208

C h a p t e r 12

Care of the Perioperative Environment

CHAPTER OBJECTIVES After studying this chapter, the learner will be able to: • Describe how a room is prepared for the fi rst case of the day. • Describe how a room is cleaned and prepared between patients. • Describe how a room is terminally cleaned at the end of the day. • Discuss environmental responsibility.

CHAPTER OUTLINE Standards for Cleanliness in the Surgical Environment, p. 208 Establishing the Surgical Environment, p. 208 Room Turnover Between Patients, p. 209 Daily Terminal Cleaning, p. 212

KEY TERMS AND DEFINITIONS Between case clean-up Cleaning that takes place at the end

of one case to prepare the environment for the next case of the day. Also referred to as turnover.

Case cart system Computerized method of selecting and delivering instrument sets and supplies to the perioperative environment. Some models include provision for the return of instruments and contaminated items to the appropriate decontamination area.

Contamination Potentially pathogenic material that must be contained.

Custom packs Prepackaged disposable supplies standardized and assembled into packages and sterilized by the manufacturer or distributor according to specifi c instructions and requests by a particular service at a facility.

Decontamination Cleaning reusable items with an approved disinfectant to render the item safe for handling.

Fomite Inanimate objects that can harbor and transmit infectious material.

Iatrogenic Condition that results during or from the process of treatment or care that has unfavorable results.

Terminal cleaning Thorough cleaning and disinfection of the peri-operative environment at the end of daily use.

Turnover Cleaning and preparation of the OR between cases for the next patient’s arrival. Areas are cleaned according to level of need.

Website http://evolve.elsevier.com/BerryKohn • Historical Perspective • Flashcards • Self-Assessment Activities • Glossary

STANDARDS FOR CLEANLINESS IN THE SURGICAL ENVIRONMENT

AORN has established standards and recommended practices for cleaning and maintaining optimal cleanliness in the peri-operative environment. The recommendations include but are not limited to the following: 1. All patients are entitled to a clean environment for their

surgical procedures. 2. Any contamination encountered during a surgical pro-

cedure should be contained and confi ned. 3. Between-case clean up should reestablish the cleanest

environment possible for the next patient. 4. Procedure rooms and utility areas should be cleaned daily. 5. A schedule should be in place for routine cleaning of all

areas and equipment in the surgical department. 6. All environmental sanitation processes should be defi ned

by facility policy and procedure.

ESTABLISHING THE SURGICAL ENVIRONMENT

The duties of the scrub person and circulating nurse are many and varied as they prepare for the arrival of the patient in the OR. They are responsible for the cleanliness of the environment preoperatively, intraoperatively, and postoperatively so that the potential for contamination of the patient is kept to a minimum. They prepare and main-tain the sterile fi eld, work within it, and then break it down for terminal cleaning. These activities are performed in spe-cifi c steps to minimize the risk of infection and maximize the use of time and supplies. Standardization is in the best interest of the patient and the personnel performing the cleanup. 1 , 2

Preliminary Preparations 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-vice personnel. It is a cooperative effort. Clean, organized surroundings are part of total patient care.

A visual inspection of the room and its contents should be performed by the team before bringing in supplies for a case. Basic room contents should include the OR bed, anesthesia machine and supplies, electrosurgical unit (ESU), instrument table, preparation (prep) table, Mayo stand, suc-tion apparatus, and receptacles for biohazard and regular

Care of the Perioperative Environment • CHAPTER 12 209

trash, and reusable woven fabrics ( Fig. 12-1 ). Other tables and equipment are added as needed.

Before the First Surgical Procedure of the Day The following housekeeping duties should be done before bringing supplies into the room for the fi rst case of the day: 1. Remove unnecessary tables and equipment from the

room. Arrange the appropriate furniture in an organized manner away from the traffi c pattern. Some head and neck procedures require the OR bed to be oriented in a sideways direction to provide working space for the an-esthesia provider.

