SARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY TITLE: PERIOPERATIVE AND WOMEN S SERVICES Job Title of Responsible Owner: POLICY #: EFFECTIVE DATE: REVISED DATE: POLICY TYPE: 1 of 17 Director of Perioperative Services 12/17/85 9/17 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE PURPOSE: POLICY STATEMENT: EXCEPTIONS: DEFINITION(S): To establish department policies to control and reduce the risk for the transmission of infection in patients undergoing surgery and other invasive procedures. It is the practice of the Perioperative Services Department and Labor and Delivery Department to prevent infection, and reduce the risk for transmission of infection in patients, healthcare personnel, physicians, and visitors. None Hospital Approved Disinfectant refers to a list of cleaning agents approved by the Infection Control Committee and available to staff for disinfecting patient care areas. Refer to policy 00.IFC.16, Standard Practices for Decontamination, Sterilization, High-Level Disinfection, Storage and Distribution of Patient Care Items Traffic control practices - refer to the controlled movement of people and equipment in perioperative areas. The surgical suites are divided into 3 designated areas (i.e., unrestricted, semi-restricted, and restricted) that are defined by the physical activities performed in each area. Unrestricted area: 1. This area includes a central control point (4 th floor Surgical Center (4SC) control desk, Labor and Delivery Recovery Room, and Cape Surgery control desk established to monitor the entrance of patients, personnel, and materials. 2. Street clothes are permitted in this area, and traffic is not limited. Semi-restricted area: 1. This area includes the peripheral support areas of the surgical suite and storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite. 2. Traffic in this area is limited to authorized personnel and patients.
2 of 17 3. Personnel are required to wear surgical attire and hair covering. Restricted areas: 1. This area includes the main OR control desk, operating and procedure rooms and sterile cores. 2. Surgical attire and hair coverings are required. 3. Masks are required when open sterile supplies and equipment or scrubbed persons are present. Beards must be covered completely when mask is required. PROCEDURE: 1. Traffic Control Practices: a. The surgical suite has been designed to facilitate movement of patients and personnel into, through, and out of the defined areas. b. Signs are posted that clearly indicate the appropriate environmental controls and surgical attire required. c. Environmental controls and scrub attire increase as progression is made from unrestricted to restricted areas. d. Movement of personnel from unrestricted areas to either semi-restricted or restricted areas can be made through locker rooms where they can change into scrub attire prior to entry. e. Patients entering the surgical suite will wear clean gowns, be covered with clean linens, and have their hair covered. f. Movement of personnel in and out of operating rooms will be kept to a minimum while surgery is in progress. g. Careful assessment and planning of patient care by surgical team members reduces excess movement or activity during procedures. h. Doors to operating rooms and sterile cores should be closed except during movement of patients, personnel, supplies, and equipment. i. Talking and the number of people present should be limited to minimum required during procedures. j. The flow of clean and sterile supplies and equipment will be separated from contaminated supplies, equipment, and waste, by space, time, and traffic patterns. k. Sterile supplies and instruments prepared for surgical procedures outside the surgical suite will be transported to the sterile supply cores or operating rooms in closed or covered carts to protect them from contamination, physical damage, and loss during transportation. l. Supplies and equipment will be removed from external shipping containers and corrugated cardboard in
