Environmental cleaning and disinfection in the operating room: a systematic scoping review through a human factors and systems engineering lens

OBJECTIVE

To synthesize evidence and identify gaps in the literature on environmental cleaning and disinfection in the operating room based on a human factors and systems engineering approach guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model.

DESIGN

A systematic scoping review.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases (ie, PubMed, EMBASE, OVID, CINAHL) for empirical studies on operating-room cleaning and disinfection. Studies were categorized based on their objectives and designs and were coded using the SEIPS model. The quality of randomized controlled trials and quasi-experimental studies with a nonequivalent groups design was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials.

RESULTS

In total, 40 studies were reviewed and categorized into 3 groups: observational studies examining the effectiveness of operating-room cleaning and disinfections (11 studies), observational study assessing compliance with operating-room cleaning and disinfection (1 study), and interventional studies to improve operating-room cleaning and disinfection (28 studies). The SEIPS-based analysis only identified 3 observational studies examining individual work-system components influencing the effectiveness of operating-room cleaning and disinfection. Furthermore, most interventional studies addressed single work-system components, including tools and technologies (20 studies), tasks (3 studies), and organization (3 studies). Only 2 studies implemented interventions targeting multiple work-system components.

CONCLUSIONS

The existing literature shows suboptimal compliance and inconsistent effectiveness of operating-room cleaning and disinfection. Improvement efforts have been largely focused on cleaning and disinfection tools and technologies and staff monitoring and training. Future research is needed (1) to systematically examine work-system factors influencing operating-room cleaning and disinfection and (2) to redesign the entire work system to optimize operating-room cleaning and disinfection.

The Association of Organizational, Environmental, and Staffing Characteristics of Residential Care Facilities and the Risk Rating of Statutory Notifications: A Cross-Sectional Study in Ireland

OBJECTIVES

Safety incidents (SIs) are an indicator of quality in health and social care services. Safety incident research has largely focused on acute health care settings. We aimed to examine the association of organizational, environmental, and staffing characteristics of residential care facilities (RCFs) and severity of regulatory SI notifications.

METHODS

This was a retrospective analysis of SI notifications to the regulator for social care in Ireland received in 2018 and 2019. The mean risk rating of SI notifications for each RCF was used as the outcome. Regression analysis was conducted for the association of RCF characteristics (beds, staff to bed ratio, staff full-time equivalent (FTE), nurse to bed ratio, nurse FTE, number of RCF operated by the service provider, non-statutory or statutory provider) and the outcome, separately for nursing homes and residential disability services.

RESULTS

A total of 53,268 SI notifications were received. One thousand nine hundred RCFs were operational during the period: 594 (31.3%) for RCF-Nursing home and 1304 (68.7%) for RCF-Disability. For nursing homes, in the most adjusted model, the number of RCF operated by a provider ( β coefficient [95% confidence interval] = 0.508 [0.223-0.793]) was positively associated with mean risk rating of SI. For disability services, the following characteristics were positively associated in the most adjusted model: beds (0.081; 0.060-0.101), staff to bed ratio (0.068; 0.017-0.120), nurse to bed ratio (0.356; 0.044-0.667), staff FTE (0.029; 0.015-0.042), and number of RCF operated by a provider (0.067; 0.050-0.084).

CONCLUSIONS

Various modifiable organizational, environmental, and staffing characteristics and severity of SI notifications were associated in this study, most of which were related to RCF-Disability. Policymakers and providers of social care services should be cognizant of the relationship of these characteristics and severity of SI, when designing and planning residential care.

Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Electrolyzed Hypochlorous Acid (HOCl) Aqueous Solution as Low-Impact and Eco-Friendly Agent for Floor Cleaning and Sanitation

Recently, the use of disinfectants has been becoming a diffused and sometimes indiscriminate practice of paramount importance to limit the spreading of infections. The control of microbial contamination has now been concentrated on the use of traditional agents (i.e., hypochlorite, ozone). However, their prolonged use can cause potential treats, for both human health and environment. Currently, low-impact but effective biocides that are prepared in a way that avoids waste, with a very low toxicity, and safe and easy to handle and store are strongly needed. In this study, produced electrochemically activated hypochlorous (HOCl) acid solutions are investigated and proposed, integrated in a scrubbing machine for floor cleaning treatment. Such an innovative machine has been used for floor cleaning and sanitation in order to evaluate the microbial charge and organic dirt removal capacity of HOCl in comparison with a machine charged with traditional Ecolabel standard detergent. The potential damage on floor materials has also been investigated by means of Scanning Electron Microscope (SEM). A comparative Life Cycle Assessment (LCA) analysis has been carried out for evaluating the sustainability of the use of the HOCl-based and detergent-based machine.