2. Damp-dust (with a facility-approved disinfectant solu-tion and lint-free cloth) the overhead operating light, articulated arms, furniture, fl at surfaces, and all portable or mounted equipment. Avoid dry-dusting because this sets dust aloft. Start at higher surfaces, and work down to lower levels because dust may fall from higher areas.

3. Damp-dust the tops and rims of the sterilizer and/or washer-sterilizer and the countertops in the substerile room adjacent to the OR.

4. Visually inspect the room for dirt and debris. The fl oor may need to be damp-mopped.

ROOM TURNOVER BETWEEN PATIENTS

Physical facilities infl uence the fl ow of supplies and equipment after the surgical procedure. However, basic principles of aseptic technique dictate the procedures to be carried out immediately after a surgical procedure is completed, to prepare the OR for the next patient. Every patient has the right to the same degree of safety in the

environment. In addition, personnel working in surgical services should be protected. Personnel cleaning the room between patients should wear personal protective equipment (PPE) appropriate for the cleaning task. Gloves worn for cleaning should be durable in the presence of cleaning agents. Vinyl gloves are not reliable and may not protect the wearer from environmental contamination in the presence of degradation caused by cleaning agents.

Some patients have known pathogenic microorganisms; others have unknown infectious organisms. Therefore ev-ery patient should be considered a potential contaminant in the environment. Cleanup procedures should be rigidly followed to contain and confi ne contamination, known or unknown. Some examples of conditions that require spe-cial consideration are the following: 1. Patients with known respiratory-borne disease (i.e.,

rubeola, varicella, tuberculosis) may deposit microorgan-isms in the environment. In addition to routine envi-ronmental decontamination, the air exchanges should be 99% complete before the next patient is brought into the room. This may take 20 to 30 minutes on a 15- to 20-air change per hour cycle. Staff should wear appropri-ate fi ltration masks during room cleaning. a

2. Patients with known endospore-forming bacterial con-tamination (i.e., Clostridia or Bacillus spp.) may deposit bacterial endospores in the environment on inanimate objects known as fomites . These endospores have been

Suction

Hea

d

Linen TrashPrep table

Mayostand Instrument table

Operating bed

Autoclave

STERISunitSink

Disposalof sharps

Anesthesiamachine

and supplies

ESU

X-ray view boxesCirculator’swork area

Doorto

substerileroom

Entrydoor

FIG. 12-1 Layout of basic OR and substerile room. The traffi c pattern from the doors should not interfere with the setup of the sterile tables or the transfer of the patient to the operating bed.

a The number of air changes per hour changed in July 2010. Please refer to the 2010 edition of the Guidelines for Design and Construction of Health 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 have been cultured in ORs 40 days after the patient has used the room. AORN recommended practices state that a hypochlorite-based disinfectant should be used for cleaning the environment. 1 , 3

3. Patients with known or suspected transmissible spongi-form encephalopathies (TSE) such as Creutzfeldt-Jakob disease (CJD) and new variant CJD may deposit prions in the environment. Prions are proteins found in neurologic tissue and fl uids that cause fatal neurodegenerative dis-eases in humans and animals. Iatrogenic introduction of prion disease can happen if the patient is exposed to the protein during the surgical procedure by instrumentation or the environment. Prions are nonliving proteins that persist on surfaces and require special cleaning solutions. Disposable equipment, instruments, linens, and supplies should be used in the presence of known or suspected prion diseases. 6

The routine cleanup procedure can be accomplished expe-ditiously by the circulating nurse and scrub person working cooperatively. While the circulating nurse secures the outer layer of dressing and prepares the patient for transport from the OR, the scrub person begins to dismantle the sterile fi eld before removing gown and gloves.

All instruments, supplies, and equipment should be decontaminated, disinfected, terminally sterilized, or con-tained for disposal as appropriate before being handled by other personnel.

After a patient leaves the room, the immediate environ-ment is cleaned and all surfaces are dried. Room cleanup between patients is directed at the prevention of cross-contamination. 4 The cycle of contamination is from patient to environment and from environment to OR personnel and subsequent patients.

