Sample chapter berry & kohn's operating room technique by_phillips_to order call_sms at +91 8527622422
Chapter 12 Care of the Perioperative Environment CHAPTER OBJECTIVES STANDARDS FOR CLEANLINESS After studying this chapter, the learner will be able to: IN THE SURGICAL ENVIRONMENT • Describe how a room is prepared for the ﬁrst case of the day. AORN has established standards and recommended practices • Describe how a room is cleaned and prepared between patients. for cleaning and maintaining optimal cleanliness in the peri- • Describe how a room is terminally cleaned at the end of the day. operative environment. The recommendations include but • Discuss environmental responsibility. are not limited to the following: 1. All patients are entitled to a clean environment for their CHAPTER OUTLINE surgical procedures. Standards for Cleanliness in the Surgical Environment, p. 208 2. Any contamination encountered during a surgical pro- Establishing the Surgical Environment, p. 208 cedure should be contained and conﬁned. Room Turnover Between Patients, p. 209 3. Between-case clean up should reestablish the cleanest Daily Terminal Cleaning, p. 212 environment possible for the next patient. 4. Procedure rooms and utility areas should be cleaned daily. KEY TERMS AND DEFINITIONS 5. A schedule should be in place for routine cleaning of all Between case clean-up Cleaning that takes place at the end areas and equipment in the surgical department. of one case to prepare the environment for the next case of the 6. All environmental sanitation processes should be deﬁned day. Also referred to as turnover. by facility policy and procedure. Case cart system Computerized method of selecting and delivering instrument sets and supplies to the perioperative environment. ESTABLISHING THE SURGICAL Some models include provision for the return of instruments and ENVIRONMENT contaminated items to the appropriate decontamination area. The duties of the scrub person and circulating nurse are Contamination Potentially pathogenic material that must be many and varied as they prepare for the arrival of the contained. patient in the OR. They are responsible for the cleanliness Custom packs Prepackaged disposable supplies standardized and of the environment preoperatively, intraoperatively, and assembled into packages and sterilized by the manufacturer or distributor according to speciﬁc instructions and requests by a postoperatively so that the potential for contamination of particular service at a facility. the patient is kept to a minimum. They prepare and main- Decontamination Cleaning reusable items with an approved tain the sterile ﬁeld, work within it, and then break it down disinfectant to render the item safe for handling. for terminal cleaning. These activities are performed in spe- Fomite Inanimate objects that can harbor and transmit infectious ciﬁc steps to minimize the risk of infection and maximize material. the use of time and supplies. Standardization is in the best Iatrogenic Condition that results during or from the process interest of the patient and the personnel performing the of treatment or care that has unfavorable results. cleanup.1,2 Terminal cleaning Thorough cleaning and disinfection of the peri- operative environment at the end of daily use. Preliminary Preparations Turnover Cleaning and preparation of the OR between cases for the next patient’s arrival. Areas are cleaned according to level of need. Preliminary preparations of the OR are completed by the circulating nurse and scrub person before each patient en- ters the OR. Assistance is provided by environmental ser- Website vice personnel. It is a cooperative effort. Clean, organized surroundings are part of total patient care. http://evolve.elsevier.com/BerryKohn A visual inspection of the room and its contents should • Historical Perspective be performed by the team before bringing in supplies for • Flashcards a case. Basic room contents should include the OR bed, • Self-Assessment Activities anesthesia machine and supplies, electrosurgical unit (ESU), • Glossary instrument table, preparation (prep) table, Mayo stand, suc- tion apparatus, and receptacles for biohazard and regular 208