Operating room disinfection: operator-driven ultraviolet 'C' vs. chemical treatment

Background

In operating room (OR) surfaces, Nosocomial pathogens can persist on inanimate surfaces for long intervals and are highly resistant to traditional surface cleaning.

Aim

This study compares traditional chemical operating room terminal disinfection to a unique operator-driven device that emits germicidal UV light at short distance onto vertical and horizontal surfaces.

Methods

A randomized crossover analogous protocol assigned 40 end-of-day operating rooms into either group A (chemical then UVC treatments) or group B (UVC then chemical treatments). Initial Staphylococcal cultures were obtained prior to disinfection treatment, after the first treatment, and after the second treatment at 16 most commonly contaminated sites to represent overall room contamination. Success was defined as no growth and failure as 1 or more colony forming units. Thoroughness of chemical treatment vs UVC treatment was compared and used to determine if the second treatment was additive to the first treatment within each group.

Findings

The operator driven UVC device outperformed chemical treatment in reducing the number of contaminated sites in the OR by more than half (P<0.001). Operator-driven UVC reduced contaminated sites after chemical treatment by nearly half (P<0.001). In contrast, chemical treatment after operator-driven UVC did not significantly reduce the number of contaminated sites. The mean employee time of disinfection for chemical treatment was 49 minutes and for the operator-driven UVC emitter 7.9 minutes (P<0.001).

Conclusions

This study demonstrates that addition of an operator-driven UVC emitter to OR rooms between cases could be helpful in overall decreasing the number of contaminated sites.

Effectiveness of Manual Terminal Cleaning Varies on High-Touch Surfaces Near the Operative Field

Background

Periprosthetic joint infection may result from pathogen to patient transmission within the environment. The purpose of this study is to evaluate the contamination level of selected high-touch surfaces in the operating room (OR) using a blacklight fluorescent marking system after a manual terminal clean.

Methods

Prior to the manual terminal clean, 16 high-touch surfaces were marked using a blacklight fluorescent gel. The marked areas were assessed the next morning for thoroughness of cleaning. Surfaces were categorized based on the average percent of the marks removed as “clean” (>75%), “partially clean” (26%-74%), or poorly cleaned (<25%). This process was repeated randomly 12 times. Terminal cleaning was done in the standard fashion, and the perioperative team was unaware of the initiation of this study.

Results

A total of 936 marks were analyzed. There was a significant difference in the number of marks completely clean (29.1%, 272/936) vs marks that were not touched (40.8%, 382/936), P < .001. Only the OR back table (75%) had a rating of clean. Partially clean areas included Mayfield table (72%), overhead lights (70.1%), infusion pump (61.1%), clock reset button (58.3%), table remote control (50%), tourniquet machine (50%), and the OR table (33.3%). Poorly cleaned surfaces included anesthesia medication cart (21.8%), door handles (20.8%), phone (16.7%), electrocautery unit (16.7%), foot pedal (16.7%), anesthesia cart (16.2%), nurses’ station (14.1%), and supply cabinet doors (6%).

Conclusions

Effectiveness of manual terminal cleaning varied greatly across surfaces. In general, surfaces further from the operative field were less likely to have markings removed.

Environmental cleaning and disinfection: Sustaining changed practice and improving quality in the community hospital

OBJECTIVE

Short-term improvements in hospital room cleaning can readily be achieved but are difficult to maintain. This is particularly true for high-risk, "high-touch" surfaces. Therefore, we embarked on a process to sustain improvements in surface cleaning and disinfection to reduce hospital-acquired infection (HAI) rates.