Exposure to infectious waste is a hazard to everyone who encounters it. After each surgical procedure the en-vironment should be made safe for the next patient to follow in that room. Institutional policies and procedures for routine room cleanup should be designed to minimize the OR team’s exposure to contamination during the cleaning process. 2

Room Turnover Activities by the Scrub Person The patient should be thought of as the center, or focal point. The surrounding sterile fi eld and all areas that have come in contact with blood or body fl uids are considered contaminated. The primary principles of cleaning proce-dures are to confi ne and contain contamination and physically remove microorganisms as quickly as possible.

Do not contaminate the table or Mayo stand until the patient has actually left the room if there is a question of patient stability, especially during trauma, cardiac, vascular, and neurologic procedures. Remain sterile until the patient leaves the room.

When the patient leaves the room, the sterile fi eld is dis-mantled by the scrub person, who remains protected with the gown, gloves, a mask, protective eyewear, and a cap dur-ing the dismantling procedure. Contaminated instruments, basins, and other reusable items are collected by the scrub person and placed in the case cart for decontamination, packaging, and sterilization in the processing department.

The following are activities/responsibilities of the scrub person at the end of the case: 1. Push the Mayo stand and instrument table away from

the operating bed (OR bed) as soon as the dressing is applied and the drapes are removed. Roll drapes off the patient from head to foot to prevent airborne contami-nation; do not pull them off.

2. Check drapes for towel clips, instruments, and other items. Be sure that no equipment is discarded with dis-posable drapes or sent to the laundry.

Disposable drapes are placed in a red biohazard con-tainer for disposal. Soiled drapes, whether disposable or reusable, should be handled as little as possible and with minimum agitation to prevent gross microbial contami-nation of air by dispersal of lint and debris.

3. Discard soiled sponges, other biologically contaminated waste, and disposable items in red biohazard containers. Discard unused sponges, nonwoven drapes, and other disposable waste into the main trash.

4. Dispose of sharp items safely. Special care should be taken in handling all knife blades, trocars, burrs and bits, surgical needles, and needles used for injection or aspiration. 7 , 8 Remove the tip from the ESU handle (pencil). A self-closing adhesive pad or box designed for this purpose is the safest device to use. A safe dis-posal procedure should be implemented and sustained. Place these items in an appropriate rigid, puncture-resistant container for safe disposal to prevent injury and potential risk of contamination.

The primary cause of accidental cuts and punctures to personnel, both inside and outside the OR, is disposal of surgical sharps at the end of the surgical procedure. Adherence to standardized systems designed specifi cally for safe handling and disposal of sharps prevents virtu-ally all accidental cuts, punctures, and lacerations. 8 Unused suture packets are discarded.

5. Basins and trays too large for the case cart are put into plastic bags for transport to the decontamination area. The Mayo tray may be included. Place these on the lower shelf of the case cart.

6. The instruments are opened completely and placed into the wire mesh basket with all box locks spread apart. Blood, tissue, bone, and any other gross debris is removed from instruments during the case as much as possible. All instruments, used and unused, must be decontaminated, terminally sterilized, or undergo high-level disinfection before they are processed for reuse. Instruments should be presoaked and/or pre-rinsed before processing in a washer-sterilizer or de-contaminator. Some facilities have the scrub person spray enzymatic foam over the instruments to start the cleaning process.

Any biologic material remaining on instruments is more diffi cult to remove after the instruments have been heat-sterilized because the material becomes baked on them. The biologic debris inhibits sterilization and disinfection processes. a. Remove knife blades from handles using a heavy he-

mostat; never use fi ngers. Using a needle holder can cause the jaws of the instrument to become misaligned. Point the blade toward the table, and away from the

Care of the Perioperative Environment • CHAPTER 12 211

fi eld and other people in the area so that if it breaks or slips it will not fl y across the room.

b. Unloaded scalpel handles and other instruments with sharp tips or edges, such as scissors, should be placed in a container separate from the other instru-ments so they can be easily identifi ed by the process-ing personnel.