3 of 17 unrestricted supply areas before transfer into restricted areas of the OR. m. The flow of supplies will be from sterile core to operating room to peripheral corridor. Soiled supplies, instruments, and equipment will not re-enter the sterile core. n. At the end of the surgical procedure, the case cart will be closed or covered with a plastic cover and biohazard label attached prior to transport to Sterile Processing. o. Trash and soiled linen will be bagged in the operating room at the end of each case and placed in a cart for transport to the trash & soiled linen room. p. The decontamination room, soiled linen and trash room are separate from personnel and patient traffic areas. To decrease the risk of infection, soiled materials will be transported separated by space and time from movement of clean and sterile supplies and equipment 2. Personnel Practices: 1) In the event that an employee has an accidental direct exposure to blood or body fluids of any patient, employee should first wash wound and exposed site with soap and water. Flush exposed mucous membranes with water and then, he/she will be advised to report the exposure to the Clinical Lead (CL) Clinical Manager (CM) or desk charge RN, and complete the Employee/Volunteer Injury Report Form. The employee will then be referred to Employee Health Services (EHS) or ECC (when EHS is closed) for follow-up. 2) Personnel will follow SMHCS Policy 00.IFC.08 Employee Health Services (EHS) Plan; Personnel who have an active infection will be referred to EHS or ECC and may be restricted in patient contact. 3) Food and/or beverages will be stored only in designated food refrigerators and are not permitted in the semi-restricted or restricted areas. 4) Personal protective equipment (PPE) will be worn whenever there is significant risk of occupational exposure to blood, body fluids, tissues, secretions and excretions (except sweat) and non-intact skin. 5) PPE will be stocked and readily available in the immediate work areas. 6) The Infection Control Department will notify Perioperative Services when a patient admitted to Perioperative Services is later diagnosed as having a communicable disease and recommend appropriate follow-up for the exposed staff with
4 of 17 EHS. 7) Scrub Attire: Personnel will wear scrub attire as outlined in SMHCS Policy 00.IFC.06 Scrub Attire for Operative and Other Invasive Procedures. 8) Hospital personnel and visitors coming into the area will wear appropriate surgical scrub, or cover street clothes with appropriate attire in the OR. in compliance with Perioperative department policy 9) OSHA approved protective eyewear will be worn by scrubbed personnel during operative and other invasive procedures. People not at the sterile field should wear eye protection when any risk of exposure exists (i.e., when changing out used suction canisters). 3. Hand Hygiene and Glove Use: Hand hygiene is defined as: cleansing of hands using either soap and water or antiseptic hand rub. Perioperative personnel will follow SMHCS Policy 00.IFC.67 for hand hygiene. Fingernails: must be kept ¼ inch or less for patient safety No artificial nails or coverings allowed. Artificial fingernails are defined as any material applied to the nail for the purposes of strengthening or lengthening nails, including but not limited to: Wraps Acrylics Tips Tapes Gel overlays (includes gel polish) Any appliqués other than those made of nail polish Nail-piercing jewelry of any kind Surgical hand scrub is defined as: The process of removing as many microorganisms as possible from the hands and forearms by mechanical washing and chemical antisepsis before participating in a surgical procedure. A surgical hand scrub will be performed by scrubbed personnel prior to a surgical procedure according to standard department procedure # IFC.08. a. Gloves will be worn before touching wounds, blood or other body fluids to which standard precautions apply, or articles contaminated by such fluids, per SMHCS Policy 00.IFC.34, Standard Precautions. Gloves will be worn for cleaning contaminated trays and instruments.
5 of 17 4. Patient Practices: a. Any patient who is known or suspected of having a communicable disease will be managed by the SMHCS Policy 00.IFC.22 Isolation of Patients using Contact, Droplet, and or Airborne Precautions. b. For patients with known or suspected active Tuberculosis (TB), patients will be managed as outlined in SMHCS Policy 00.IFC.46: Tuberculosis Exposure Control Plan c. Operative and other invasive procedures will be performed using sterile supplies and instruments and aseptic technique as outlined in SMHCS Policy 01.IFC.12 Basic Aseptic Technique and SMHCS Policies #00.IFC.16 Standard Practices For Decontamination, Sterilization, High-Level Disinfection, Storage, and Distribution Of Patient Care Items. d. Doors will be kept closed. e. Organic material on the floor will be wiped up as soon as possible with an approved germicidal wipe or solution and cloth using a gloved hand. f. Supplies will remain in the room until the procedure is completed. g. Kick buckets will have waterproof clear plastic liners. Used sponges will be discarded into the plastic lined kick buckets. At the end of case during cleaning, the