INTERVENTIONS

Our environmental services (EVS) and infection prevention departments incorporated a formal education, monitoring, and feedback process for focused cleaning and disinfection of high-touch surfaces into their routine policies and procedures in 2011. Cleaning validation was performed by infection prevention liaison nurses using a fluorescent targeting method to evaluate the thoroughness of cleaning.

RESULTS

Surface cleaning performance on medical-surgical units in 2011 was 74.7%, but this rate incrementally increased in response to the interventions and has been sustained at >90% for the past 6 years. Similar patterns of improvement were observed in the operating room, labor and delivery, endoscopy suite and cardiac catheterization laboratory. Conversely, HAI rates, particularly C. difficile rates, decreased by 75% and surgical site infection rates decreased by 55%.

CONCLUSIONS

EVS training, monitoring, and feedback interventions, instituted 10 years ago have enhanced our environmental cleaning and disinfection efforts in multiple areas of the hospital and have been sustained to the present. Although other concurrent initiatives to reduce infection rates also existed, the improvements in environmental cleaning were associated with dramatic reductions in HAI rates over the 10-year period.

Investigation of Airflow Distribution and Contamination Control with Different Schemes in an Operating Room

Controlling contamination via proper airflow distribution in an operating room becomes vital to ensure the reliable surgery process. The heating, ventilation, and air conditioning (HVAC) systems significantly influence the operating room environment, including temperature, relative humidity, pressurization, particle counts, filtration, and ventilation rate. A full-scale operating room has been investigated extensively through field measurements and numerical analyses. Computational fluid dynamics (CFD) simulation was conducted and verified with the field measurement data. The simulation was analyzed with three different operating room schemes, including at-rest conditions (case 1), normal operational conditions with personnel (case 2), and actual conditions with personnel inside and some medical equipment blocking the return air (case 3). The concentration decay method was used to evaluate this study. The results revealed that the contamination concentration in case 1 could be diluted quickly with the average value of 404 ppm, whereas the concentration in case 2 slightly increased while performing a surgery with the average value of 420 ppm. The return air grilles in case 3, blocked by obstacles from some medical equipment, resulted in the average concentration value of 474 ppm. Other than that, the contaminant dilution could be obstructed dramatically, which revealed that proper and smooth airflow distribution is essential for contamination control. The ventilation efficiency of case 2 and case 3 dropped around 6% and 17.91% compared to case 1 in the unoccupied and ideal condition. Ventilation efficiency also decreased along with decreasing the air change rate per hour (ACH), while with increasing ACH, the ventilation efficiency in case 3 actually increased, approaching case 2 in the ideal condition.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Guidelines in Practice: Environmental Cleaning

All perioperative personnel are responsible for providing a clean environment for patients undergoing operative or other invasive procedures. A contaminated environment can contribute to the incidence of surgical site infections when a patient's skin contacts a contaminated surface or personnel touch a contaminated surface and then transmit microbes to the patient. Airborne contaminants may settle on the sterile field or in the surgical wound. The AORN "Guideline for environmental cleaning" provides guidance on cleaning product selection, cleaning procedures, personnel education, competency verification, and monitoring cleanliness through performance improvement processes. This article discusses guideline recommendations for cleaning procedures and cleaning of operating and procedure rooms. A scenario describes how an ambulatory surgery center team identifies gaps in cleaning processes and modifies the cleaning checklist to improve these processes. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for environmental cleaning.

Environmental Surface Hygiene in the OR: Strategies for Reducing the Transmission of Health Care-Associated Infections

Health care-associated infections (HAIs) cost billions of dollars annually in the United States and cause patient morbidity and mortality. There is increasing evidence that environmental surfaces in the OR setting, including anesthesia work areas, can harbor pathogens that can lead to HAIs. Patient-care equipment used routinely in the OR, such as electrocardiograph wires, blood pressure cuffs, pulse oximetry probes, and monitor cables, can become contaminated with pathogens during surgical procedures; without proper cleaning and disinfection between procedures, these items pose a risk for pathogen transmission and subsequent patient infections. This article discusses the association between contaminated surfaces in the OR and the risk for HAIs. It is essential that perioperative nurses, environmental services personnel, anesthesia technicians, and anesthesia professionals properly disinfect environmental surfaces to prevent HAIs.

Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections

PURPOSE OF REVIEW

This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety.