Care of the Perioperative Environment • CHAPTER 12 209 Linen Trash Mayo Autoclave Prep table stand Instrument table Disposal of sharps Door to substerile room Head Anesthesia machine Operating bed STERIS and supplies unit Sink ESU Suction Circulator’s X-ray view boxes work area Entry door FIG. 12-1 Layout of basic OR and substerile room. The trafﬁc pattern from the doors should not interfere with the setup of the sterile tables or the transfer of the patient to the operating bed.trash, and reusable woven fabrics (Fig. 12-1). Other tables environment. In addition, personnel working in surgicaland equipment are added as needed. services should be protected. Personnel cleaning the room between patients should wear personal protectiveBefore the First Surgical Procedure of the Day equipment (PPE) appropriate for the cleaning task. GlovesThe following housekeeping duties should be done before worn for cleaning should be durable in the presence ofbringing supplies into the room for the ﬁrst case of the day: cleaning agents. Vinyl gloves are not reliable and may not1. Remove unnecessary tables and equipment from the protect the wearer from environmental contamination in room. Arrange the appropriate furniture in an organized the presence of degradation caused by cleaning agents. manner away from the trafﬁc pattern. Some head and Some patients have known pathogenic microorganisms; neck procedures require the OR bed to be oriented in a others have unknown infectious organisms. Therefore ev- sideways direction to provide working space for the an- ery patient should be considered a potential contaminant esthesia provider. in the environment. Cleanup procedures should be rigidly2. Damp-dust (with a facility-approved disinfectant solu- followed to contain and conﬁne contamination, known or tion and lint-free cloth) the overhead operating light, unknown. Some examples of conditions that require spe- articulated arms, furniture, ﬂat surfaces, and all portable cial consideration are the following: or mounted equipment. Avoid dry-dusting because this 1. Patients with known respiratory-borne disease (i.e., sets dust aloft. Start at higher surfaces, and work down rubeola, varicella, tuberculosis) may deposit microorgan- to lower levels because dust may fall from higher areas. isms in the environment. In addition to routine envi-3. Damp-dust the tops and rims of the sterilizer and/or ronmental decontamination, the air exchanges should washer-sterilizer and the countertops in the substerile be 99% complete before the next patient is brought into room adjacent to the OR. the room. This may take 20 to 30 minutes on a 15- to4. Visually inspect the room for dirt and debris. The ﬂoor 20-air change per hour cycle. Staff should wear appropri- may need to be damp-mopped. ate ﬁltration masks during room cleaning.a 2. Patients with known endospore-forming bacterial con- ROOM TURNOVER BETWEEN tamination (i.e., Clostridia or Bacillus spp.) may deposit PATIENTS bacterial endospores in the environment on inanimatePhysical facilities inﬂuence the ﬂow of supplies and objects known as fomites. These endospores have beenequipment after the surgical procedure. However, basicprinciples of aseptic technique dictate the procedures tobe carried out immediately after a surgical procedure is a The number of air changes per hour changed in July 2010. Please refercompleted, to prepare the OR for the next patient. Every to the 2010 edition of the Guidelines for Design and Construction of Healthpatient has the right to the same degree of safety in the Care Facilities available at www.fgiguidelines.org/2010guidelines.html.
210 SECTION FOUR • The Perioperative Environment shown to survive in the environment for 5 months and The following are activities/responsibilities of the scrub have been cultured in ORs 40 days after the patient has person at the end of the case: used the room. AORN recommended practices state that 1. Push the Mayo stand and instrument table away from a hypochlorite-based disinfectant should be used for the operating bed (OR bed) as soon as the dressing is cleaning the environment.1,3 applied and the drapes are removed. Roll drapes off the3. Patients with known or suspected transmissible spongi- patient from head to foot to prevent airborne contami- form encephalopathies (TSE) such as Creutzfeldt-Jakob nation; do not pull them off. disease (CJD) and new variant CJD may deposit prions in 2. Check drapes for towel clips, instruments, and other the environment. Prions are proteins found in neurologic items. Be sure that no equipment is discarded with dis- tissue and ﬂuids that cause fatal neurodegenerative dis- posable drapes or sent to the laundry. eases in humans and animals. Iatrogenic introduction of Disposable drapes are placed in a red biohazard con- prion disease can happen if the patient is exposed to the tainer for disposal. Soiled drapes, whether disposable or protein during the surgical procedure by instrumentation reusable, should be handled as little as possible and with or the environment. Prions are nonliving proteins that