2.4 Surgical Suites (OR), ICU & High-Risk Clinical Area Protocols

Surgical Suites (OR), ICU & High-Risk Clinical Area Protocols

High-risk healthcare environments—including Surgical Suites (Operating Rooms), Intensive Care Units (ICUs), Burn Centers, Hemodialysis Units, and Sterile Compounding Pharmacies—demand rigorous environmental decontamination protocols. Patients in these units possess compromised immune systems, open surgical incisions, or invasive vascular devices, making them exceptionally vulnerable to Surgical Site Infections (SSIs) and bloodstream infections. EVS leadership must align operational procedures with standards from the Association of periOperative Registered Nurses (AORN), the Centers for Disease Control and Prevention (CDC), and the United States Pharmacopeia (USP).

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1. AORN Surgical Suite Cleaning Standards

The surgical environment requires distinct cleaning phases aligned with surgical scheduling. The operating room (OR) is a tightly controlled positive-pressure environment where airborne particulate matter and surface bioburden directly impact surgical asepsis.

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|                        THE THREE PHASES OF OR CLEANING (AORN)                           |
|                                                                                         |
|   [PHASE 1: MORNING DAMP DUSTING (FIRST CLEAN)]                                         |
|   - Conducted 30-60 min prior to the first scheduled surgical case of the day.          |
|   - Damp wipe all horizontal surfaces (surgical lights, booms, anesthesia top, tables) |
|     using a lint-free microfiber cloth moistened with EPA-registered disinfectant.      |
|                                     |                                                   |
|                                     v                                                   |
|   [PHASE 2: BETWEEN-CASE TURNOVER CLEANING]                                             |
|   - Initiated immediately after the patient is wheeled out of the OR.                   |
|   - Center-to-periphery workflow: surgical table, Mayo stands, ring stands, monitors,   |
|     anesthesia carts, kick buckets, and floor perimeter (3-4 ft radius or fluid zone).  |
|                                     |                                                   |
|                                     v                                                   |
|   [PHASE 3: END-OF-DAY TERMINAL CLEANING]                                               |
|   - Executed at the conclusion of the daily surgical schedule across ALL OR suites.     |
|   - 100% wall-to-wall disinfection: ceiling tracks, overhead lights, walls, all mobile   |
|     equipment moved across room, wet-vacuum flood mopping of entire floor substrate.    |
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Detailed Perioperative Operational Protocols:

1. Morning Damp Dusting (First Case Preparation):

• Dust particles settle onto horizontal surfaces overnight due to reduced airflow turbulence.
• Action: Using an EPA-registered hospital disinfectant and a lint-free microfiber cloth, damp wipe all overhead surgical light reflectors, ceiling-mounted equipment booms, anesthesia machine flat surfaces, back tables, and Mayo stands.
• Never dry dust in an OR suite, as dry dusting aerosolizes viable particulate matter into the sterile field airflow.

2. Between-Case Turnover Cleaning:

• Zone of Focus: The immediate sterile field perimeter—a 3 to 4 foot radius around the central operating table.
• Workflow Sequence:
  1. Remove biohazard trash and soiled surgical linen bags; close bags inside the room.
  2. Disinfect the surgical table: remove table pads, wipe all 6 sides of cushions, disinfect table frame, tilt mechanisms, attachments, and strap buckles.
  3. Disinfect surgical lights, anesthesia machine exterior, IV poles, Mayo stands, and electrosurgical unit (ESU) generators.
  4. Spot-mop blood and body fluids on the floor using a dedicated microfiber flat mop or wet-vacuum system; expand mopping radius if fluid traveled.
  5. Dispose of kick-bucket liners and replace with new biohazard bags.

3. End-of-Day Terminal Cleaning:

• Conducted regardless of whether the OR suite was used during the day (unopened rooms accumulate static dust).
• Comprehensive Scope:
  • Clean ceiling-mounted tracks, surgical booms, ventilation diffusers, and wall surfaces from 6 feet down to the baseboards.
  • Disinfect scrub sinks, sub-sterile utility rooms, sterilization corridors, and dirty core holding areas.
  • The Equipment Relocation Rule: Move all mobile equipment (anesthesia machines, back tables, C-arms, laser towers) to one side of the room. Thoroughly disinfect the exposed floor via flood-and-wet-vacuum or two-sided flat microfiber mopping. Relocate equipment back to the clean side and disinfect the remaining floor.