RECENT FINDINGS

Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention.

SUMMARY

Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.

Infectious Risk of the Hospital Environment in the Center of Morocco: A Case of Care Unit Surfaces

BACKGROUND

Equipment and hospital surfaces constitute a microbial reservoir that can contaminate hospital users and thus create an infectious risk. The aim of this work, which was carried out for the first time at a hospital in Meknes (regional hospital in the center of Morocco), is to evaluate the microbiological quality of surfaces and equipment in three potential risk areas (burn unit, operating room, and sterilization service).

METHODS

This study was carried out over a period of 4 months (February-May 2017). A total of 60 samples were taken by swabbing according to the standard (ISO/DIS 14698-1 (2004)) in an environment of dry area and equipment after biocleaning. Isolation and identification were performed according to conventional bacteriological methods and by microscopic observation for fungi.

RESULTS

The study showed that 40% of surface samples were contaminated after biocleaning. The burn unit recorded a percentage of 70% contamination (p value <0.001), 13% for the sterilization service, and 7% for the operating room. 89% of the isolates were identified as Gram-positive bacteria against 11% for fungi (p value <0.001). Bacterial identification showed coagulase-negative staphylococci (32%), Bacillus spp. (16%), Corynebacterium (8%), and oxidase-negative Gram-positive bacillus (40%) while fungal identification showed Aspergillus niger (n = 2) and Aspergillus nidulans (n = 1).

CONCLUSION

To control the infectious risk related to equipment and hospital surfaces, it would be necessary to evaluate the disinfection protocol applied in these units.

Implementation of human factors engineering approach to improve environmental cleaning and disinfection in a medical center

Background

Inadequate hospital cleaning may contribute to cross-transmission of pathogens. It is important to implement effective cleaning for the safe hospital environment. We conducted a three-phase study using human factors engineering (HFE) approach to enhance environmental cleanliness.

Methods

This study was conducted using a prospective interventional trial, and 28 (33.3%) of 84 wards in a medical center were sampled. The three-phases included pre-intervention analysis (Phase 1), implementing interventions by HFE principles (Phase 2), and programmatic analysis (Phase 3). The evaluations of terminal cleaning and disinfection were performed using the fluorescent marker, the adenosine triphosphate bioluminescence assay, and the aerobic colony count method simultaneously in all phases. Effective terminal cleaning and disinfection was qualified with the aggregate outcome of the same 10 high-touch surfaces per room. A score for each high-touch surface was recorded, with 0 denoting a fail and 10 denoting a pass by the benchmark of the evaluation method, and the total terminal cleaning and disinfection score (TCD score) was a score out of 100.

Results

In each phase, 840 high-touch surfaces were collected from 84 rooms after terminal cleaning and disinfection. After the interventions, the TCD score by the three evaluation methods all showed significant improved. The carriage incidence of multidrug-resistant organism (MDRO) decreased significantly from 4.1 per 1000 patient-days to 3.6 per 1000 patient-days (P = .03).

Conclusion

The HFE approach can improve the thoroughness and the effectiveness of terminal cleaning and disinfection, and resulted in a reduction of patient carriage of MDRO at hospitals. Larger studies are necessary to establish whether such efforts of cleanliness can reduce the incidence of healthcare-associated infection.

Improving children's and their visitors' hand hygiene compliance

Background

Numerous interventions have tried to improve healthcare workers' hand hygiene compliance. However, little attention has been paid to children's and their visitors' compliance.

Aim

To test whether interactive educational interventions increase children's and visitors' compliance with hand hygiene.

Methods

This was a cluster randomised study of hand hygiene compliance before and after the introduction of educational interventions. Observations were compared for different moments of hygiene and times of the day. Qualitative data in the form of questionnaire-based structured interviews were obtained.

Findings

Hand hygiene compliance increased by 24.4% (P < 0.001) following the educational interventions, with children's compliance reaching 40.8% and visitors' being 50.8%. Compliance varied depending on which of the five moments of hygiene was observed (P < 0.001), with the highest compliance being 'after body fluid exposure' (72.7%). Responses from questionnaires showed educational interventions raised awareness of the importance of hand hygiene (69%, 57%) compared to those who had not experienced the educational intervention (50%).