minimum agitation to prevent gross microbial contami- persist on surfaces and require special cleaning solutions. nation of air by dispersal of lint and debris. Disposable equipment, instruments, linens, and supplies 3. Discard soiled sponges, other biologically contaminated should be used in the presence of known or suspected waste, and disposable items in red biohazard containers. prion diseases.6 Discard unused sponges, nonwoven drapes, and otherThe routine cleanup procedure can be accomplished expe- disposable waste into the main trash.ditiously by the circulating nurse and scrub person working 4. Dispose of sharp items safely. Special care should becooperatively. While the circulating nurse secures the outer taken in handling all knife blades, trocars, burrs andlayer of dressing and prepares the patient for transport from bits, surgical needles, and needles used for injection orthe OR, the scrub person begins to dismantle the sterile aspiration.7,8 Remove the tip from the ESU handleﬁeld before removing gown and gloves. (pencil). A self-closing adhesive pad or box designed All instruments, supplies, and equipment should be for this purpose is the safest device to use. A safe dis-decontaminated, disinfected, terminally sterilized, or con- posal procedure should be implemented and sustained.tained for disposal as appropriate before being handled by Place these items in an appropriate rigid, puncture-other personnel. resistant container for safe disposal to prevent injury After a patient leaves the room, the immediate environ- and potential risk of contamination.ment is cleaned and all surfaces are dried. Room cleanup The primary cause of accidental cuts and puncturesbetween patients is directed at the prevention of cross- to personnel, both inside and outside the OR, is disposalcontamination.4 The cycle of contamination is from patient of surgical sharps at the end of the surgical procedure.to environment and from environment to OR personnel Adherence to standardized systems designed speciﬁcallyand subsequent patients. for safe handling and disposal of sharps prevents virtu- Exposure to infectious waste is a hazard to everyone ally all accidental cuts, punctures, and lacerations.8who encounters it. After each surgical procedure the en- Unused suture packets are discarded.vironment should be made safe for the next patient to 5. Basins and trays too large for the case cart are put intofollow in that room. Institutional policies and procedures plastic bags for transport to the decontamination area.for routine room cleanup should be designed to minimize The Mayo tray may be included. Place these on thethe OR team’s exposure to contamination during the lower shelf of the case cart.cleaning process.2 6. The instruments are opened completely and placed into the wire mesh basket with all box locks spreadRoom Turnover Activities by the Scrub Person apart. Blood, tissue, bone, and any other gross debrisThe patient should be thought of as the center, or focal is removed from instruments during the case as muchpoint. The surrounding sterile ﬁeld and all areas that have as possible. All instruments, used and unused, mustcome in contact with blood or body ﬂuids are considered be decontaminated, terminally sterilized, or undergocontaminated. The primary principles of cleaning proce- high-level disinfection before they are processed fordures are to conﬁne and contain contamination and reuse. Instruments should be presoaked and/or pre-physically remove microorganisms as quickly as possible. rinsed before processing in a washer-sterilizer or de- Do not contaminate the table or Mayo stand until the contaminator. Some facilities have the scrub personpatient has actually left the room if there is a question of spray enzymatic foam over the instruments to startpatient stability, especially during trauma, cardiac, vascular, the cleaning process.and neurologic procedures. Remain sterile until the patient Any biologic material remaining on instruments isleaves the room. more difﬁcult to remove after the instruments have When the patient leaves the room, the sterile ﬁeld is dis- been heat-sterilized because the material becomes bakedmantled by the scrub person, who remains protected with on them. The biologic debris inhibits sterilization andthe gown, gloves, a mask, protective eyewear, and a cap dur- disinfection processes.ing the dismantling procedure. Contaminated instruments, a. Remove knife blades from handles using a heavy he-basins, and other reusable items are collected by the scrub mostat; never use ﬁngers. Using a needle holder canperson and placed in the case cart for decontamination, cause the jaws of the instrument to become misaligned.packaging, and sterilization in the processing department. Point the blade toward the table, and away from the
