OR Manager

Vol. 30 No. 9
September 2014

Sterilization & infection control

Environmental cleaning in
sterile processing areas

T
horough environmental cleaning limits the number of microorganisms that can
be transferred to the patient and the healthcare provider, thus helping to pre-
vent healthcare-associated infections. A team consisting of perioperative nurs-
ing, sterile processing, environmental services, and infection prevention staff needs
to be established to develop cleaning procedures for all areas of the facility, including
the sterile processing area.
Routine cleaning as well as special cleaning procedures for multidrug-resistant or-
ganisms, construction, and environmental contamination—such as flooding or spills
of chemicals or blood, body fluids, or other potentially infectious materials—should
be addressed. These policies and procedures should be reviewed and revised peri-
odically and readily available to personnel performing these tasks.
Some of the aspects to consider are described in this column, but readers should
also consult the section on environmental cleaning in the 2014 AORN Perioperative
Standards and Recommended Practices.

Cleaning materials
This team should select the cleaning materials to be used. Cleaning chemicals (eg, de-
tergent, disinfectant, or a combination) should be registered and rated as hospital grade
by the US Environmental Protection Agency (EPA), according to Recommendation 1 of
the AORN Recommended Practices on environmental cleaning. A low-level disinfec-
tant should be used. High-level disinfectants or liquid chemical sterilants should not
be used because they are not labeled for this use, and alcohol is not an EPA-registered
disinfectant.
The cleaning chemicals should target the microorganisms that need to be removed,
and these chemicals should be compatible with surfaces, cleaning materials, and
equipment. Follow the cleaning chemical manufacturer’s written instructions for use
(IFU) for dilution; contact times needed to kill targeted microorganisms; ventilation;
types of cleaning materials, tools, and equipment to use; and disposal (also follow
local, state, and federal regulations). Consider the cost, personnel ergonomics and
safety, and effect on the environment when choosing these products.
Always check the expiration date of the chemicals before using. Clean environmen-
tal services with a detergent prior to disinfection. This can be a combined detergent
and disinfectant product or two separate products. Always follow the manufacturer’s
written IFU.
Reusable or disposable cleaning materials (eg, mop heads, cloths) may be used.
Microfiber or low-linting cotton cleaning materials are popular. Reusable mops or
cloths should be changed after each use and not returned to the cleaning solution
container, which would then become contaminated. Disposable mops and cloths
should also be discarded after each use to prevent cross-contamination. Disassemble
cleaning equipment according to the manufacturer’s written IFU, and clean, disinfect,
and dry before storage to prevent the growth of microorganisms.
Wet and moist mopping are effective in reducing organic soil on floors. Items that
contact the floor for any amount of time, eg, instruments that are dropped when pre-
1
 OR Manager
Vol. 30 No. 9
September 2014

paring trays for sterilization, should be con-

sidered contaminated and re-cleaned.
Follow the SDS (Safety Data Sheet) and
standard precautions to prevent contact with
blood, body fluids, or other potentially infec-
tious materials when choosing the appro-
priate personnel protective equipment (eg,
gloves, mask or N95 respirator, and protec-
tive eyewear).

Terminal cleaning in sterile

processing
AORN defines terminal cleaning as “thorough
environmental cleaning that is performed at
the end of each day when the area is being
used.” Both AORN and AAMI (Association for
the Advancement of Medical Instrumentation)
ST79 recommend that sterile processing be ter-
minally cleaned the same as the operating, de-
livery, and invasive procedure rooms. AAMI
ST79 (Section 3.4) states that the best practice is
to provide separate housekeeping facilities for
the decontamination and clean areas to avoid
transferring contaminates from “dirty to clean” The New York University Langone Medical Center Hospital for Joint Diseases,
areas. New York City, used market data to establish reasonable price points for joint
AORN recommends that terminal clean- implants. Surgeon support gave the hospital leverage in vendor negotiations,
ing and disinfection of the sterile processing resulting in annual savings of more than $2 million. Ongoing monitoring is
areas “be performed daily when the areas are helping the OR maintain cost savings.
being used.” Terminal cleaning should not be Source: Surgical Directions.
performed when personnel are actively de-
contaminating instruments. Cleaning should progress from cleanest to dirtiest areas.
Specific AORN recommendations for terminal cleaning (Recommendation IV) are as
follows:
• Clean floors with a wet vacuum or single-use mop and a disinfectant using the dis-
infectant manufacturer’s written IFU contact time to prevent disease transmission.
Disinfect floor surfaces in the center of the room (highest level of contamination)
before the perimeter (lowest level of contamination). Clean the distribution, prepa-
ration and packaging, sterile processing, and sterile storage areas (cleanest work
surfaces) before cleaning the decontamination area (dirty work surfaces) to reduce
the possibility of contamination of clean areas.
• Damp-dust with an EPA-registered disinfectant and a clean, low-linting cloth from
top to bottom all horizontal and other work surfaces and high-touch objects: work
tables, countertops, furniture (eg, chairs and stools); sterilizers and sterilizer carts;
shelving; sinks; pass-through window; door handles and push plates; telephone
and mobile communication devices; computer accessories; and trash and linen re-
ceptacles.
• Remove trash from receptacles when full and at least daily.

Scheduled cleaning
Scheduled cleaning is a cleaning schedule that defines areas and equipment that
should be cleaned on a regular (eg, weekly, monthly) basis.

