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The Guideline for Environmental Cleaning was approved by the AORN Guidelines Advisory Board and became effective as of January 13, 2020. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance on the selection and use of cleaning products, cleaning procedures, personnel education and competency verification, and monitoring cleanliness through performance improvement processes. All perioperative team members have a responsibility to provide a clean and safe environment for patients. Perioperative and environmental services leaders can cultivate an environment in which perioperative and environmental services personnel work collaboratively to accomplish cleanliness in a culture of safety and mutual support.

Researchers have shown that cleaning practices in the operating room (OR) are not always thorough or consistent with the policies of the health care organization.1-3  Jefferson et al3  observed a mean cleaning rate of 25% for objects monitored in the OR setting in six acute care hospitals. Munoz-Price et al1  observed cleaning in 43 ORs of a large urban hospital and found only 50% of the surfaces were being cleaned. In both studies, fluorescent gel markers were used to measure cleanliness. These findings demonstrate that some ORs may not be as clean as previously thought,1  although the literature has not defined the concept of cleanliness.

In a literature review, Ibrahimi et al4  stated that the amount of bacteria present in the operative site is one of the most important factors associated with surgical site infection (SSI) development, although the minimum number of bacteria that causes an infection varies depending on the qualities of the organism, the host, and the procedure performed. The review authors also found that fomites near the surgical field may harbor bacteria. These fomites may serve as a reservoir for wound contamination through either direct contact with the patient’s skin or by personnel contact with the fomite and subsequent skin-to-skin or glove-to-skin contact with the patient.

A high risk for pathogen transmission exists in the perioperative setting because of multiple contacts between perioperative team members, patients, and environmental surfaces.5-7  Cleaning and disinfecting the environment is a basic infection prevention principle used to reduce the likelihood that exogenous sources will contribute to health care–associated infections (HAIs).8,9  Operating room environmental surfaces and equipment can become contaminated with pathogens that cause SSIs, particularly if cleaning is suboptimal, and pathogens can then be transmitted to the hands of perioperative team members. Thus, thorough cleaning and disinfection of high-touch objects as part of a comprehensive environmental cleaning and disinfection program that includes hand hygiene are essential in preventing the spread of potentially pathogenic microorganisms.1 

In a prospective multifacility observational study, Loftus et al10  followed patients undergoing general anesthesia (N = 548) to identify which bacterial reservoir was associated with transmission events from intravenous (IV) tubing three-way stopcocks. The researchers sampled three bacterial reservoirs: providers’ hands, the patient’s axillae and nasopharynx, and two high-touch sites on the anesthesia machine. All three reservoirs contributed to transmission, although 64% of stopcock contamination was traced to the anesthesia machine. The researchers also linked the bacterial reservoirs to 30-day postoperative infections. Loftus et al11  conducted a subset analysis of the previous study10  and found that gram-negative organisms caused 85% of the HAIs, with the source most often being the anesthesia machine. In two additional analyses12,13  of the original data,10  researchers examined the transmission of Staphylococcus aureus and found that two strains were frequently transmitted in the anesthesia work area and were highly transmissible, virulent, and drug resistant.

Other studies have identified microorganisms that contribute to environmental contamination of surfaces in the OR, including staphylococcal species,1,5,14,15  Corynebacterium species,14  Micrococcus species,6,14  Bacillus species,6,14  Klebsiella pneumoniae,1,16  Pseudomonas species,1,6  Acinetobacter species,1  Enterococcus species,1,17  and Escherichia coli.1 

Environmental cleaning and disinfection includes considerations for a safe environment of care, transmission-based precautions, and hand hygiene. Although these topics are mentioned briefly where applicable (eg, standard precautions), they are addressed in other AORN guidelines,18-20  and broader discussions are outside the scope of this document. Laundering of textiles and evaluation of self-disinfecting surfaces are also outside the scope of these recommendations.

Figure 1
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2013 through November 2018. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until May 2019. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included adenosine triphosphate, air sampling, ambulatory surgery center/facilit*, ants, aspergill*, auto scrubber, bacterial count, bacterial load, bedding and linens, beds, bioluminescence detection, bleach, body fluids, central processing, central service department, central supply (hospital), checklist, cleaning program/regimen/schedule/standard/policies/guideline/protocol/routine, cleaning zone, cleansing agents, cloths, cockroaches, colony count (microbial), contact surface, contact time, Creutzfeldt-Jakob disease/syndrome, cross infection, curtains, decontamination, decontamination (hazardous materials), detergents, diphtheria, disease reservoirs, disease transmission (infectious), disinfectants, disinfection, dust, dwell time, enhanced environmental cleaning, environmental microbiology/monitoring/cleaning/services/surface, fleas, flies, fluid waste management, fluorescent light, fomites, gram-negative bacteria, gram-positive bacteria, green cleaning, healthcare associated infection, heater-cooler, high-touch objects/ surfaces, hospital housekeeping, hospital laundry service, housekeeping department, housekeeping (hospital), hydrogen peroxide, ice machine, infection control, insects, keyboard covers, laundry, laundry department, laundry service (hospital), lice, luminescent measurements, mattresses, microbial colony count, microfib*, mites, mouse, nosocomial infection, occupational health/exposure/ injuries/safety, operating room tables, operating rooms/suites/ theat*, ozone, patient monitors/transfer board, pest control/management, phenols, Phthiraptera, previous patient, prior patient/ room occupant, quaternary ammonium compounds/disinfectant, room contamination, scrub sink, silver, Siphonaptera, sodium hypochlorite, solvents, sterile processing/supply, sterilization and disinfection, sticky mat, storage areas, subacute spongiform encephalopathy, surgical wound infection, surgical wound infection, surgicenters, tacky mat, terminal cleaning/disinfection/ decontamination, textiles, ultraviolet light, ultra-violet light, ultraviolet rays, vermin, viruses, visual inspection, waste disposal (fluid), and wet time.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Historical studies were also included. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted if there was a disagreement between the lead author and the primary evidence appraiser. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier, B.V., Amsterdam, The Netherlands.

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