sponge bags will be disposed of in a red biohazard trash bag. h. Instruments used during the procedure will be returned to their original instrument trays (exception: all ortho loaner instruments will be returned to their original pans). All instruments will be placed on the case cart, and delivered to Sterile Processing Decontamination Room per department procedure OR.02 Surgical Management Instrument Protocol, Set-up to End of Case. The soiled instruments and case cart must be covered/closed and labeled with a biohazard sticker prior to transport through corridors 5. Contact Isolation Patients: a. The chart is not in isolation. Handle with clean or gloved hands. During transport place chart in plastic bag or under mattress. b. A green bonnet is on the patient s head to alert contact precautions. Ensure the green bonnet is on when transporting (from pre-op to OR and from OR to PACU/nursing unit). c. Disposable blood pressure cuffs should be applied in pre-op and then follow the patient to the OR and then to PACU/nursing unit. d. Before transporting patient, wipe areas of contamination
6 of 17 on stretcher with disinfectant wipes. Perform hand hygiene. Transport patient. e. Gowns and gloves should only be worn in the hallway if the patient requires hands-on care (such as a ventilated patient). In this case, one staff member will be designated as the clean transporter for touching elevator buttons, carrying chart etc. f. Gloves should be used whenever there is contact with the patient and removed before contact with equipment, chart etc. g. Gowns are required if there is direct contact with the patient or bed. Gowns are not to be worn throughout the procedure. Once removed they are to be discarded (single-use item) and not to be saved for later use. h. After the patient is transferred to the OR /procedural table, remove all linens from the stretcher/bed while in the suite and place into the linen hamper. i. The stretcher/bed will be removed from the suite into the hallway. If the stretcher/bed will be unattended, place a green contact isolation card (found in isolation caddy) on the stretcher/bed to alert staff of contact isolation stretcher/bed. j. Wipe down the entire stretcher/bed with a hospital approved disinfectant and apply fresh linens. 6. Biohazardous Waste: a. All surgical waste will be treated as infectious waste and will be placed into red biohazard waste bags/containers, per SMHCS Policy 00.IFC.12, Biomedical Waste and Sharps. b. Bulk blood, suctioned fluids, excretions and secretions may be carefully poured down a flushing hopper or a drain connected to a sanitary sewer, while wearing PPE (i.e., mask, protective eyewear, gown and gloves). c. Neptune suction devices will be used whenever possible to decrease employee exposure to body fluids. d. Surgical waste and soiled linens will be transported to the trash and soiled linen collection room and placed in designated bins (roll-on trailers): 1) RED biohazardous waste; 2) GRAY - cardboard boxes (broken down only); 3) Yellow - soiled linen; 4) Rigid containers lined with red bags, biohazard hard plastic items, and suction canisters. 5) Solidifier bag must be placed in biohazard boxes containing fluid. 6) Environmental technicians will remove and transport waste to the designated loading dock. 7) Linen Services personnel will remove and transport soiled linen to designated loading dock.
7 of 17 8) All bags and containers must be appropriately sealed before transporting. e. Urine and Feces: 1) Disposable bedpans and urinals will be used. 2) Urine and feces will be flushed down the toilet or hopper. 7. Air Quality: a. Discharge and return grills are cleaned daily by environmental personnel and vacuumed quarterly by OPL. b. Laminar flow equipment is re-certified on an annual basis. c. Humidity is continuously monitored. Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, instrument processing areas, and sterilization areas and should be maintained below 60% in sterile storage areas. d. Room temperature for the OR should be maintained between 68-73 degrees F (20-23 degrees C) and clean/sterile storage areas should be maintained at 75 degrees F or less. e. OPL will monitor humidity and temperatures for Perioperative Services and Women s Services Satellite OR per SMH Policy 01.FAC.06, Ventilation Control For The Protective Environment. 