Care of the Perioperative Environment • CHAPTER 12 211 ﬁeld and other people in the area so that if it breaks or Clean, but not sterile examination gloves are worn to com- slips it will not ﬂy across the room. plete the room cleanup. The scrub person changes gloves b. Unloaded scalpel handles and other instruments after the sterile ﬁeld is dismantled. Decontamination of the with sharp tips or edges, such as scissors, should be environment includes the following tasks: placed in a container separate from the other instru- • Furniture. Wash horizontal surfaces of all tables and equip- ments so they can be easily identiﬁed by the process- ment, including the anesthesia machine, with a disinfec- ing personnel. tant. Apply disinfectant from a squeeze-bottle dispenser, Do not put knife handles in an instrument tray and wipe with a clean cloth or a disposable wipe that is with blades left on them. Other instruments designed changed frequently. Spray bottles can cause particles to for replaceable cutting blades, such as dermatomes, become aerosolized and should be avoided. should have blades removed; thereafter they may be All surfaces of mattress, pads, and screw connections of handled with other instruments. the OR bed are included. Safety straps should be cleaned Place reusable surgical needles, either on a nee- between patients. Velcro straps can be laundered accord- dle rack or loose, into a perforated stainless steel ing to the manufacturer’s recommendations. Mobile fur- box to be decontaminated and sterilized with the niture can be pushed through disinfectant solution used instruments. for ﬂoor care to clean casters. Excess strands of loose7. Dispose of solutions and suction bottle contents in a suture should be removed from the wheels. ﬂushing hopper connected to a sanitary sewer. Wear • Overhead operating light. Wipe overhead lights with a clean PPE to protect from splashes. Disposable suction units cloth that has been wetted with disinfectant solution spe- simplify disposal. Commercial substances can be added ciﬁcally intended to prevent clouding of the surface that to liquid in the disposable canister to solidify or gel can cause dullness and glare. Lights and overhead tracks contents for solid waste disposal. If disposable units are become contaminated quickly and present a possible haz- not used, decontaminate contents with disinfectant ard from fallout of dust particles onto sterile surfaces or before hopper disposal. into wounds during surgical procedures.8. The scrub person removes gown and gloves before tak- • Anesthesia equipment. Most masks and anesthesia tubing ing the case cart to the processing area. The gown is are disposable. Any reusable anesthesia masks and tub- removed ﬁrst before removing gloves. The circulating ing are cleaned and sterilized between patient uses. Some nurse unfastens neck and back closures. Protect arms of this equipment can be steam-sterilized; if not, it may and scrub clothes from the contaminated outside of the be sterilized by ethylene oxide gas and aerated before gown. The gown is turned inside out as it is removed to reuse. If this method is not available, items should be prevent contamination of the scrub suit. Discard the chemically sterilized according to the sterilant manufac- gown in a laundry hamper if it is reusable or in a trash turer’s recommendations. receptacle if it is disposable. • Laryngoscope blades and handles should be disassem- To remove gloves, use a glove-to-glove and then skin- bled, thoroughly decontaminated, and disinfected. Any to-skin technique to protect the hands from the contami- parts that can tolerate a sterilization process should be nated outside of gloves. Turn gloves inside out as they are terminally sterilized. removed to contain the biologic contamination, and then • Noncritical items, such as blood pressure cuffs, should discard them into a trash receptacle. Wash hands after be cleaned with an approved disinfectant between removing gloves. patient uses.9. Fresh exam gloves are worn when transporting the case • Laundry. After all cleaning procedures have been com- cart to the processing area. pleted, discard cleaning cloths or put into a laundry bag if they are not disposable. When all reusable woven fab-Room Turnover Activities by the Team ric items, used and unused, have been placed inside theAfter the patient leaves, the environmental service per- laundry bag, close it securely. To help protect laundrysonnel should be