you would between cases using cleaning checklist (room should be ready if needs to be used urgently)

Environmental services terminally cleans at end of day

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Room turn-over

Cleaning and disinfection cannot begin until after the room is vacated unless emergent situation

Follow OR Cleaning Checklist Clear room of contaminated items:

• Remove instruments, basins, trays to appropriate locations for reprocessing

• Place all sharps in appropriate containers • Remove all soiled linen including gowns, towels,

and washcloths

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Surgical equipment

Equipment• Examine for damage before cleaning/ disinfecting• Remove clean equipment as appropriate• Refer to cleaning checklists for equipment surgical

services staff cleaning responsibility Follow manufacturers’ equipment cleaning

instructions (disinfectant compatibility and procedure)

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Room cleaning and disinfecting

Start with table:1.Remove all unnecessary table attachments, and clean all exposed surfaces with a cleaner disinfectant2.Wipe joints, table attachments, frame, legs, and rails3.Turn down mattress and wipe the table bed frame and back of the mattress working from the top and repeat at the bottom4.Wipe sides of the mattress. Change disinfectant wipe or cloth as needed.5.Wipe both sides of coated pillows6.Allow all elements to air dry.

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Room cleaning and disinfecting

Remaining surfaces:• Clean from top to bottom and front to back following

cleaning checklist• Spot clean floor as needed

• Disinfect:o Tables, instrument stands, and equipment (e.g. cables, leads,

BP cuff, stethoscope, phone, gas machine, monitor)o OR table and arm/leg boardso Non-disposable safety strapo Standing stools (lifts)o Kick bucketso Overhead OR lights and reflectors

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Environmental monitoring

Environmental monitoring- used to identify opportunities for improving cleaning process• UV fluorescent gel

o Monitors whether the right surfaces are cleaned

• ATPo Monitors the effectiveness of the cleaning process.

Measures the amount of organic debris on a surface in relative light units (RLU)

• Both will be used to monitor the effectiveness of our cleaning processes

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What types of surfaces are monitored?

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Summary of major cleaning changes

Wait until the patient is out to start disinfecting (gathering garbage, etc. is allowed while patient is in room)

Starting with the patient bed to allow sufficient contact time

Emphasis on sticking with required disinfectant wet contact time

Terminal room clean and prep on last case of the day just as you would for between case cleaning

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Summary

C. difficile spores, MRSA, and VRE can survive on surfaces for weeks

Thorough between case cleaning is needed to minimize risk of transmission between patients

Use new checklists to ensure that all items are disinfected between cases

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