8. Storage of Blood and Blood Products: a. Blood issued to Surgery will be transported in insulated coolers designed to maintain the units between 1 and 6 degrees C. Once the insulated cooler arrives in Surgery, the units will be signed in and transferred to a monitored Blood Bank refrigerator which maintains a temperature between 1 and 6 degrees C. The temperature will be monitored and recorded daily by the Suncoast Communities Blood Bank. b. Transfer of blood units from Surgery refrigerators to Intensive Care: Surgery personnel will sign out blood and blood products removed from the Surgery blood refrigerator. The nurse transporting the patient from Surgery will report during hand-off communication in the Intensive Care how many blood products have been transported and receiving RN is responsible for the transfusion or disposition of all blood and blood products. Unused blood will be returned to the Blood Bank each evening. 9. Equipment: a. Equipment and furniture that has been used in close
8 of 17 proximity to the patient will be cleaned with hospital approved disinfectant using gloved hands to remove organic matter. b. If equipment needs to be serviced that has been contaminated, it will be decontaminated and labeled appropriately prior to servicing. c. Equipment from areas outside the OR should be damp dusted with a clean, lint-free cloth moistened with a hospital approved disinfectant before being brought into the OR, and when returned back to storage location outside of the OR suite (OR equipment will also have blue tape applied after cleaning). 10. Needles and other Sharps: a. Precautions will be taken to prevent injuries caused by needles, scalpels and other sharp instruments or devices during procedures, when cleaning used instruments, during disposal of used needles and when handling sharp instruments. b. Focus attention on the intent of the action when working with sharp items, and minimize rushing and distractions while applying safety techniques during critical moments. c. Use needleless systems or sharps with engineered sharp injury protection devices whenever possible. d. Double gloving is encouraged and gloves should be monitored for punctures. e. Two sharps containers will be conveniently located for disposal of sharps in every OR one for use by the anesthesia care provider and one for use by the scrub person and/or circulator. 1) Inspect the sharps container to ensure fill line is not exceeded before discarding disposable sharps in it. 2) Make sure the sharp container is large enough to accommodate the entire device. 3) Avoid bringing hands close to the opening of a sharps container. f. The user of the sharp is responsible for the sharp including disposal according to safety protocols. g. Only one scrub personnel at a time should handle sharps at the field. If there are two scrubs present (such as when a student technologist is assigned), they will determine at the beginning of the case, which one is responsible for sharps. h. Give verbal notification when passing a sharp device i. Establish and implement a Sharps SAFE ZONE : 1) Before the first incision or injection is made, a SAFE ZONE should be selected and designated by the surgeon in consultation with the scrub
9 of 17 person (This can be a tray, basin, instrument mat, or designated area of the sterile field). 2) Surgical team members should use a safe zone or hands-free technique for passing sharp instruments, blades, and needles whenever possible and practical. 3) Only one sharp item is to occupy the SAFE ZONE at any time. 4) After using the sharp, the surgeon should place the sharp in the designated SAFE ZONE and make a statement to indicate sharp is down (e.g., sharp down, safe zone etc.). The scrub person will take the sharp only after the motion of the surgeon has stopped. 5) When placing a sharp for the surgeon in the SAFE ZONE, the scrub person should orient the sharp so the surgeon may pick it up with the dominant hand without the need for turning or repositioning. 6) The scrub personnel should ensure that suture needles are mounted and positioned optimally to avoid the need for the surgeon to reposition them in the needle holder. (Note: the preference card should indicate if the surgeon is left-handed). 7) After use, the surgeon should protect the point of the needle by clamping over the tip with the needle holder. j. Minimally Invasive Surgery: 1) Pass trocars, needles, and other short sharps through the SAFE ZONE. 2) Pass long laparoscopic instruments that don t fit in the SAFE ZONE, such as needle-tip cautery and sharp-pointed scissors, handle first and tip down. 3) Place long-pointed cautery needles, hollow-bore needles or other long sharps into the cannula port using two hands preferably one person s hands and then angle the handle toward the surgeon s waiting hand. 4) Use shielded rather than exposed trocars and shielded needle systems wherever possible. k. Wound closure safety: 1) Scrub personnel will use appropriate size and type of retractor when retracting for wound closure, keeping hands protected from suture needles. 2) Avoid movement and close proximity of hands to incision during cutting and suturing activities as much as possible. l. Scalpel/knife blades: 1) Remove scalpel blades from handles by use of