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2. Intensive Care Units (ICUs) & Burn Units

Critical care units house patients with multi-organ failure, invasive endotracheal tubes, central venous lines, and open burn wounds. In these settings, indirect contact transmission via contaminated environmental surfaces is the leading cause of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSIs).

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|                        CRITICAL CARE DEVICE CLUSTER DECONTAMINATION                     |
|                                                                                         |
|   [VENTILATOR & MONITOR HOUSINGS]   ---> Wipe screen, frame, knobs, alarm buttons       |
|   [INFUSION PUMP STACKS]            ---> Disinfect keypads, pole clamps, power cords    |
|   [HEMODIALYSIS / CRRT CONSOLES]    ---> Wipe chassis, fluid catchment tray, wheels     |
|   [DEVICE CABLES & LEAD WIRES]      ---> Full-length linear disinfectant wipe (CRITICAL)|
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[!IMPORTANT] The Overlooked Vector: Medical Cords and Lead Wires: Telemetry wires, pulse oximeter cables, blood pressure cuff hoses, and ventilator tubing frequently rest directly on patient bedding or drag along the floor. EVS personnel must perform a dedicated linear wipe of all cables from device chassis to patient connector during daily and terminal cleans using a fresh quadrant of a disinfectant wipe.

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3. Emergency Department (ED) Trauma Rooms & Hemodialysis Units

ED Trauma Suite Protocols:

• Rapid Biohazard Turnover: Trauma rooms frequently experience massive blood loss, bodily fluid splashing, and rapid patient transitions.
• Biohazard Containment: Treat all blood spills >10 mL with an EPA-registered hospital disinfectant with an OSHA Bloodborne Pathogen kill claim (or 1:10 sodium hypochlorite at ~5,000 ppm available chlorine). Allow full dwell time before mechanical extraction.
• Mobile Equipment Decontamination: Gurneys, defibrillator paddles, trauma carts, ultrasound probes, and lead aprons must be disinfected between every trauma case.

Hemodialysis Station Turnover Protocols:

• Hepatitis B Virus (HBV) is exceptionally hardy and survives on dry environmental surfaces for >7 days.
• Mandatory Station Turnover:
  • Wait until the dialysis patient has departed the station before initiating environmental cleaning.
  • Disinfect the entire dialysis machine exterior, touchscreens, dialysate line connections, prime waste containers, and the motorized dialysis recliner chair (including crevices between cushions and beneath the armrests).

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4. Pharmacy Cleanroom Compounding Standards (USP <797> & USP <800>)

Compounding pharmacies prepare sterile injectables, parenteral nutrition, and hazardous chemotherapy agents. EVS personnel assigned to clean pharmacy cleanrooms must adhere to strict United States Pharmacopeia standards.

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|                         USP <800> FOUR-STEP HAZARDOUS CLEANING CYCLE                    |
|                                                                                         |
|   [STEP 1: DEACTIVATION]                                                                |
|   - Render hazardous drug compounds inert using an EPA-registered oxidizing agent        |
|     (e.g., sodium hypochlorite, hydrogen peroxide) or validated deactivating chemical.   |
|                                     |                                                   |
|                                     v                                                   |
|   [STEP 2: DECONTAMINATION]                                                             |
|   - Physically remove deactivated hazardous chemical residues from surfaces via         |
|     sterile water or alcohol rinsing and non-shedding wipers.                            |
|                                     |                                                   |
|                                     v                                                   |
|   [STEP 3: CLEANING]                                                                    |
|   - Apply neutral surfactant / germicidal detergent to emulsify inorganic soils         |
|     and particulate matter.                                                             |
|                                     |                                                   |
|                                     v                                                   |
|   [STEP 4: DISINFECTION]                                                                |
|   - Apply Sterile 70% Isopropyl Alcohol (sIPA) or sterile sporicidal agent to destroy   |
|     viable microbial bioburden; allow full dwell time.                                  |
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