Conclusion

Educational interventions may result in a significant increase in children's and visitors' hand hygiene (P < 0.001).

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room

BACKGROUND

Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands.

METHODS

To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period.

RESULTS

Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness.

CONCLUSIONS

This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Influence of a visible-light continuous environmental disinfection system on microbial contamination and surgical site infections in an orthopedic operating room

BACKGROUND

A growing body of research has demonstrated that manual cleaning and disinfection of the operating room (OR) is suboptimal. Residual environmental contamination may pose an infection risk to the surgical wound. This study evaluates the impact of a visible-light continuous environmental disinfection (CED) system on microbial surface contamination and surgical site infections (SSI) in an OR.

METHODS

Samples from 25 surfaces within 2 contiguous ORs sharing an air supply were obtained after manual cleaning on multiple days before and after a visible-light CED system installation in 1 of the ORs. Samples were incubated and enumerated as total colony-forming units. SSIs in both ORs, and a distant OR, were tracked for 1 year prior to and 1 year after the visible-light CED system installation.

RESULTS

There was an 81% (P = .017) and 49% (P = .015) reduction in total colony-forming units after the visible-light CED system installation in the OR in which the system was installed, and in the contiguous OR, respectively. In the OR with the visible-light CED system, SSIs decreased from 1.4% in the year prior to installation to 0.4% following installation (P = .029).

CONCLUSIONS

A visible-light CED system, used in conjunction with manual cleaning, resulted in significant reductions in both microbial surface contamination and SSIs in the OR.

Assessment of focused multivector ultraviolet disinfection withshadowless delivery using 5-point multisided sampling ofpatientcare equipment without manual-chemical disinfection

BACKGROUND

The aim of this study was to evaluate the performance of a focused multivector ultraviolet (FMUV) system employing shadowless delivery with a 90-second disinfection cycle for patient care equipment inside and outside the operating room (OR) suite without manual-chemical disinfection.

METHODS

A 5-point multisided sampling protocol was utilized to measure the microbial burden on objects inside and outside the OR environment in a 3-phase nonrandomized observational study. Surface sampling was performed pre- and postdisinfection in between cases (IBCs) to assess the performance of manual-chemical disinfection. FMUV system performance was separately assessed pre- and postdisinfection before the first case and IBCs. Additionally, visibly clean high-touch objects were sampled outside the OR, and the microbial burden reductions after FMUV disinfection were quantified without manual-chemical disinfection.

RESULTS

Manual-chemical disinfection reduced the active microbial burden on sampled objects IBCs by 52.8%-90.9% (P < .05). FMUV reduced the active microbial burden by 92%-97.7% (P < .0001) before the firstcase and IBCs combined, and 96.3%-99.6% (P < .0001) on objects outside the OR without chemical disinfection.

CONCLUSIONS

Five-point multisided sampling proved effective for assessing disinfection performance on all exterior sides of equipment. FMUV produced significant overall reductions of the microbial burden on patient care equipment in all study phases and independent of manual cleaning and chemical disinfection.

Remote Video Auditing to Verify OR Cleaning: A Quality Improvement Project

There are many sources of contamination in the perioperative environment. Patient experience can be negatively affected by the presence of environmental contamination, especially if it is the cause of a surgical site infection. Perioperative and environmental services staff members and leaders are tasked with ensuring a clean and safe environment for their patients while maintaining an awareness of time and budgetary constraints. In addition, leaders are responsible for the competency of their staff members and must address performance issues when needed. New technological advances designed to streamline monitoring and reporting processes related to OR cleanliness are available for use. This article describes the quality improvement project that one multifacility organization completed related to the use of remote video auditing and the positive effect it had on the organization's environmental contamination.

Cutibacterium acnes and the shoulder microbiome

BACKGROUND

Advances in DNA sequencing technologies have made it possible to detect microbial genome sequences (microbiomes) within tissues once thought to be sterile. We used this approach to gain insights into the likely sources of Cutibacterium acnes (formerly Propionibacterium acnes) infections within the shoulder.

