A clean operating room is a happy operating room

Every surgeon wishes that was true but there is a lot more to happiness in the operating room than cleanliness. However, a dirty operating room could potentially lead to unhappiness and  disastrous consequences. 

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Cleaning the operating room is perhaps one of the most understated aspects of veterinary surgery. Although it may not seem like this should be included as part of the surgical procedure, cleaning is just as critical as any other aspect of the surgery to ensure asepsis and excellent surgical outcomes.  To be sure, there are a variety of factors related to surgical site infections including patient factors, environmental factors, and surgical technique (among others), however minimizing the influence of environmental factors should be the goal of all surgeons. 

Three Phases of Surgical Cleaning

Pre operatively

The axiom an ounce of prevention is worth a pound of cure can be applied to cleanliness as well. It’s much easier to clean an OR that is not severely soiled. Also, it is vitally important to not perform surgical procedures with debris from the surgical preparation. Therefore, ensure that all pre surgical preparation occurs outside of the operating room. This includes clipping nails, manually evacuating the colon, clipping hair, and removal of gross debris with the initial skin preparation and other preparation. Local anesthetic agents should be administered after the preliminary skin preparation but before the final preparation and avoid reusing needles between  if multiple doses are needed from the same bottle. Before entering the surgical suite with the patient ensure that no visible smudges or debris is found on any of monitoring devices or surfaces in the OR. 

Intra-operatively 

Before the surgery begins, and at all times, caps and masks should be utilized.  In order to ensure that caps and mask are being worn before entering the OR but,  they must be stored out of the OR. It is important to minimize the anesthesia time, surgical time, the amount of people in the OR and the traffic in the OR.  The operating room should only include essential people of the surgical team in the OR and close the door when operating to both symbolically and physically minimize traffic in the operating room. 

Post operatively

 This is perhaps the most critical phase of cleaning. There are a host of surgical procedures and steps he surgical team has to perform prior to the patient entering the operating room and minimizing the need for cleaning will help focus your attention on the patient and the pre surgical preparation.  After the procedure is completed the majority of the OR cleaning can take place. 

Small Cleaning 

Small cleaning is used to refer to smaller surfaces. Like the instruments and monitoring devices that are used directly on the patient and other small surfaces. Ensure that the floor is clean and all gauze sponge have been picked up and all trash cans are emptied. If there is an errant splash of blood found on a wall, door knob or monitoring devices, a spot cleaning can be performed. All towels and blankets should be cleaned and warning devices should be replaced or cleaned by hand. All minimally invasive equipment like arthroscopy towers, light boxes, cameras and other materials should be hand cleaned. Instrument tables as well as the thermometers, and pulse oximeters can be gently cleaned and wiped.  Clean all equipment surfaces including cautery, IV pumps and and IV poles scavenger, anesthesia machine  carts, walls, cans, countertops and windows, and blinds. 

Small cleaning also includes verifying that all the surgical instruments have been sterilized appropriately. Check lap sponges, the surgical packs, gauze, drapes, and instruments wrapped individually to make sure that they have been cleaned appropriately.. The anesthetic equipment can be checked at this time to ensure the gas anesthetic is refilled, the soda lime is replaced and the anesthetic circuits and bags have been thoroughly cleaned. 

Big Cleaning

This cleaning refers to larger surfaces and should be performed daily.  Ensure that the patient table, shelves, the top of equipment, computers, keyboards and mayo stands, are cleaned and wiped my hand.  The floor is swept of debris and then moped with the cleaning agent of choice. The walls are cleaned with fresh, clean, hand cloth. If possible, start the big cleaning in the center of the OR and move towards the periphery in the same spirit as surgical preparation of an abdomen. Start cleaning with the surgery table then gradually move out to items that are lower to the ground like foot pedals. Cabinet handles, sub sinks, chairs and wheel casters and eventually the phone and clock by the door.   The OR can be visually sectioned into smaller areas (i.e. 3 x4 ft ) and each section is cleaned sequentially.  It is also ok to declutter your OR. Only essential items should be included in the operating room and there should be no opportunity for storage of books, clothes, mops, antiquated equipment or non-medical items. 

When it comes to cleaning, the mechanical action of removing debris is the most essential component of the process however the proper use of disinfectants and cleaners is crucial as well. Ensure that the cleaning team has read the instructions on the proper use of the disinfectant which includes, contact times and drying times.  

The Team 

Having a dedicated team to clean is ideal. The quality of the cleaning process is likely to be superb with a group that has gained experience in the entire process. Having dedicated staff, with a checklist, and with particular knowledge and experience cleaning is invaluable. Less experienced members of the cleaning term should undergo a regimented training protocol under the guidance of the more experienced members. Staff safety is of particular concern during the cleaning process. Using nontoxic disinfectants and ensuring that your staff uses the proper PPE when cleaning will help keep everyone healthy. 

Preoperatively 

A safe and salubrious operating theatre is an environment in which all sources of pollution and any micro-environmental alterations are kept strictly under control. This can be achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff.

1.  Clip hair outside of surgery room 

2. Use different blades

3. Clean and disinfect - Ensure that you are removing all organic debris, using the proper disinfectant, adhering to contact times and drying time. According to the Centers for Disease Control and prevention the physical removal of microorganisms and soil by scrubbing is more important than the actual antimicrobial used

Intra-operatively 

1.  Limit questions from staff during operations can increase times.  A study about music and mistakes found that any stimulus that requires a response increases mistakes

2. Keep traffic to a minimum 

3.  A cap and mask should be worn at all time when entering an OR  especially prior to opening instruments

Post operatively 

1. Have a team -  A clean OR is a life-saving procedure. Have the most experienced person and team member on your surgical team train the others on the proper cleaning protocols 

2. New Materials. If possible, a new materials should be used for each patient including towels, blankets, new drapes, and warmer blanket.

3. Clean the trash - Replace the trash bag.  This may sound clear and obvious to some but there may be those who - in an attempt to minimize environmental impact and exert some cost savings - may simply empty the trash while continuing to use the same bag.  Clean the OR free of organic material - blood, pus, elimination including blood and feces, again using the proper disinfectant.  Delicate cleaning should also include all the probes used for anesthetic monitoring.   Forgotten surfaces - The surfaces in the operating room should be cleaned daily to reduce microbial burden. This includes horizontal surfaces which includes desks, shelves, the surgery table, surgical equipment also vacuuming and mopping,  the floor,  surgery lights Wheels, foot pedals, walls, cabinet handles, and computer mouse keyboard and monitor,  cautery, arthroscopy, IV pumps and poles, anesthetic machines, anesthesia hoses and bags, cautery, laser units, countertops, shelves, ventra, windows, blind, doors, Check dates of sterilization and check filters.