Do not put knife handles in an instrument tray with blades left on them. Other instruments designed for replaceable cutting blades, such as dermatomes, should have blades removed; thereafter they may be handled with other instruments.

Place reusable surgical needles, either on a nee-dle rack or loose, into a perforated stainless steel box to be decontaminated and sterilized with the instruments.

7. Dispose of solutions and suction bottle contents in a fl ushing hopper connected to a sanitary sewer. Wear PPE to protect from splashes. Disposable suction units simplify disposal. Commercial substances can be added to liquid in the disposable canister to solidify or gel contents for solid waste disposal. If disposable units are not used, decontaminate contents with disinfectant before hopper disposal.

8. The scrub person removes gown and gloves before tak-ing the case cart to the processing area. The gown is removed fi rst before removing gloves. The circulating nurse unfastens neck and back closures. Protect arms and scrub clothes from the contaminated outside of the gown. The gown is turned inside out as it is removed to prevent contamination of the scrub suit. Discard the gown in a laundry hamper if it is reusable or in a trash receptacle if it is disposable.

To remove gloves, use a glove-to-glove and then skin-to-skin technique to protect the hands from the contami-nated outside of gloves. Turn gloves inside out as they are removed to contain the biologic contamination, and then discard them into a trash receptacle. Wash hands after removing gloves.

9. Fresh exam gloves are worn when transporting the case cart to the processing area.

Room Turnover Activities by the Team After the patient leaves, the environmental service per-sonnel should be available to perform room cleaning. Regardless of which member of the team performs them, specifi c functions should be carried out to complete room cleanup. The following personnel and areas are considered contaminated during and after the surgical procedure: • Members of the sterile team, until they have discarded

their gowns, gloves, caps, masks, and shoe covers. These items remain in the contaminated area; scrub clothes are changed if they are wet or contaminated.

• All furniture, equipment, and the fl oor within and around the perimeter of the sterile fi eld. If accidental spillage has occurred in other parts of the room, these areas are also considered contaminated.

• All anesthesia equipment. • Stretchers used to transport patients and patient moving

devices. These should be cleaned after each patient use.

Clean, but not sterile examination gloves are worn to com-plete the room cleanup. The scrub person changes gloves after the sterile fi eld is dismantled. Decontamination of the environment includes the following tasks: • Furniture. Wash horizontal surfaces of all tables and equip-

ment, including the anesthesia machine, with a disinfec-tant. Apply disinfectant from a squeeze-bottle dispenser, and wipe with a clean cloth or a disposable wipe that is changed frequently. Spray bottles can cause particles to become aerosolized and should be avoided.

All surfaces of mattress, pads, and screw connections of the OR bed are included. Safety straps should be cleaned between patients. Velcro straps can be laundered accord-ing to the manufacturer’s recommendations. Mobile fur-niture can be pushed through disinfectant solution used for fl oor care to clean casters. Excess strands of loose suture should be removed from the wheels.

• Overhead operating light. Wipe overhead lights with a clean cloth that has been wetted with disinfectant solution spe-cifi cally intended to prevent clouding of the surface that can cause dullness and glare. Lights and overhead tracks become contaminated quickly and present a possible haz-ard from fallout of dust particles onto sterile surfaces or into wounds during surgical procedures.

• Anesthesia equipment. Most masks and anesthesia tubing are disposable. Any reusable anesthesia masks and tub-ing are cleaned and sterilized between patient uses. Some of this equipment can be steam-sterilized; if not, it may be sterilized by ethylene oxide gas and aerated before reuse. If this method is not available, items should be chemically sterilized according to the sterilant manufac-turer’s recommendations.

• Laryngoscope blades and handles should be disassem-bled, thoroughly decontaminated, and disinfected. Any parts that can tolerate a sterilization process should be terminally sterilized.