METHODS

Tissue samples were collected from the skin, subcutaneous fat, anterior supraspinatus tendon, middle glenohumeral ligament, and humeral head cartilage of 23 patients (14 male and 9 female patients) during primary arthroplasty surgery. Total DNA was extracted and microbial 16S ribosomal RNA sequencing was performed using an Illumina MiSeq system. Data analysis software was used to generate operational taxonomic units for quantitative and statistical analyses.

RESULTS

After stringent removal of contamination, genomic DNA from various Acinetobacter species and from the Oxalobacteraceae family was identified in 74% of rotator cuff tendon tissue samples. C acnes DNA was detected in the skin of 1 male patient but not in any other shoulder tissues.

CONCLUSION

Our findings indicate the presence of a low-abundance microbiome in the rotator cuff and, potentially, in other shoulder tissues. The absence of C acnes DNA in all shoulder tissues assessed other than the skin is consistent with the hypothesis that C acnes infections are derived from skin contamination during surgery and not from opportunistic expansion of a resident C acnes population in the shoulder joint.

Application of a fluorescent marker with quantitative bioburden methods to assess cleanliness

BACKGROUND

Improvement of environmental cleaning in hospitals has been shown to decrease in-hospital cross transmission of pathogens. Several objective methods, including aerobic colony counts (ACCs), the adenosine triphosphate (ATP) bioluminescence assay, and the fluorescent marker method have been developed to assess cleanliness. However, the standard interpretation of cleanliness using the fluorescent marker method remains uncertain.

OBJECTIVE

To assess the fluorescent marker method as a tool for determining the effectiveness of hospital cleaning.

DESIGN

A prospective survey study.

SETTING

An academic medical center.

METHODS

The same 10 high-touch surfaces were tested after each terminal cleaning using (1) the fluorescent marker method, (2) the ATP assay, and (3) the ACC method. Using the fluorescent marker method under study, surfaces were classified as totally clean, partially clean, or not clean. The ACC method was used as the standard for comparison.

RESULTS

According to the fluorescent marker method, of the 830 high-touch surfaces, 321 surfaces (38.7%) were totally clean (TC group), 84 surfaces (10.1%) were partially clean (PC group), and 425 surfaces (51.2%) were not clean (NC group). The TC group had significantly lower ATP and ACC values (mean ± SD, 428.7 ± 1,180.0 relative light units [RLU] and 15.6 ± 77.3 colony forming units [CFU]/100 cm2) than the PC group (1,386.8 ± 2,434.0 RLU and 34.9 ± 87.2 CFU/100 cm2) and the NC group (1,132.9 ± 2,976.1 RLU and 46.8 ± 119.2 CFU/100 cm2).

CONCLUSIONS

The fluorescent marker method provided a simple, reliable, and real-time assessment of environmental cleaning in hospitals. Our results indicate that only a surface determined to be totally clean using the fluorescent marker method could be considered clean.

Update on infection control practices in cancer hospitals

Therapies in oncology have evolved rapidly over the last years. At the same pace, supportive care for patients receiving cancer therapy has also evolved, allowing patients to safely receive the newest advances in treatment in both an inpatient and outpatient basis. The recognition of the role of infection control and prevention (ICP) in the outcomes of patients living with cancer has been such that it is now a requirement for hospitals and involves multidisciplinary groups. Some unique aspects of ICP for patients with cancer that have gained momentum over the past few decades include catheter-related infections, multidrug-resistant organisms, community-acquired viral infections, and the impact of the health care environment on the horizontal transmission of organisms. Furthermore, as the potential for infections to cross international borders has increased, alertness for outbreaks or new infections that occur outside the area have become constant. As the future approaches, ICP in immunocompromised hosts will continue to integrate emerging disciplines, such as antibiotic stewardship and the microbiome, and new techniques for environmental cleaning and for controlling the spread of infections, such as whole-genome sequencing. CA Cancer J Clin 2018;000:000-000. © 2018 American Cancer Society.

Environmental effectiveness of pulsed-xenon light in the operating room

BACKGROUND

Manual cleaning and disinfection of the operating room (OR) environment may be inadequate due to human error. No-touch technologies, such as pulsed-xenon ultraviolet light (PX-UV), can be used as an adjunct to manual cleaning processes to reduce surface contamination in the OR. This article reports the cumulative results from 23 hospitals across the United States that performed microbiologic validation of PX-UV disinfection after manual cleaning.

