Surgical room turnover is a quick, complicated dance that takes place between surgical procedures and is intended to ensure that everything is ready for the next patient.  At a high level, the goals for this process are to ensure that the room is disinfected, that all instruments and equipment needed are in the room and ready to go, and that the patient and staff are prepared for the procedure.  There are constant time and cost pressures on this critical, but often under-appreciated step.  The between-case cleaning portion of surgical room turnover is often considered less important than the more directly patient focused activities by clinicians; however, if done properly, it can provide great value to hospitals. In truth, there are important clinical, operational and financial benefits to be realized if the room is cleaned and disinfected effectively and efficiently between cases.

Clinical Benefits of Effective Between-Case Cleaning and Disinfection

Healthcare-associated infections (HAIs) affect 2%–5% of all surgical patients, and result in substantial morbidity, poor surgical outcomes, and total healthcare costs.¹ In the U.S. alone, it has been estimated that more than 500,000 surgical site infections (SSIs) occur annually, with a direct cost of as much as $10 billion.³ In addition, a surgical site infection increases the length of stay by 4.9 days, which can have a significant impact on both patient outcomes as well as hospital costs.¹

 

The environment has long been considered a vector for the transmission of HAIs.  In 2015, the Agency for Healthcare Research and Quality (AHRQ) published a technical bulletin entitled Environmental Cleaning for the Prevention of Healthcare-associated Infections.  The first sentence of this document states what many of us have long known, “The cleaning of hard surfaces in hospital rooms is essential for reducing the risk of healthcare-associated infections.”³. 

 

To reduce the risk of surgical site infections, operating rooms have practiced strict aseptic technique at least since 1865, when Lister discovered the benefits of antiseptics to sterilize instruments and clean wounds in surgery.  Additional measures to ensure asepsis include surgical scrub, patient skin antisepsis, maintenance of the sterile field and specialized air handling. 

 

Cleaning practices in the OR are increasingly in focus as perhaps the last frontier OR practices to prevent SSIs.  In 2017, Yezli published a review article summarizing the published studies supporting the role of the environment on the transmission of healthcare-associated pathogens via the hands of healthcare workers in the OR.  He concluded that, “It is clear that the inanimate environment of the OR, including medical equipment, can become contaminated with pathogens that cause SSIs despite infection control measures such as standard environmental cleaning.”⁴ The key phrase here is “standard environmental cleaning” because in a multicenter study published by Jefferson, et al in 2011, they too found that only 25% of high-touch objects in the OR were cleaned when standard cleaning methods were used.⁵  What does this suggest?  That standardized cleaning alone isn’t enough.  In 2012, Munoz-Price showed that a combination of training, monitoring and feedback on the thoroughness of cleaning of high-touch objects in the OR was successful in decreasing the presence of gram negative bacilli in the environment.⁶  So while standard cleaning practices alone may not help reduce the risk of surgical site infections, standardized processes combined with thorough cleaning and disinfection, training, monitoring and feedback on cleaning best practices can in fact help reduce the contamination in the environment, thereby reducing the risk of infection and contributing to positive patient outcomes.

Operational Benefits of Efficient Between-Case Cleaning and Disinfection

While thorough cleaning and disinfection is critical to support patient outcomes, it is equally important that the work be accomplished efficiently so that procedures can start on-time.  Operating rooms often feel a lot of pressure for quick turnover times to help increase the surgical volume in the department (often a source of revenue for the hospital). Many hospitals have a goal of 20-30 minutes total to turn a room over from wheels out to wheels in. A lot has to happen in that short period of time, including: removing the case cart, bagging trash and linen, cleaning and setting up anesthesia equipment, cleaning and disinfecting high-touch objects, mopping the floor, making the bed, opening for the next case, interviewing the patient, preparing medications for the next case, and counting and prepping.

As important as it is, the cleaning and disinfecting portion of room turnover is only one small part of the activity that must take place during that time frame.  As a result, it must be done as efficiently as possible.  There are several factors that can hinder efficiency during room turnovers including poorly defined roles and responsibilities, inadequate training, lack of a monitoring and feedback process, poor workflow, and ineffective cleaning tools. 

