PROCEDURE
SubjectSurgery, Minor Procedure, Interventional Minor Procedure and C-Section Cleaning Procedures / Number
Original Issue
Revised
Page / 1 of 1
Reviewed by:
Department Head Date:
Objective:
To ensure that the operating rooms in the Surgery Centers and Family Beginnings Unit (FBU), and rooms used for invasive procedures in Interventional Radiology, are thoroughly cleaned and sanitized after each procedure, at the end of each day, and additionally as scheduled.
To ensure that all other patient care areas, supply/equipment areas, and support areas in the surgery centers and FBU are cleaned and sanitized daily or as scheduled.
Scope:
This procedure applies to the following specific locations that do invasive procedures:
- Ambulatory Surgery Center (BASC)
- Ambulatory Surgery Center (CHOSC)
- Ambulatory Surgery Center (TASC)
- Family Beginnings Unit (FBU) C–Section Operating Rooms
- Interventional Radiology (IR) Special Procedure Rooms used for invasive procedures (CH, BVU, TSC)
References:
Guidelines for Environmental Infection Control in Health-Care Facilities, CDC, 2003
Perioperative Standards and Recommended Practices, Chapter 16: Recommended Practices for Environmental Cleaning in the Perioperative Setting. Association of Perioperative Registered Nurses, 2012
Each locationwill provide these documents for their specific location if deemed applicable or needed by the location:
Guiding Principles
Zone Procedure
OR Furniture/Equipment Diagrams
Refer to Surgery Services Department Policies:
Environmental Sanitation 4.002
Surgical Attire 4.009
Traffic Patterns in the Surgical Center 4.012
Page 1 of 18
PROCEDURE FM-EVS-0146
Use in Conjunction with:
FM-EVS Policy 0147 Emergency Cleanup of Blood Spills and Other Body Fluids (Hard Floor Surfaces)
FM-EVS Policy 0128 Cleaning Pails
FM-EVS Policy 0161 Housekeeping Chemicals and Supplies
FM-EVS Policy 0102 Floor Stripping
FM-EVS Policy 0104 Operating Auto Scrubber
FM-EVS Policy 0166 Wet Vac Cleaning and Care
FM-EVS Policy 0162 Use and Care of Standard Floor Machines
Equipment/Supplies Needed
- Appropriate personal protective equipment (PPE) including:
○Disposable, single use gloves
○Protective eyewear (goggles or face shield)
- GH approved disinfectant, preferably dispensed by a chemical solution dispenser
- Mop bucket and wringer
- Mop head (lint free or microfiber) and handle
- Wall mop and heads (lint free or microfiber)
- Small plastic pail
- Cleaning cloths (lint-free or microfiber); not washcloths.
- Scrubbing pads
- Hand broom and dust pan
- Plastic liners for garbage/trash containers
- Disposablelaundry bags
- Biohazard bags
Note: Use 1-2 or more cleaning cloths on each surface/item to prevent debris inactivation of the disinfectant. Start at the top of the surface and work down to legs/wheels then discard rag(s). Example: an OR table or gurney may require 2-3 rags.
I.Cooperative wide Surgical Services, Interventional Radiology, and Family Birthing Unit staff and Environmental Services cleaning check lists define which service is responsible for the cleaning of the operating room and surgical services environment specific areas to assure a safe and clean environment for the patient and staff.
- See attached staff departmental responsibility checklists
- See attached Environmental Services (EVS) responsibility checklists
- Individual checklists, in collaboration with EVS, may be developed specific to each site using this procedure as the guideline.