• Noncritical items, such as blood pressure cuffs, should be cleaned with an approved disinfectant between patient uses.

• Laundry. After all cleaning procedures have been com-pleted, discard cleaning cloths or put into a laundry bag if they are not disposable. When all reusable woven fab-ric items, used and unused, have been placed inside the laundry bag, close it securely. To help protect laundry personnel, an alginate bag that dissolves in hot water may be used as the primary laundry bag or as a liner within a cloth bag. Transport reusable woven fabrics soiled with blood or body fl uids in leakproof bags.

• Trash. Collect all trash in plastic or impervious bags, in-cluding disposable drapes and kick bucket and wastebas-ket liners. Bags should be sturdy to resist bursting or tearing during transport. Trash can be separated into biohazardous waste, noninfectious trash, and recyclable items. Separate receptacles for each type of trash should be available. Disposition of potentially infectious waste must comply with local, state, and/or federal leakproof regulations for contamination control measures. Use ap-propriately labeled and color-coded bags for infectious waste, and use puncture-resistant containers for sharps.

• Floors. Clean a perimeter of 3 to 4 feet in circumference of the surgical fi eld between cases. This perimeter expands in

212 SECTION FOUR • The Perioperative Environment

the direction of visible soilage. Hot water may hasten the biocidal action of the disinfectant agent but may also soften tile adhesive. Standing platforms (step stools) are considered part of the fl oor and should be cleaned between cases.

• Mops. Fresh, clean mops are used with fresh Environmen-tal Protection Agency (EPA)–registered disinfectant solu-tion. The fl oor can be fl ooded with detergent-disinfectant solution. One mop is used to apply solution, and one is used to take up solution. Continually dipping and mop-ping spreads the biologic matter instead of removing it. After one-time use, remove mop heads and place in a laundry hamper with other contaminated reusable woven fabrics. Mop handles should be cleaned with disinfectant after use and stored in the housekeeping storage area until they are needed again. Use clean mops and disinfectant solution for each cleanup procedure.

• Walls. If walls are splashed with blood or organic debris during the surgical procedure, wash those areas. Other-wise, walls are not considered contaminated and need not be washed between surgical procedures.

Cart System Cleanup All contaminated reusable instruments and basins are put on or inside the case cart. The cart is covered or closed and taken to the central decontamination area outside surgical services for cleanup. The case cart with contaminated sup-plies should be removed from surgical services via the outer corridor if this is the design of the suite. If dumbwaiters or elevators are used, a separate one is provided for contami-nated carts. Even when covered, the person returning the cart to the processing area must wear exam gloves.

The instrument processing personnel will unload the contaminated cart in the workroom. The instruments will be managed in the following manner: 1. The instrument-washing tray is loaded with heavy in-

struments in the bottom. All hinged instruments are fully opened to expose maximum surface area, including box locks. Instruments designed to be disassembled are taken apart. The instruments are spaced apart to prevent contact of sharp edges or points with other instruments. Small basins and solution cups are inverted in a tray. Concave surfaces are turned down.

2. Glass syringes, medicine glasses, and other glassware, in-cluding those used by the anesthesia provider, are placed in a separate tray. Reusable syringe plungers are removed from the barrels.

3. Detergent-disinfectant solution is suctioned through the lumen of reusable suction tips. The lumen is diffi cult to clean if biologic debris dries. Disposable suction tips and tubing are recommended.

4. The cart is designed to go through an automatic steam cart washer or a manual power wash for terminal decon-tamination after it is emptied and before it is restocked with clean and sterile supplies.

Getting the Room Ready for the Next Patient The cleaning procedures described provide adequate de-contamination and terminal sterilization after any surgical procedure. With a well-coordinated team, minimal turn-over time between surgical procedures can be accom-plished. In an average time of 10 to 15 minutes, the room

will be ready for the next patient. The turnover time in-cludes cleaning up after one procedure and setting up for the next procedure. Additional equipment brought into the room for the next patient should be damp-dusted before sterile supplies are opened.