available to perform room cleaning. personnel, an alginate bag that dissolves in hot waterRegardless of which member of the team performs them, may be used as the primary laundry bag or as a linerspeciﬁc functions should be carried out to complete within a cloth bag. Transport reusable woven fabricsroom cleanup. The following personnel and areas are soiled with blood or body ﬂuids in leakproof bags.considered contaminated during and after the surgical • Trash. Collect all trash in plastic or impervious bags, in-procedure: cluding disposable drapes and kick bucket and wastebas-• Members of the sterile team, until they have discarded ket liners. Bags should be sturdy to resist bursting or their gowns, gloves, caps, masks, and shoe covers. These tearing during transport. Trash can be separated into items remain in the contaminated area; scrub clothes are biohazardous waste, noninfectious trash, and recyclable changed if they are wet or contaminated. items. Separate receptacles for each type of trash should• All furniture, equipment, and the ﬂoor within and around be available. Disposition of potentially infectious waste the perimeter of the sterile ﬁeld. If accidental spillage has must comply with local, state, and/or federal leakproof occurred in other parts of the room, these areas are also regulations for contamination control measures. Use ap- considered contaminated. propriately labeled and color-coded bags for infectious• All anesthesia equipment. waste, and use puncture-resistant containers for sharps.• Stretchers used to transport patients and patient moving • Floors. Clean a perimeter of 3 to 4 feet in circumference of devices. These should be cleaned after each patient use. the surgical ﬁeld between cases. This perimeter expands in
212 SECTION FOUR • The Perioperative Environment the direction of visible soilage. Hot water may hasten the will be ready for the next patient. The turnover time in- biocidal action of the disinfectant agent but may also soften cludes cleaning up after one procedure and setting up for tile adhesive. Standing platforms (step stools) are considered the next procedure. Additional equipment brought into the part of the ﬂoor and should be cleaned between cases. room for the next patient should be damp-dusted before• Mops. Fresh, clean mops are used with fresh Environmen- sterile supplies are opened. tal Protection Agency (EPA)–registered disinfectant solu- tion. The ﬂoor can be ﬂooded with detergent-disinfectant Individual Patient Setups solution. One mop is used to apply solution, and one is Each patient has a right to individual supplies prepared used to take up solution. Continually dipping and mop- just for him or her. Sterile supplies should not be opened ping spreads the biologic matter instead of removing it. until they are ready to be used. Case cart systems and the After one-time use, remove mop heads and place in a use of custom packs eliminate the need for preparing the laundry hamper with other contaminated reusable woven sterile ﬁeld several hours ahead of the patient’s arrival. fabrics. Mop handles should be cleaned with disinfectant Tables should not be prepared and covered for use at a after use and stored in the housekeeping storage area until later time. The scrub person, working with an efﬁcient they are needed again. Use clean mops and disinfectant circulating nurse, should have time to set up the instru- solution for each cleanup procedure. ment table immediately before each surgical procedure.• Walls. If walls are splashed with blood or organic debris There is no arbitrary life span of a setup table once it is during the surgical procedure, wash those areas. Other- open and prepared as a sterile ﬁeld for a patient. Sterility wise, walls are not considered contaminated and need is event related, not time related. The sterile table must be not be washed between surgical procedures. under surveillance at all times. The practice of covering sterile setups is not in the bestCart System Cleanup interest of the patient. Unless it is under constant surveil-All contaminated reusable instruments and basins are put lance, sterility of any setup cannot be guaranteed. Uncov-on or inside the case cart. The cart is covered or closed and ering a sterile table is difﬁcult and may compromise steril-taken to the central decontamination area outside surgical ity. If a scheduled surgical procedure is delayed and aservices for cleanup. The case cart with contaminated sup- sterile setup has not been contaminated by the patient’splies should be removed from surgical services via the outer presence in the room, the setup may remain open, undercorridor