Roles and responsibilities for cleaning the operating room varies from hospital to hospital. To better understand who actually cleans the operating room, Ecolab surveyed 250 hospital operating room directors across the country. The results showed that 62 percent of between-case cleaning is completed by operating clinical room staff, 19 percent are completed by a combination of operating room clinical staff and environmental services staff, and 19 percent are cleaned by environmental services staff alone.⁷  And while they may be experts at aseptic technique and the importance of preventing cross-contamination, most operating room clinical staff  would probably tell you that they have had minimal training on OR-specific cleaning and disinfection practices. 

Of course, workflow is very important for efficiency as well.  It may seem like having more people helping in room turnover would improve efficiency, but as part of a lean six sigma project, one study found that efficiency and effectiveness actually decrease when more than two people are involved in cleaning an OR between cases.⁸ In addition to the number of people cleaning, the way in which the room is cleaned can also lead to inefficiency.  A clearly defined and communicated workflow or cleaning process is key to ensuring that cleaning is done both thoroughly and quickly.

OR staff are used to working with many complex medical devices in the operating room, and yet we often use the same tired tools to clean and disinfect a room between cases that we’ve used for decades: dusty whisk brooms, open mop buckets, string mops, and cotton linens.  Whisk brooms are not to be used in operating rooms because they can aerosolize dust and debris and are impossible to disinfect.  The disinfectant used in open mop buckets must be changed out regularly, but often isn’t which can cause splashes and spills.  String mops have been shown to be less effective at picking up soil and debris than microfiber mops, and cotton linens sometimes appear with stains, hair or other quality issues.  In fact, in a survey of 50 nurses across the United States, it was reported that anywhere from 1 (33%) to 10 (7%) sheets per day were found to be unusable due to stains, slowing turnover efficiency as they had to take time to replace the linen. In the same study, just 24% of nurses responded that they never had stained linen that could not be used, suggesting this is a widespread issue.⁹

Change is hard, and clearly there are many things that can prevent hospitals from achieving the OR turnover efficiency that they desire.  As we work to implement new processes, training and tools, we have to find a way to measure our success and keep people engaged in the right behaviors.  Multiple studies have shown that one of the most effective ways to drive improvement in thoroughness of cleaning is to perform process monitoring and provide performance feedback.¹⁰ This is not a new idea.  In 2010, The Centers for Disease Control published a toolkit “Options for Evaluating Environmental Cleaning” that outlines how to develop programs to optimize the thoroughness of high-touch surface cleaning.¹¹ In this toolkit, they describe the methods currently available to monitor environmental hygiene and recommend that all hospitals develop a program to monitor environmental hygiene.  In general, they recommend the following:

• Focus on identifying and cleaning high-touch objects (HTOs)
• Use an objective method to monitor the thoroughness of disinfection cleaning of HTOs
• Provide continuous feedback that drives continuous improvement
• Develop reports documenting progress to share with staff, leadership and surveyors

 

Financial Benefits of Effective and Efficient Between-Case Cleaning and Disinfection

Last but certainly not least, there is a financial incentive to perform effective and efficient cleaning and disinfection between patients.  As mentioned above, the cost of healthcare-associated infections in the United States is as high as $10 billion per year in the United States.  To make that number more meaningful in the perioperative setting, 17% of patients will develop a surgical site infection each year¹ and the average cost of a surgical site infection is $34,000.²  If you perform 15,000 surgical procedures per year, and 2.5% of patients acquire a surgical site infection, the cost is an astounding $12.5 M, and that excludes the added cost of outpatient follow up treatment of the infection or its sequelae.

In addition, cost studies have shown that the average cost of operating room time ranges from $22 to $133 per minute depending on the methods used to calculate it.¹³  For healthcare facilities, time is money — and that is especially true in the operating room. 

 

A Programmatic Approach is Needed

It isn’t enough to introduce a new product or tool alone and expect it to have an impact on the effectiveness and efficiency of between-case cleaning.  Optimizing between-case cleaning requires a multi-pronged approach.   A multi-center, randomized trial done in 11 acute care hospitals demonstrated that a programmatic approach improves cleaning and may reduce healthcare associated infections.¹⁴ Their programmatic approach introduced a cleaning bundle for routine cleaning, focusing on:

• Optimizing product use
• Technique
• Staff training
• Auditing with feedback
• Communication

In a study evaluating the use of an operating room environmental hygiene program to improve thoroughness of cleaning and reduce between-case turnover time, they demonstrated that they could improve clinical, operational and financial metrics.¹⁵ See Table below.