10 of 17 special blade removal devices or durable surgical instruments, such as a needle holder never with the fingers. m. Hypodermic Needles: 1) Recapping of hypodermic needles should be totally avoided by direct disposal of the needle into a puncture-resistant container or secured in red needle cap lock. 2) If a hypodermic needle is needed for incremental injections during the procedure, a new needle must be used each time, unless a safety syringe with safety shield is used. If a safety syringe is used, the barrel will be advanced to protect the hypodermic needle when passed to and from the surgeon, at the end of the case the barrel of the syringe will be locked before disposing into sharps container. n. After use, all sharps will be accounted for and properly disposed of in red sharps containers at the end of the case, per SMH Policy 01.PAT.19 Prevention of Retained Surgical Items: Soft Goods, Sharps and Instrument Counts. o.. 11. Blood Pressure Cuffs and Stethoscopes: a. If contaminated with blood or body fluids, the blood pressure cuff will be sent to Clinical Processing for washing, drying and disinfection. The stethoscope will be cleaned with an approved hospital disinfectant. 12. Laboratory Specimens: a. Specimens will be handled as outlined in SMH Policy 01.PAT.24 Specimen Preparation and Handling for Operative and Other Invasive Procedures. 13. Utilization of Pneumatic Tube System for Transporting Blood Units and Specimens: a. All tube stations will be designated as potential Biohazard areas if used for transporting blood units and/or specimens. b. The specimen or unit of blood must be containerized to prevent leaking or puncturing of the primary container. c. Specimens or units of blood must be placed into a padded insert (blister pack bag) which is labeled Biohazard to prevent breakage and leakage during transport. d. Employees who handle carriers must be trained to regard as contaminated any carrier which contains a blister pack bag labeled Biohazard. Employees who open Biohazard carriers must wear gloves when
11 of 17 removing specimens from the carriers, as leakage may have occurred. e. Wearing gloves and other protective apparel as appropriate, contaminated carriers and other contaminated surfaces will be cleaned immediately by first rinsing off organic matter, then cleaning with a fresh solution of 1:10 bleach. The contaminated blister pack bag must be disposed of into a red bag. f. If there is a possibility that contamination of the tube system may have occurred, the Facilities Department must be contacted immediately to evaluate and, if necessary, decontaminate the system. See Policy 01.IFC.10, Infection Control of the Pneumatic Tube System. 14. Transporting case carts from 2 nd floor OR s to Sterile Processing if elevators are out of service: a. Clean Elevator non-operational utilize the H Elevators and cover any open case cart with either a clean sheet or a clear bag. Closed Case Carts travel uncovered. b. Dirty Elevator non-operational utilize the H Elevator; however, prior to using the H elevator ensure that Housekeeping is already in place on the sixth floor to place the elevator on emergency stop and disinfect the elevator prior to putting it back into service. The dirty carts must be accompanied by a staff member due to the bio-hazardous nature of the Case Carts. c. Do not to use the Clean elevator that serves the OR and SPD to transport soiled case carts at any time due to the following reasons: 1.) If there is an emergent need to get items to the OR quickly there is no guarantee the H elevator will arrive quickly enough. 2.) The Clean Lift would have to be cleaned and disinfected, and a large portion of the SP Dispatch Area would need to be disinfected due to the unloading of the biohazardous case carts 15. Contaminated Patient Record: a. If a portion of the patient s medical record appears to be contaminated do not handle it with bare hands. b. Don gloves for the management of the item. c. In a two-person process have one person designated as the clean person, who will, while wearing gloves, hold open a plastic sleeve to contain the item. d. The second person, who will also be wearing gloves, will place the piece of paper into the plastic sleeve. e. If there is any risk that the outer sleeve became