if this is the design of the suite. If dumbwaiters or surveillance by someone in the room, with the doorselevators are used, a separate one is provided for contami- closed. Taping the door shut has no assurance of sterilitynated carts. Even when covered, the person returning the of the setup. The setup should be used as close to the timecart to the processing area must wear exam gloves. of preparation as possible. The instrument processing personnel will unload the If a patient is taken into the OR and for some reason thecontaminated cart in the workroom. The instruments will surgical procedure is canceled before the procedure hasbe managed in the following manner: begun, the tables should be torn down and the room1. The instrument-washing tray is loaded with heavy in- cleaned as if the surgical procedure had taken place. The struments in the bottom. All hinged instruments are setup is considered potentially contaminated and may not fully opened to expose maximum surface area, including be saved for another patient. Disposable items may be use- box locks. Instruments designed to be disassembled are ful for the clinical educator in the department during ori- taken apart. The instruments are spaced apart to prevent entation and education sessions. contact of sharp edges or points with other instruments. Small basins and solution cups are inverted in a tray. DAILY TERMINAL CLEANING Concave surfaces are turned down.2. Glass syringes, medicine glasses, and other glassware, in- In the Operating Room cluding those used by the anesthesia provider, are placed At completion of the day’s schedule, each OR, whether or in a separate tray. Reusable syringe plungers are removed not it was used that day, should be terminally cleaned. Ad- from the barrels. ditional and more rigorous cleaning is done in all areas3. Detergent-disinfectant solution is suctioned through the already discussed for cleanup between surgical procedures. lumen of reusable suction tips. The lumen is difﬁcult to At the end of the day’s schedule, the following routine clean if biologic debris dries. Disposable suction tips and should be followed: tubing are recommended. • Furniture is thoroughly scrubbed, using mechanical fric-4. The cart is designed to go through an automatic steam tion in addition to chemical disinfection. Special attention cart washer or a manual power wash for terminal decon- to high use items such as computer keyboards, telephones, tamination after it is emptied and before it is restocked intercom buttons, and cabinet handles is important.5 with clean and sterile supplies. • Casters and wheels should be cleaned and kept free of suture ends and debris.Getting the Room Ready for the Next Patient • Equipment, such as ESUs and lasers, should be cleanedThe cleaning procedures described provide adequate de- with care so as not to saturate surfaces to the degree thatcontamination and terminal sterilization after any surgical disinfectant solution runs into the mechanism, causingprocedure. With a well-coordinated team, minimal turn- malfunction and requiring repairs.over time between surgical procedures can be accom- • Ceiling- and wall-mounted ﬁxtures and tracks are cleanedplished. In an average time of 10 to 15 minutes, the room on all surfaces.
Care of the Perioperative Environment • CHAPTER 12 213• Kick buckets, laundry hamper frames, and other waste • Air-conditioning grilles. The exterior of air-conditioning receptacles are decontaminated and disinfected. grilles should be vacuumed at least weekly. Additional• Floors are thoroughly wet-mopped with a fresh mop- cleaning is necessary when ﬁlters are checked and head and disinfectant solution. changed. Debris may be discharged into the room when• Walls and ceilings should be checked for soil spots and the ﬁlter is changed. In-room air handlers are positive cleaned as necessary. pressure. The ﬁlters should be changed on an off-shift or• Cabinets and doors should be cleaned, especially around on the weekend. The room should be terminally cleaned handles or push plates, where contamination is common. after changing the ﬁlters.