Page 1 of 18
PROCEDURE FM-EVS-0146
II.DIFFERENCES BETWEEN THE FACILITY LOCATIONS
Variables / FBU C-Section / Interventional Rad (CH/BVU) / BASC / CHOSC / TASCEVS Staff On Site During Day / Yes / Yes / No (evening only)
Hours:
5pm -1:30 am / Days-on call only
Evening Hours:
(4pm-1:30 am) / No (evening only)
Hours:
5pm-1:30am
Core or No Core / No Core / No core / No core / Core / Core
Booms or Towers / N/A / N/A / Booms
(items not unplugged from boom) / Towers / Towers
Suction Disposal / Biowaste / NA / Dornoch Disposal System
Biowaste / Biowaste / Biowaste
Green Light Outside Operating Rooms Identifying Positive Pressure / None / NA / Yes / None / None
Gel pad storage location / NA / NA / Varies / Varies / Varies
Cart washer in CSR / Yes / NA / No / Yes / No
Anesthesia Techs / Come from CH OSC on a periodic scheduled basis / NA / Yes / Yes / Yes
Page 1 of 18
PROCEDURE FM-EVS-0146
Departmental Staff Responsibility ChecklistOPERATING/PROCEDURE ROOM / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
Instruments – Remove / Staff / Staff / Yes / Yes
Sharps – Place all used in sharps container / Staff / staff / Yes / Yes
Sharps container - Replace when 2/3rds full. Seal and place in biomedical waste container. / Staff / Staff / As needed / As needed
Suction canisters/tubing - Remove all used liners and tubing / Staff / Staff / Yes / Yes
Suction stand - Clean / CH EVS / EVS / Yes / No
Suction connections (ceiling & between canisters – Replace) / Staff / Staff / As needed / As needed
Black/reusable straps - Remove & place in CSR laundry bin (picked up by CSR on Friday) / N/A / N/A / Yes / Yes
White/disposable straps - Remove & discard in trash / NA / N/A / Yes / Yes
Laundry – Remove & clean stand / CH EVS / Staff / Yes / Remove laundry only
Trash – Remove & clean stand/trash containers / CH EVS / Staff / Yes / Remove trash only
Floors - Mop / CH EVS / EVS / Yes / No
Equipment: Damp wipe with disinfectant
- Clipper
- BairHugger machine and hose
- SCD machine and cable
- Cautery
- Headlight/light source
- Towers
- Neopuff
- Other
and see
End of Day Responsibilities
Departmental Staff Responsibility Checklist
OPERATING/PROCEDURE ROOM / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
Positioning Equipment: Damp wipe with disinfectant
- Stirrups
- Gel pads
Gel Pads = N/A / N/A / Yes / No
and see
End of Day Responsibilities
Operating Room Table: Damp wipe with disinfectant
- All pads
- Armboards
- Other accessories
- Base of table
Other Furniture: Damp wipe with disinfectant
- Chairs/stools/carts/stands/tables/OR Table
Other Miscellaneous: Damp wipe with disinfectant
- Computer console, cart, mouse, keyboard, monitors, tray
- Telephone
- Boom box (CD Player) Cover with plastic bag which is changed between patients
Other: / Yes / Yes
- Erase white board
- Remove all confidential patient information
Anesthesia Med/Supply Cart: / Leave in OR / Leave in OR / Leave in OR / Remove from OR
- Discard all opened single use meds & anesthesia-prepared syringes
Departmental Staff Responsibility Checklist
OPERATING/PROCEDURE ROOM / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
- Laryngoscope handle - Remove disinfect each case
- Laryngoscope used blade(s) – Remove
- Remove towel on top of cart and trash bag
- Damp clean with disinfectant: Top of cart, all drawer handles, trash container
- Replace towel, trash bag
- Restock cart
Anesthesia Machine/Cardiac Monitor/Computer:
- Remove: Used suction container/tubing, and towel
- Remove: Used circuit / hoses and all items on top of machine
- Anesthesia Machine: Damp clean with disinfectant all flat surfaces, drawer handles, knobs, hoses, etc.
- Cardiac monitor, cable and lead wires: Damp clean with disinfectant
- Computer, keyboard, mouse, tray, monitor: Damp clean with disinfect
- Restock machine
Departmental Staff Responsibility Checklist
OPERATING/PROCEDURE ROOM / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
Miscellaneous End of Day:
- Dedicated Room Equipment: Turn off, unplug, secure all cords/cables/ hoses, and damp wipe with disinfectant
- Clipper
- BairHugger machine and hose
- SCD machine and cable
- Cautery
- Towers
- Other
DRTs / Yes / Yes / Yes
- Case SpecificEquipment: Turn off, unplug, secure all cords/cables, console and damp wipe with disinfectant, and return to storage
- Headlight/light source
- Towers
- Neoprobe / NeoPuff
- Other
DRTs / Yes / Yes / Yes
- Case specific positioning equipment and OR table attachments: Damp wipe and return to storage
- Store all clean items (armboards and other table attachments, hoses, wires, cords, autoclave racks, BairHugger, SCD machine/hose, etc) off the floor
- Return all clean, unused supplies (gloves, sutures, implants, medications, etc) to their proper storage areas.
Departmental Staff Responsibility Checklist
OPERATING/PROCEDURE ROOM / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
- Restock in-room supplies as needed.