METHODS

We obtained samples from 732 high-touch surfaces in 136 ORs at 23 hospitals, after manual terminal cleaning, and again after PX-UV disinfection (n = 1464 surface samples). Samples were enumerated after incubation, and the results are reported as total colony-forming units (CFU).

RESULTS

The average CFU after manual cleaning ranged from 5.8 to 34.37, and after PX-UV, from 0.69 to 6.43. With manual cleaning alone, 67% of surfaces were still positive for CFUs; after PX-UV disinfection, that number decreased to 38% of all sampled surfaces-a 44% reduction. When comparing manual cleaning to PX-UV, the reduction in CFU count was statistically significant.

CONCLUSION

When used after the manual cleaning process, the PX-UV device significantly reduced contamination on high-touch surfaces in the OR.

Cleaning and disinfection of surfaces in hospitals. Improvement in quality of structure, process and outcome in the hospitals in Frankfurt/Main, Germany, in 2016 compared to 2014

The cleaning and disinfection of surfaces in hospitals is becoming increasingly important in the multi-barrier approach for preventing infection, in addition to hand hygiene and proper reprocessing of medical devices. Therefore, in 2014, the quality of structure, process and outcome of surface preparation was checked in all hospitals in Frankfurt/Main, Germany. Because of great need for improvements, this monitoring was repeated in 2016. The data are presented in comparison to those in 2014.

Methods: All 16 hospitals provided information on the quality of structure. Data on quality of process was obtained through direct observation during cleaning and disinfection of rooms and their bathrooms. Data on quality of result was acquired using the fluorescence method, i.e., marking surfaces with a fluorescent liquid and testing whether this mark has been sufficiently removed by cleaning. The results are compared to those of the 17 hospitals monitored in 2014, before the closing of one of the hospitals.

Results: Quality of structure [data from 2014]: In all hospitals, the employees were trained regularly. In 14 (88%) [12; 71%] of those, the foremen had the required qualifications. In 1 (6%) [6; 35%] hospitals, some uncertainty remained concerning the interface of the cleaning and nursing care services. A complete cleaning was reported to take place in 12 (75%) [12; 70%] hospitals on Saturdays and in 4 (25%) [2; 11%] hospitals on Sundays. Quality of process: During process monitoring, the different surfaces with frequent hand or skin contact were prepared to different extents (91–100%) [70–100%]. Quality of result: 88% [75%] of fluorescent marks were appropriately removed.

Conclusion: Compared to 2014, a clear improvement were seen in 2016, especially in the qualification of the foremen and in terms of clearly defining the interface between cleaning and care services as well as the quality of process and outcome. Nevertheless, regarding the growing importance of proper reprocessing of hospital surfaces for prevention of infections and/or colonizations, further improvements are mandatory, including a program for better education of the cleaning staff.

Hand hygiene compliance monitoring in anaesthetics: Feasibility and validity

Background:

Hand hygiene compliance scores in the anaesthetic department of an acute NHS hospital were persistently low.

Aims:

To determine the feasibility and validity of regular accurate measurement of HHC in anaesthetics and understand the context of care delivery, barriers and opportunities to improve compliance.

Methods:

The hand hygiene compliance of one anaesthetist was observed and noted by a senior infection control practitioner (ICP). This was compared to the World Health Organization five moments of hand hygiene and the organisation hand hygiene tool.

Findings:

In one sequence of 55 min, there were approximately 58 hand hygiene opportunities. The hand hygiene compliance rate was 16%. The frequency and speed of actions in certain periods of care delivery made compliance measurement difficult and potentially unreliable. During several activities, taking time to apply alcohol gel or wash hands would have put the patients at significant risk.

Discussion:

We concluded that hand hygiene compliance monitoring by direct observation was invalid and unreliable in this specialty. It is important that hand hygiene compliance is optimal in anaesthetics particularly before patient contact. Interventions which reduce environmental and patient contamination, such as cleaning the patient and environment, could ensure anaesthetists encounter fewer micro-organisms in this specialty.