12 of 17 contaminated in the process, wipe it down with a disinfectant wipe. f. Remove gloves. g. Perform Hand hygiene. h. Make a copy of the original through the plastic sleevestamp COPY on it. i. Discard the original as biomedical waste. j. Documentation/Reporting Each occurrence is to be documented with an occurrence report for Risk Management. Contact with a contaminated piece of the patient s record without personal protective equipment may potentially be an occupational exposure. The employee will need to report to Employee Health to make this determination. k. Lab requisitions that appear to be soiled will not be accepted. 16. Visitors: a. Visitors will be instructed by the nursing staff of the appropriate precautions required. b. Visitor lockers will be cleaned daily 17. Transporting known infectious or colonized patients: a. Personnel in the area to which the patient is to be taken will be notified of the patient s impending arrival and precautions to prevent transmission of infection. b. Where appropriate, patients will be informed as to how they can assist in maintaining a barrier against transmission of their infection to others. c. Patients on Contact Precautions will have a green bonnet placed on their head to visibly indicate their status. 18. Patient Clothing: a. Patient clothing that is soiled with blood or body fluids will be sealed in an impervious plastic bag and given to family member, if available, or will accompany patient when transferred to another area. b. When appropriate, families will be instructed to wash clothing in detergent, and if possible, hot water and bleach or Lysol. 19. Books, Magazines and Toys, etc.: a. Articles visibly soiled with blood and body fluids will be disinfected or destroyed. Special items may be decontaminated in Sterile Processing with prior approval. 20. Routine Cleaning:
13 of 17 a. The following areas will be cleaned at least daily by OR environmental personnel as outlined in SMHCS Policy 00.IFC.62 Infection Control for Environmental Services. 1) Patient Care and Support Areas (including but not limited to the Laboratory, Satellite Pharmacy, Radiology light and dark rooms, and Sterile Cores, etc.). 2) Common Areas (to include Restrooms, Corridors, Alcoves, Storage Rooms, Elevators, Lobbies, Entrances and Stairwells, etc.). 3) Non-Patient Areas (to include but not limited to Offices, Employee Lounges and Restrooms, Pantries, Utility & House- keeping Rooms, and Nurses Stations/ Control Desks, etc.). b. Surgery: 1) Routine between-case and end-of-case cleaning will be done by department personnel in operating rooms/procedure rooms according to Perioperative department procedure #IFC.01 Between Case / End of Case Cleaning Protocol. 2) Anesthesia equipment will be disinfected as outlined in Perioperative department policy 139.1205 Infection Control for Anesthesia. 3) Only hospital approved disinfectants will be used for cleaning all inanimate surfaces. Correct dilution of disinfectant is prepared in designated containers daily, labeled and dated. 4) Clean mopheads and cleaning cloths will be used for cleaning after each procedure and laundered following use (or disposable products, if used, will be disposed of with Biohazard waste). 5) The scrub sinks are to be considered clean areas, and should not be used to clean soiled or contaminated items. 6) During the Procedure: a) Areas contaminated by organic debris (i.e., blood or body fluids) will be disinfected as soon as possible. b) Sponges will be discarded into plastic-lined kick-buckets, and then placed in plastic sponge bags/counters for counting. 7) Between the Procedures: a) Circulating personnel will disconnect and/or move equipment out of the way of cleaning as appropriate (i.e., suction, cautery, microscope, laser, air powered equipment, etc.) b) Scrub personnel will collect and roll up disposable drapes to confine and contain
