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Introduction

The Guideline for Environmental Cleaning was approved by the AORN Recommended Practices Advisory Board. It was presented as proposed recommendations for comments by members and others. The guideline is effective November 15, 2013. 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 and other invasive procedures may be performed.

Purpose

Historically, perioperative registered nurses (RNs) have played a critical role in providing a clean environment for patients undergoing operative or other invasive procedures. In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health care-associated infections and transmission of multidrug-resistant organisms (MDROs).1-4 

The literature describes a high risk of pathogen transmission in the perioperative setting due to multiple contacts among patients, perioperative team members, and environmental surfaces.1  Thus, thorough cleaning and disinfection of perioperative areas is essential to preventing the spread of potentially pathogenic microorganisms.1  Because surfaces that health care providers touch frequently may present a high risk for pathogen transmission to patients,2  routine cleaning of high-touch objects is an effective approach to limiting transmission of pathogens5  when implemented as part of a comprehensive environmental cleaning and disinfection program.

Researchers have shown that cleaning practices in the operating room (OR) have not been adequately thorough or consistent with the policies of the health care organization.1,6,7  Jefferson et al observed a mean cleaning rate of 25% for objects monitored in the OR setting in six acute care hospitals.7  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. All perioperative team members have a responsibility to provide a clean environment for patients. Perioperative and environmental services leaders can cultivate an environment where perioperative and environmental services personnel work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support.

This document provides guidance for environmental cleaning and disinfection in the perioperative practice setting and are based on the highest quality evidence available. The quality of the research investigating environmental cleaning has not yet achieved a level of rigor to thoroughly define and evaluate best practices for environmental cleaning in health care, including the perioperative setting.3  According to Carling, published studies have not separated cleaning thoroughness from the cleaning chemicals being evaluated, and there is a need for outcome studies to determine the impact of environmental cleaning on the transmission of disease.3 

Donskey found that although much of the evidence for environmental disinfection as a control strategy for reducing health care-associated infections is suboptimal, the practice of environmental cleaning is supported by several high-quality investigations.8  Conscientious application of these recommendations should result in a clean environment for perioperative patients and minimize the exposure risk of health care personnel and patients to potentially infectious microorganisms. Any patient could be infected with bloodborne or other pathogens, so all surgical procedures should be considered potentially infectious. This document provides specific guidance for cleaning procedures; selection of appropriate cleaning chemicals, materials, tools, and equipment; ongoing education and competency verification; policies and procedures; and quality assurance and performance improvement processes.

Although these recommendations include references to cleaning a wide variety of surfaces, the focus of this document is specific to the environmental cleaning of perioperative areas. These recommendations may be applicable to sterile processing areas. Laundering of textiles is outside the scope of these recommendations. Environmental cleaning includes considerations for a safe environment of care, prevention of transmissible infections, and hand hygiene. These topics are addressed in other AORN guidelines, and although they are mentioned briefly where applicable (eg, standard precautions), broader discussions are outside the scope of this document.9-11 

Evidence Review

A medical librarian conducted systematic searches of the databases MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized controlled and nonrandomized trials and studies, opinion documents, case reports, letters, reviews, and guidelines. Scopus was also consulted, although not searched systematically.

Search terms included operating room, operating theater, operating suite, surgical suite, recovery room, post-anesthesia, post-anaesthesia, perioperative nursing, ambulatory care facilities, surgicenters, ambulatory surgery, outpatient surgery, healthcare facilities, terminal cleaning, terminal disinfecting, terminal decontamination, cleaning schedule, cleaning program, cleaning regimen, prior patient, prior room occupant, previous patient, cleaning standard, cleaning policies, cleaning guideline, cleaning protocol, routine cleaning, hospital housekeeping, housekeeping department, environmental services, cross infection, infection control, decontamination, room decontamination, disinfection, disinfectants, adenosine triphosphate, detergents, solvents, phenols, disinfectants, hydrogen peroxide, ultraviolet rays, fluorescent light, quaternary ammonium disinfectant, sodium hypochlorite, ozone, silver, copper, gram-negative bacteria, gram-positive bacteria, viruses, Staphylococcus aureus, methicillin resistance, vancomycin, multi-drug resistant organism, clostridium, chickenpox, measles, varicella, rubeola, tuberculosis, prion diseases, prions, Creutzfeldt-Jakob, disease reservoir, dust, surgical wound infection, blood, body fluids, tissues, blood spill, semen, cerebrospinal fluid, synovial fluid, vaginal secretions, pericardial fluid, peritoneal fluid, saliva, amniotic fluid, air microbiology, air pollution, bacterial load, microbial colony count, environmental microbiology, environmental cleaning, green cleaning, mop, mopping, bucket, wringer, brush, buffers, floor machine, sweepers, microfiber, microfibre, paper towel, cloths, wiping, vacuum, environmental surface, contact surface, fomites, floors and floor coverings, interior design and furnishings, mites, lice, fleas, cockroaches, vermin, flies, ants, insects, pest control, textiles, bedding and linens, beds and mattresses, curtains, laundry, laundry service, cellular phone, cellphones, cell phones, telephones, wireless communications, mobile devices, iPad, tablets, laptops, computer systems, computers, keyboards, mouse, tables, beds, operating tables, mattress, stretcher, examination tables, patient transfer board, trolleys, carts, scrub sink, durable medical equipment, disposable equipment, equipment reuse, storage areas, hospitals, eye wash, operating room waste, clinical waste, medical waste, medical waste disposal, biohazardous waste, hazardous materials, formaldehyde, formalin, methyl methacrylate, storage, disposal, transport, handling, safety management, occupational health, occupational-related injuries, occupational exposure, contact precautions, standard precautions, droplet precautions, universal precautions, eye protective devices, masks, respiratory protective devices, protective clothing, gloves, goggles, gowns, environmental monitoring, luminescent measurements, checklists, visual inspection, fluorescent light, audit, tacky mat, sticky mat, hospital design and construction, demolition, construction materials, aspergillus, aspergillosis, central service department, sterile processing, sterile supply, central supply, central processing, task performance and analysis, job performance, competency-based education, continuing education, and human factors.

The search was originally limited to literature published in English between 2008 and 2013. The lead author and the medical librarian identified relevant guidelines from government agencies and standards-setting bodies, and the lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The medical librarian also established continuing alerts on the environmental cleaning topics and provided relevant results to the lead author.

Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author, three members of the Recommended Practices Advisory Board, and two doctorally prepared evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the Johns Hopkins Evidence-Based Practice Model and the Research or Non-Research Evidence Appraisal Tools as appropriate. 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.

The collective evidence supporting each intervention within a specific recommendation was summarized and used to rate the strength of the evidence using the AORN Evidence Rating Model. Factors considered in review of the collective evidence were the quality of research, quantity of similar studies on a given topic, and consistency of results supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

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, Netherlands.

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