1. Controlling CDI — OR room turn-over cleaning Contents courtesy of Allina Healthcare

2. 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 Contents courtesy of Allina Health

3. 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 Contents courtesy of Allina Health

4. 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 Contents courtesy of Allina Health

5. One patient’s story  Cost of CDI: Lost his colon 9 readmissions 143 days in the hospital OVER 1.2 MILLION in healthcare costs Contents courtesy of Allina Health

6. 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 Contents courtesy of Allina Health

7. 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 Contents courtesy of Allina Health

8. 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. Contents courtesy of Allina Health

9. 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 Contents courtesy of Allina Health

10. 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. Contents courtesy of Allina Health

11. 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 Contents courtesy of Allina Health

12. Using AF or bleach wipes: 1) Use friction 2) 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! Contents courtesy of Allina Health

13. 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 Contents courtesy of Allina Health

14. 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 Contents courtesy of Allina Health

15. Recommended cleaning procedures  Before first case of the day  Between cases  Terminal clean after the last case of the day Contents courtesy of Allina Health

16. 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 Contents courtesy of Allina Health

17. 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 Contents courtesy of Allina Health

18. 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 Contents courtesy of Allina Health

20. 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) Contents courtesy of Allina Health

21. Room cleaning and disinfecting Start with table: 1.Remove all unnecessary table attachments, and clean all exposed surfaces with a cleaner disinfectant 2.Wipe joints, table attachments, frame, legs, and rails 3.Turn down mattress and wipe the table bed frame and back of the mattress working from the top and repeat at the bottom 4.Wipe sides of the mattress. Change disinfectant wipe or cloth as needed. 5.Wipe both sides of coated pillows 6.Allow all elements to air dry. Contents courtesy of Allina Health

22. 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 boards o Non-disposable safety strap o Standing stools (lifts) o Kick buckets o Overhead OR lights and reflectors Contents courtesy of Allina Health

23. Environmental monitoring  Environmental monitoring- used to identify opportunities for improving cleaning process UV fluorescent gel o Monitors whether the right surfaces are cleaned ATP o 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 Contents courtesy of Allina Health

24. What types of surfaces are monitored? Contents courtesy of Allina Health

25. 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 Contents courtesy of Allina Health

26. 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 Contents courtesy of Allina Health