- Make sure autoclave is empty
- Send all lakeside/case carts to CSR for cleaning
- Windows restart all computers
- Place all patient confidential info in confidential waste bin
Miscellaneous:
- Shelves –spot clean / damp dust with disinfectant
- Supply Cart plastic covers - replace
PACU (PRE-OP & RECOVERY) / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
Damp wipe with disinfectant:
- Counters/work surfaces/chairs
- Patient furniture: stretchers, recliners, bedside tables/carts including drawer handles, chairs
- Patient equipment: Monitors including cables and leads, SCD machines, BairHugger machines, other
- Computer keyboards, mice, trays and stands
- Keep area clean (pick up after self)
- Shelves
- Bins/totes
Departmental Staff Responsibility Checklist
CORE/CLEAN or STERILE EQUIPMENT/SUPPLY STORAGE AREAS/
ANESTHESIA WORKROOMS / FBU / IR / ASCs / ASCs
Task / Between Each Case / Between Each Case / Between Each Case / At End of Day/Other
- Replace supply cart covers
- Remove dust from lower shelves of carts
- Clean bins to remove dust
CORRIDORS / FBU / IR / CHOSC / ASCs
- Pick up trash
- Clean equipment stored in hallway
- Cover items not used frequently and change cover weekly
RESTROOMS & LOUNGES / FBU / IR / ASCs / ASCs
- Pick up after self
- Pick up trash off floor & counter
- Place all patient info in confidential waste
- Clean lounge refrigerator (surgery center is responsible for cleaning weekly)
- Clean microwave (surgery center is responsible for cleaning weekly)
OFFICES & NURSING STATIONS / FBU / IR / ASCs / ASCs
- Clean counters, desks & shelves
- Clean computer keyboard, mouse, tray, monitor
Environmental Services Responsibility Checklist (As Applicable To Location)
EVS: OPERATING ROOMS / FBU / IR / BASC/TASC / CHOSC
Task / Frequency / Frequency / Frequency / Frequency
Laundry Cart– Remove to pick up location / Each case / As needed / Daily / Daily
Trash Cart – Remove to pick up location / Each case / As needed / Daily / Daily
Biomedical Waste Bins – Remove to pick up location / Each case / As needed / Daily / Daily
Equipment/Furniture: Clean with disinfectant
- Wheels/casters – Clean all wheels/casters of equipment/furniture
- Overhead surgical light & boom
- Suction stand
- Laundry stand – Clean & replace bag
- Trash stand/container – Clean & replace bag
- Chairs/stools/carts/stands
- Tape – remove sticky residue with adhesive remover
Clean with disinfectant:
- Ceiling & Walls –spot clean (walls are spot cleaned up to 6 feet)
- Vents & light covers
- Window & wall sills
- Surgical light & boom
- Telephones
- Electrical cords – ceiling to connection
- Gas hoses
- Trash can
- Kick bucket
- Laundry hamper & lid (inside & out)
- Door handles & plates
- Light switches
- Wall mounted hand sanitizer & catch plate
- Wheel guards
- Stools/chairs including armrests
Clean with disinfectant:
- Positioning Equipment: Stirrups, arm boards and other table attachments
- IV poles
- Step stool
- Mayo stand
- Gurney/stretcher/surgilift (remove pad-clean both sides of pad)
- Surgical table (disassemble)
- Surgical table pads (top, bottom, and sides) & attachments
- C locker top and sides
- Floors - Mop
- Cupboard/cabinet handles & exterior of drawers
Rearrange furniture & equipment / Each case / Daily / Daily / Daily
Clean, Dry & Store all Cleaning Equipment in a clean EVS storage closet / Daily / Daily / Daily / Daily
Weekly Cleaning With Disinfectant:
- Shelves-spot clean/damp dust with disinfectant
- Entire ceiling
- Ceiling tracks
- Curtain tracks
- Vent covers
- Light covers
- Sprinkler heads
- Entire walls (including base coves)
- All Linoleum lips
- Door jams & hardware
Environmental Services Responsibility Checklist (As Applicable To Location)
EVS: OPERATING ROOMS / FBU / IR / BASC/TASC / CHOSC
Task / Frequency / Frequency / Frequency / Frequency
Quarterly Cleaning
- Engineering will damp clean light diffusers
Semi-Annual Cleaning
- Change MOR curtains (TASC)
- Refinish floors
All Staff shall report immediately:
- Any safety issue
- Burned out or flickering lights
- Sharps found on floor or hard surfaces
- Frayed cords or wires
- Torn vinyl
- Chipped surfaces
Environmental Services Responsibility Checklist (As Applicable To Location)
EVS: PACU (PREOP & RECOVERY) / FBU / IR / BASC/TASC / CH-OSC
Task / Frequency / Frequency / Frequency / Frequency
Remove trash / NA / NA / Daily / As needed
Remove linen / NA / NA / Daily / As needed
Clean with disinfectant: / NA / NA
- All surfaces under 6 feet
- Cabinets and handles
- Doorknobs
- Spot Clean Walls
- Hopper/Sinks
- Beds/Chairs/Stools/Furniture
- Electrical Cords (ceiling to connection)
- IV poles
- Telephones
- Mop Floor
- Trash containers
- Laundry hampers
- Dispensers
- Ceiling
- Ceiling Vents
- Lights
- Sprinkler Heads
High Dust all Surfaces above 6 feet / NA / Daily / Daily / Daily
Restock all dispensers / NA / Daily / Daily / Daily
Clean/Dry and Store Cleaning Equipment / NA / Daily / Daily / Daily