• Air intake grilles, ducts, and ﬁlter covers should be cleaned. • Storage shelves. Storage cabinets have been replaced in many OR suites by portable storage carts or pass-throughOutside the Operating Room shelving to a sterile core. Storage areas should be cleaned• Countertops and sinks in the substerile room should be at least weekly or more often, if necessary, to control ac- cleaned. The outer surface of the sterilizer, including the cumulation of dust, especially in sterile storage areas. top, should be washed. • Sterilizers. All types of sterilizers should be cleaned regu-• Scrub sinks and spray heads on faucets should undergo larly and tested as recommended by the manufacturer. thorough cleaning daily. A mild abrasive on sinks re- • Transfer zones. Walls, ceilings, ﬂoors, air-conditioning moves the oily ﬁlm residue left by scrub antiseptics. Spray grilles, lockers, cabinets, and furniture should be cleaned heads, faucet aerators, or sprinklers should be removed on a regular schedule. and disassembled, if possible, for thorough cleaning and sterilization of parts. Contaminated faucet aerators and Greening of the OR: Environmental sprinklers can transfer organisms directly to hands or Responsibility items washed under them. Scrub sinks should not be used Many surgical supplies are recyclable. Recycling reduces for routine cleaning purposes. not only air pollution and the amount of waste in landﬁlls• Soap dispensers should be disassembled, cleaned, and ter- but also the amount of virgin resources consumed. Paper minally sterilized, if possible, before they are reﬁlled with wrappers and many plastic items that are noninfectious, antiseptic solution. These dispensers can become reser- nonregulated trash can and should be recycled. Recycling voirs for microorganisms. in the OR should be an integral part of the overall recy-• Walls around scrub sinks should receive daily attention. cling and sustainment program of the health care facility. Spray and splash from scrubbing cause buildup of antisep- Consideration of recycling potential can be part of the tic soap ﬁlm around the sink. This ﬁlm should be removed. evaluation process in selecting products.• Transportation and storage carts need to be cleaned, The team should take care not to use more consumable with speciﬁc attention given to wheels and casters. product than necessary. Overﬁlling prep basins with chem-• Cleaning equipment should be disassembled, cleaned, ical antiseptic solution and then disposing of it in the and dried before storage. sanitary sewer exposes the environment to risk for resistant microorganisms and pollution.Weekly or Monthly CleaningA weekly or monthly cleaning routine is set up, in additionto the daily cleaning schedule, by the director of environ- Re f e re nc e smental/housekeeping services and the OR manager. Anyroutines for housekeeping are based on the physical con- 1. Anderson BM, et al: Floor cleaning: Effect on bacteria and organicstruction of the department. However, if speciﬁc schedules materials in hospital rooms. J Hosp Infect 71(1):57–65, 2009. 2. Dumigan DG, et al: Who is really caring for your environment ofare not established, some areas could be inadvertently care? Developing standardized cleaning procedures and effectivemissed. Areas to be considered are the following: monitoring techniques. Am J Infect Control 38(5):387–392, 2010.• Walls. Walls should be cleaned when they become visi- 3. Hacek DM, et al: Signiﬁcant impact of terminal room cleaning bly soiled. If they are painted or tiled with wide porous with bleach on reducing nosocomial Clostridium difﬁcile. Am J Infect Control 38(5):350–353, 2010. grouting, these factors should be considered in planning 4. Jansen I, Murphy J: Environmental cleaning and healthcare- cleaning routines. Washing walls in the OR and through- associated infections. Healthcare Papers 9(3):38–43, 2009. out the suite once a week is reasonable, but less frequent 5. Po JL, et al: Dangerous cows: An analysis of disinfection cleaning of time intervals for cleaning may be acceptable if spot dis- computer keyboards on wheels. Am J Infect Control 37(9):778–780, infection is performed on a daily basis. This requires ad- 2009. 6. Spry C: Preparing for the patient who has prion disease. Periop Nurs equate continuous supervision. Clin 3(2):115–120, 2008.• Ceilings. Ceilings may require regular special cleaning 7. Virmani A: Safe disposal of used sharp objects. Ind Pediatr 46(6): techniques because of mounted tracks, air diffusers, and 539, 2009. lighting ﬁxtures. Specialized ceiling mounts for micro- 8. Vose JG, McAnara-Berkowitz J: Reducing scalpel injuries in the operating room. AORN J 90(6):867–872, 2009. scopes and booms for suspended equipment should be included in this plan. The types of ﬁxtures are consid- ered in planning cleaning routines. Bibliogr aphy• Floors. Floors throughout surgical services should be machine-scrubbed periodically to remove accumulated AORN (Association of periOperative Registered Nurses): AORN stan- deposits and ﬁlms. Rounded corners and edges facilitate dards, recommended practices, and guidelines, Denver, 2010, The cleaning. Association.