Individual Patient Setups Each patient has a right to individual supplies prepared just for him or her. Sterile supplies should not be opened until they are ready to be used. Case cart systems and the use of custom packs eliminate the need for preparing the sterile fi eld several hours ahead of the patient’s arrival. Tables should not be prepared and covered for use at a later time. The scrub person, working with an effi cient circulating nurse, should have time to set up the instru-ment table immediately before each surgical procedure. There is no arbitrary life span of a setup table once it is open and prepared as a sterile fi eld for a patient. Sterility is event related, not time related. The sterile table must be under surveillance at all times.

The practice of covering sterile setups is not in the best interest of the patient. Unless it is under constant surveil-lance, sterility of any setup cannot be guaranteed. Uncov-ering a sterile table is diffi cult and may compromise steril-ity. If a scheduled surgical procedure is delayed and a sterile setup has not been contaminated by the patient’s presence in the room, the setup may remain open, under surveillance by someone in the room, with the doors closed. Taping the door shut has no assurance of sterility of the setup. The setup should be used as close to the time of preparation as possible.

If a patient is taken into the OR and for some reason the surgical procedure is canceled before the procedure has begun, the tables should be torn down and the room cleaned as if the surgical procedure had taken place. The setup is considered potentially contaminated and may not be saved for another patient. Disposable items may be use-ful for the clinical educator in the department during ori-entation and education sessions.

DAILY TERMINAL CLEANING

In the Operating Room At completion of the day’s schedule, each OR, whether or not it was used that day, should be terminally cleaned. Ad-ditional and more rigorous cleaning is done in all areas already discussed for cleanup between surgical procedures. At the end of the day’s schedule, the following routine should be followed: • Furniture is thoroughly scrubbed, using mechanical fric-

tion in addition to chemical disinfection. Special attention to high use items such as computer keyboards, telephones, intercom buttons, and cabinet handles is important. 5

• Casters and wheels should be cleaned and kept free of suture ends and debris.

• Equipment, such as ESUs and lasers, should be cleaned with care so as not to saturate surfaces to the degree that disinfectant solution runs into the mechanism, causing malfunction and requiring repairs.

• Ceiling- and wall-mounted fi xtures and tracks are cleaned on all surfaces.

Care of the Perioperative Environment • CHAPTER 12 213

• Kick buckets, laundry hamper frames, and other waste receptacles are decontaminated and disinfected.

• Floors are thoroughly wet-mopped with a fresh mop-head and disinfectant solution.

• Walls and ceilings should be checked for soil spots and cleaned as necessary.

• Cabinets and doors should be cleaned, especially around handles or push plates, where contamination is common.

• Air intake grilles, ducts, and fi lter covers should be cleaned.

Outside the Operating Room • Countertops and sinks in the substerile room should be

cleaned. The outer surface of the sterilizer, including the top, should be washed.

• Scrub sinks and spray heads on faucets should undergo thorough cleaning daily. A mild abrasive on sinks re-moves the oily fi lm residue left by scrub antiseptics. Spray heads, faucet aerators, or sprinklers should be removed and disassembled, if possible, for thorough cleaning and sterilization of parts. Contaminated faucet aerators and sprinklers can transfer organisms directly to hands or items washed under them. Scrub sinks should not be used for routine cleaning purposes.

• Soap dispensers should be disassembled, cleaned, and ter-minally sterilized, if possible, before they are refi lled with antiseptic solution. These dispensers can become reser-voirs for microorganisms.

• Walls around scrub sinks should receive daily attention. Spray and splash from scrubbing cause buildup of antisep-tic soap fi lm around the sink. This fi lm should be removed.

• Transportation and storage carts need to be cleaned, with specifi c attention given to wheels and casters.

• Cleaning equipment should be disassembled, cleaned, and dried before storage.