2
 OR Manager
Vol. 30 No. 9
September 2014

AAMI ST79 states:

• Walls, storage shelves, and air intake and return ducts should be cleaned on a
regularly scheduled basis and more often if needed.
• Stained ceiling tiles should be replaced, and any leaks causing the stains should
be repaired.
• Lighting fixtures or covers should be cleaned at least once every 6 months.
AORN recommends (Recommendation V) a schedule for cleaning the follow-
ing:
• clean and soiled storage areas
• storage cabinets, sterile storage area (except floors)
• ventilation ducts (including air vents and grills) should be cleaned and filters
changed on a routine basis according to the manufacturer’s written IFU
• eye wash stations and aerators on faucets should be cleaned and disinfected on a
routine basis
• sterilizer service access room
• elevators
• pneumatic tubes and carriers
• lounges, waiting rooms, offices
• environmental services closets

Joint Commission Surveys

The Joint Commission will have on their white gloves while surveying the cleanli-
ness of the department and will be looking for dust bunnies. The Commission will
observe and ask about the frequency of departmental cleaning, including:
• daily versus deep cleaning
• behind closed doors and under racks
• hidden corners and high level flat spaces
• behind and around automatic cleaning equipment
• sterilizer service access room, including the tops of sterilizers
The Commission will also ask if the dirty room is clean.

Role of personnel
Designated cleaning responsibilities are important to reduce the number of items that
personnel forget to clean. Environmental cleaning service and sterile processing per-
sonnel need to decide who is responsible for cleaning what.
In the surgical processing area at Overlake Hospital Medical Center in Bellevue,
Washington, Don Williams, CRCST CIS, CHL, manager, has environmental clean-
ing service staff do the wet mopping, empty the trash, and clean walls, vents, and
lights. Sterile processing staff clean all work surfaces on a daily basis: sterilizer
carts, sterilizer chambers, and storage shelves and cabinets. This list should be ex-
panded to cover all the areas discussed above.

Quality assurance and performance improvement

These programs provide data to evaluate worker safety and determine whether
the performance of environmental cleaning meets benchmark goals of the organi-
zation. Process monitoring ensures compliance with regulatory standards (eg, Oc-
cupational Safety and Health Administration), recommended practices (eg, AORN,
AAMI, Centers for Disease Control and Prevention), manufacturer’s written IFU,
and the facility’s policies and procedures with regard to monitoring of the envi-
ronmental cleaning and disinfection process as well as reporting and investigation
of adverse events (eg, outbreaks, product failures, inadequate cleaning).
AORN states that EVS and SP personnel should receive initial and ongoing
3
 OR Manager
Vol. 30 No. 9
September 2014

education as well as ongoing competency verification of their understanding of the

principles and performance of the processes for environmental cleaning.
To monitor the effectiveness of the environmental cleaning process,
AORN states (Recommended Practice X.c) cleaning practices should be mea-
sured using qualitative (eg, visual, fluorescent marking) and quantitative mea-
sures (eg, adenosine triphospate cultures) as part of process improvement.
Quantitative measures provide more information about cleaning effectiveness faster
than a visual method, and they allow you to determine whether problems are im-
proving, stabilizing, or worsening.
Checklists help to prevent human errors or missed cleaning of items, and they fa-
cilitate communication between environmental cleaning service and sterile process-
ing personnel. A sample checklist is available in the AORN Environmental Cleaning
Tool Kit available on their website.
The three cleaning steps recommended by the AORN environmental cleaning
recommended practice (Recommendation VI.b) establish a routine for cleaning so
that items are not missed during this process. Following these steps will reduce the
risk of cross-contamination of environmental surfaces by limiting the transmission of
microorganisms:
• Move from the clean areas into the dirty areas.
• Start from the top and work down.
• Use a clockwise or counter-clockwise method. ✥

Martha Young, MS, CSPDT, is president, Martha L. Young, LLC, providing SAVVY Steril-
ization Solutions for Healthcare in Woodbury, Minnesota. She is an independent consultant
with long experience in medical device sterilization and disinfection.

References
AORN. Recommended practices for environmental cleaning. Perioperative Standards
and Recommended Practices. Denver, CO: AORN, 2014. www.aorn.org
Association for the Advancement of Medical Instrumentation. Comprehensive guide
to steam sterilization and sterility assurance in health care facilities. ANSI/AAMI
ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013. Section 3.4. www.aami.org Get Your CE Credits!
Eiland J E. Joint Commission presentation at IAHCSMM annual meeting in May 2011.
Each issue of OR Manager
Environmental Cleaning Tool Kit from AORN, 2014. www.aorn.org is preapproved for
Spruce L, Wood A. Back to basics: Environmental cleaning. AORN Journal, July 3.0 nursing contact hours
2014;100(1), 54-64. for registered nurses.
The Joint Commission: 2014 Hospital Accreditation Standards. www.jcrinc.com/store/ To complete an online
publications/manual/ post-test and earn
continuing education (CE)
credits, simply login to
www.ormanager.com
and go to My Account.
Click on “My Courses”
and click into the issues.
Need help? Contact
clientservices@
accessintel.com.

Copyright © 2014. Access Intelligence. All rights reserved. 888/707-5814. www.ormanager.com 4