14 of 17 the contamination and place in a red plastic biohazard bag. Dispose of soiled linens similarly in yellow linen hamper. c) Cleaning of equipment, trash removal or mopping of floor should not be started until the patient has left the room. d) Remaining trash, including anesthesia circuit and bags, kick bucket liners, trash bag from anesthesia cart, and disposable tubing, will be collected, red-bagged or boxed per medical waste protocols, and removed from the room to the trash collection room. Suction canisters containing evidence of any blood will be placed in a small bag and removed to the trash room and placed in rigid container lined with red biohazard bag. e) The operating room table (to include base), prep stand, neuro stand, mayo stand, arm boards, IV poles, kick bucket, OH TEE machines, OH booms, transfer roller or slider, and any other equipment, cables, etc., that have come in contact with the patient and/or sterile field, will be disinfected. f) Spot cleaning will be done for any area which has become contaminated with blood or body fluids, such as walls, cabinets, ESU units. Other equipment used during the procedure will be disinfected as appropriate. g) The floors will be sprinkled with disinfectant (3 feet perimeter around the OR table, and including any visible contamination which has occurred beyond 3 feet), and mopped using a clean mop head. The OR table should be moved and floor mopped underneath to ensure there are no sponges, sharps or needles that could compromise future counts. h) All hamper, waste, and kickbucket liners, suction canisters and tubing, anesthesia breathing circuits, and linens on OR table will be replaced. i) In the GU Rooms, in addition to above, hoses and buckets used for drainage will be cleaned, and the uro-drain will be disinfected according to Perioperative department procedure URO.02. j) Overhead operating lights and all horizontal surfaces will be wiped with a damp cloth
15 of 17 daily before the schedule starts, and after each procedure. c. Pre-operative Care Units 1) Pre-op beds will be cleaned after each patient use with a hospital-approved disinfectant. 2) All counter tops, sinks, and floors will be cleaned daily with a hospital-approved disinfectant. 3) Trash containers will be emptied at least daily. 4) Cubicle curtains will be checked for spots and cleaned or removed for laundering as needed. Curtains will be replaced if the patient has C- diff. Curtains will be sprayed with hydrogen peroxide post MDRO patient. 5) Walls will be cleaned monthly and as needed. 21. Terminal (End of Day) Cleaning: a. Terminal cleaning will be done throughout the department by environmental personnel according to Perioperative department procedure IFC.04 Terminal Cleaning Operating Room and SMHCS Policy 00.IFC.62 Infection Control for Environmental Services. b. Only a hospital approved disinfectant will be used for the terminal cleaning of OR s. c. Terminal cleaning in the OR will be done daily including but not limited to: 1) All furniture and equipment, including wheels and/or castors. 2) Spotlights and tracks. 3) All wall and ceiling mounted equipment and hoses. 4) Kick buckets will be cleaned and relined with appropriate liners. 5) All sinks and faucets. 6) Windows, counters, and outside of autoclaves in all sub-sterile rooms and sterile cores. 7) Soap dispensers, foot pumps, and matting. 8) All doors of cabinets and operating rooms, paying particular attention to push plates and handles. 9) Air conditioning grates and vents openings. 10) Walls will be spot washed daily and completely washed during terminal cleaning. 11) TRU-D robotic decontamination on a rotating basis RESPONSIBILITY: It is the responsibility of the department Directors to ensure that all personnel adhere to Infection Control policies and procedures. REFERENCE (S): Guidelines for Perioperative Practices, AORN, 2017. SMHCS Corporate Policy:
16 of 17 00.IFC.12 Biomedical Waste and Sharps (Handling and Disposal of) 00.IFC.08 Employee Health Services (EHS) Plan 00.IFC.34 Standard Precautions 01.FAC.06 Ventilation Control For The Protective Environment Center for Disease Control and Prevention (CDC), Hospital Infections Program, Guideline for Prevention of Surgical Site Infection, 1999. Accessed from http://www.cdc.gov/hicpac/ssi/001_ssi.html National Institute for Occupational Safety and Health (NIOSH). Preventing Needlestick Injuries in Health Care Settings accessed from : http://www.cdc.gov/niosh/docs/2000-108/ Association For The Advancement of Medical Instrumentation (AAMI) Current Edition REVIEWING AUTHOR (S): ATTACHMENT(S): Debbie Dietz, MSN, RN, NPD Specialist, Women s Services Risa Benoit, DNP, CNS-BC,CNOR, NPD Specialist, Perioperative Services Sherry Wolabaugh, Manager, Infection Prevention None
17 of 17 APPROVALS: Signatures indicate approval of the new or reviewed/revised Department Date Policy Committee/Sections (if applicable): Infection Prevention & Control Committee 9/6/17 Clinical Practice Council 9/7/17 Signature: 9/12/17 Title: Director of Perioperative Services Signature: Title: Signature: Title:, Signature: Title: Pam Beitlich, Director of Women and Children s Services Vice President/Administrative Director (if applicable): 9/12/17 9/14/17 Signature: Title: Connie Andersen, Vice President and Chief Nursing Officer