Weekly or Monthly Cleaning A weekly or monthly cleaning routine is set up, in addition to the daily cleaning schedule, by the director of environ-mental/housekeeping services and the OR manager. Any routines for housekeeping are based on the physical con-struction of the department. However, if specifi c schedules are not established, some areas could be inadvertently missed. Areas to be considered are the following: • Walls. Walls should be cleaned when they become visi-

bly soiled. If they are painted or tiled with wide porous grouting, these factors should be considered in planning cleaning routines. Washing walls in the OR and through-out the suite once a week is reasonable, but less frequent time intervals for cleaning may be acceptable if spot dis-infection is performed on a daily basis. This requires ad-equate continuous supervision.

• Ceilings. Ceilings may require regular special cleaning techniques because of mounted tracks, air diffusers, and lighting fi xtures. Specialized ceiling mounts for micro-scopes and booms for suspended equipment should be included in this plan. The types of fi xtures are consid-ered in planning cleaning routines.

• Floors. Floors throughout surgical services should be machine-scrubbed periodically to remove accumulated deposits and fi lms. Rounded corners and edges facilitate cleaning.

• Air-conditioning grilles. The exterior of air-conditioning grilles should be vacuumed at least weekly. Additional cleaning is necessary when fi lters are checked and changed. Debris may be discharged into the room when the fi lter is changed. In-room air handlers are positive pressure. The fi lters should be changed on an off-shift or on the weekend. The room should be terminally cleaned after changing the fi lters.

• Storage shelves. Storage cabinets have been replaced in many OR suites by portable storage carts or pass-through shelving to a sterile core. Storage areas should be cleaned at least weekly or more often, if necessary, to control ac-cumulation of dust, especially in sterile storage areas.

• Sterilizers. All types of sterilizers should be cleaned regu-larly and tested as recommended by the manufacturer.

• Transfer zones. Walls, ceilings, fl oors, air-conditioning grilles, lockers, cabinets, and furniture should be cleaned on a regular schedule.

Greening of the OR: Environmental Responsibility Many surgical supplies are recyclable. Recycling reduces not only air pollution and the amount of waste in landfi lls but also the amount of virgin resources consumed. Paper wrappers and many plastic items that are noninfectious, nonregulated trash can and should be recycled. Recycling in the OR should be an integral part of the overall recy-cling and sustainment program of the health care facility. Consideration of recycling potential can be part of the evaluation process in selecting products.

The team should take care not to use more consumable product than necessary. Overfi lling prep basins with chem-ical antiseptic solution and then disposing of it in the sanitary sewer exposes the environment to risk for resistant microorganisms and pollution.

References

1. Anderson BM , et al : Floor cleaning: Effect on bacteria and organic materials in hospital rooms . J Hosp Infect 71 ( 1 ): 57 – 65 , 2009 .

2. Dumigan DG , et al : Who is really caring for your environment of care? Developing standardized cleaning procedures and effective monitoring techniques . Am J Infect Control 38 ( 5 ): 387 – 392 , 2010 .

3. Hacek DM , et al : Signifi cant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium diffi cile . Am J Infect Control 38 ( 5 ): 350 – 353 , 2010 .

4. Jansen I, Murphy J : Environmental cleaning and healthcare-associated infections . Healthcare Papers 9 ( 3 ): 38 – 43 , 2009 .

5. Po JL , et al : Dangerous cows: An analysis of disinfection cleaning of computer keyboards on wheels . Am J Infect Control 37 ( 9 ): 778 – 780 , 2009 .

6. Spry C : Preparing for the patient who has prion disease . Periop Nurs Clin 3 ( 2 ): 115 – 120 , 2008 .

7. Virmani A : Safe disposal of used sharp objects . Ind Pediatr 46 ( 6 ): 539 , 2009 .

8. Vose JG, McAnara-Berkowitz J : Reducing scalpel injuries in the operating room . AORN J 90 ( 6 ): 867 – 872 , 2009 .

Bibl iography

AORN (Association of periOperative Registered Nurses) : AORN stan-dards, recommended practices, and guidelines , Denver , 2010 , The Association .