Setting: 576-bed hospital | 27 ORs | 23,000 surgeries per year

Benefits	Hospital Challenges	Solutions	Metric
Clinical	High-touch objects cleaned just 20% of time for between-case cleaning	Standardize the cleaning process across OR teams to address cleaning thoroughness and efficiency concerns	High-touch object cleaning improved 66%
Operational	Poor communication, low job morale and high staff turnover among OR aides No method for determining thoroughness of cleaning	Environmental monitoring tools for real-time and direct environmental hygiene monitoring and thoroughness of cleaning reporting Surgical room turnover kits with disposable linens, microfiber cloths and mops to increase room turnover efficiency and cleaning effectiveness Point-of-use cleaning carts and tools to streamline the cleaning process and ensure compliance with best practices	Staff retention increased to 86% - 100% and absenteeism decreased OR turnover time decreased by an average of 21 minutes
Financial	Between-case process and turnover times inconsistent and high cost	On-site best practices training on between-case and terminal cleaning for all staff	Achieved $800 cost savings per room Facility potential savings per 1,000 procedures of $800,000 + 167 hours

Part of any continuous improvement process includes collecting and sharing data on metrics for success.  In the case of improving between-case cleaning and disinfection, these metrics are turnover time and thoroughness of cleaning.  Environmental monitoring programs that provide customizable, easy-to-read dashboards are helpful because they collate data points in one place, providing visibility to all stakeholders whenever they need it.  However, not all dashboards are created equally so it’s important to find one that meets your specific needs.  For OR between-case cleaning, it can be especially helpful to be able to measure compliance and pinpoint precisely where corrective action is needed, down to a department, team or individual level. These actionable insights allow department managers, clinicians, EVS staff and other authorized users to lead process improvements where and when they are needed most to standardize workflows and keep patients safe.

To summarize, successful surgical procedures are the highest priority in the surgical services department, but taking a closer look at OR between-case cleaning can provide hospitals with additional value.  There are clinical, operational and financial benefits to improving the efficacy and efficiency of between-case cleaning and disinfection that your hospital can begin to realize today.   

Here are 6 ways to improve your OR between-case cleaning:

1. Define roles and responsibilities clearly
2. Have efficient and effective between-case cleaning and disinfection supplies available
3. Train on best practices for cleaning and disinfecting an operating room
4. Objectively monitor the thoroughness of cleaning
5. Have access to actionable data on thoroughness of cleaning and room turnover time
6. Share data with staff to drive continuous improvement
 
Linda Homan, RN, BSN, CIC, is senior manager of clinical affairs for Ecolab Healthcare.

This article originally appeared in the March 2020 issue of Healthcare Hygiene magazine.

 

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References:
1. Umscheid CA, Mitchell MD, Doshi JA et al. Estimating the proportion of healthcare -associated infections that are reasonable preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101–114.
2. Shepard J, Ward, W, Milstone Aaron, Carlson T et al. Financial Impact of Surgical Site Infections on Hospitals The Hospital Management Perspective.JAMA Surg. 2013;148(10):907-914.
3. Thompson KM, Oldenburg WA, Deschamps C et al. Chasing zero: The drive to eliminate surgical site infections.  Ann Surg 2011:254:430-436.
4. Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Environmental Cleaning for the Prevention of Healthcare-Associated Infections. Technical Brief No. 22 (Prepared by the ECRI Institute – Penn Medicine Evidence-based Practice Center under Contract No. 290-2012-00011-I.) AHRQ Publication No. 15-EHC020-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. www.effectivehealthcare.ahrq.gov/reports/final/cfm.
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12. Centers for Disease Prevention and Control, Options for Evaluating Environmental Cleaning. https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html
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14. Mitchell BG et al. An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial. Lancet Infect Dis. 2019 Apr;19(4):410-418.
15. Kramer M and Kriznik S. The impact of an OR environmental hygiene program on OR culture and cleanliness. OR Manager Conference; Las Vegas, NV; Oct. 21-23, 2016.