Controlling infectious disease outbreaks in low-income and middle-income countries

When an infectious disease outbreak is detected or suspected, a healthcare facility’s infection control personnel should be notified and an outbreak control team formed that is pertinent to the size and severity of the outbreak and healthcare facility. Management of an infectious disease outbreak in a middle- or low-income country is challenging. Cost-effective recommendations that are easy to carry out and that have been stratified according to the type of infection and prevention and control intervention used are provided in this paper and constitute basic practices.

Assessing a Novel Method to Reduce Anesthesia Machine Contamination: A Prospective, Observational Trial

Background

Anesthesia machines are known reservoirs of bacterial species, potentially contributing to healthcare associated infections (HAIs). An inexpensive, disposable, nonpermeable, transparent anesthesia machine wrap (AMW) may reduce microbial contamination of the anesthesia machine. This study quantified the density and diversity of bacterial species found on anesthesia machines after terminal cleaning and between cases during actual anesthesia care to assess the impact of the AMW. We hypothesized reduced bioburden with the use of the AMW.

Methods

In a prospective, experimental research design, the AMW was used in 11 surgical cases (intervention group) and not used in 11 control surgical cases. Cases were consecutively assigned to general surgical operating rooms. Seven frequently touched and difficult to disinfect “hot spots” were cultured on each machine preceding and following each case. The density and diversity of cultured colony forming units (CFUs) between the covered and uncovered machines were compared using Wilcoxon signed-rank test and Student's t-tests.

Results

There was a statistically significant reduction in CFU density and diversity when the AMW was employed.

Conclusion

The protective effect of the AMW during regular anesthetic care provides a reliable and low-cost method to minimize the transmission of pathogens across patients and potentially reduces HAIs.

Evaluation of a pulsed xenon ultraviolet disinfection system to decrease bacterial contamination in operating rooms

Background

Environmental cleanliness is one of the contributing factors for surgical site infections in the operating rooms (ORs). To decrease environmental contamination, pulsed xenon ultraviolet (PX-UV), an easy and safe no-touch disinfection system, is employed in several hospital environments. The positive effect of this technology on environmental decontamination has been observed in patient rooms and ORs during the end-of-day cleaning but so far, no study explored its feasibility between surgical cases in the OR.

Methods

In this study, 5 high-touch surfaces in 30 ORs were sampled after manual cleaning and after PX-UV intervention mimicking between-case cleaning to avoid the disruption of the ORs’ normal flow. The efficacy of a 1-min, 2-min, and 8-min cycle were tested by measuring the surfaces’ contaminants by quantitative cultures using Tryptic Soy Agar contact plates.

Results

We showed that combining standard between-case manual cleaning of surfaces with a 2-min cycle of disinfection using a portable xenon pulsed ultraviolet light germicidal device eliminated at least 70% more bacterial load after manual cleaning.

Conclusions

This study showed the proof of efficacy of a 2-min cycle of PX-UV in ORs in eliminating bacterial contaminants. This method will allow a short time for room turnover and a potential reduction of pathogen transmission to patients and possibly surgical site infections.

A model for choosing an automated ultraviolet-C disinfection system and building a case for the C-suite: Two case reports

Environmental disinfection has become the new frontier in the ongoing battle to reduce the risk of health care-associated infections. Evidence demonstrating the persistent contamination of environmental surfaces despite traditional cleaning and disinfection methods has led to the widespread acceptance that there is both a need for reassessing traditional cleaning protocols and for using secondary disinfection technologies. Ultraviolet-C (UV-C) disinfection is one type of no-touch technology shown to be a successful adjunct to manual cleaning in reducing environmental bioburden. The dilemma for the infection preventionist, however, is how to choose the system best suited for their facility among the many UV-C surface disinfection delivery systems available and how to build a case for acquisition to present to the hospital administration/C-suite. This article proposes an approach to these dilemmas based in part on the experience of 2 health care networks.

[Cleaning and disinfection of surfaces in hospitals: Data on structure, process and result in the Frankfurt/Main Metropolitan Area]

INTRODUCTION

In addition to hand hygiene and reprocessing of medical products, cleaning and disinfection of surfaces is also an important issue in the prevention of germ transmission and by implication infections. Therefore, in 2014, the quality of the structure, process and result of surface preparation of all hospitals in Frankfurt am Main, Germany, was monitored.

METHODS

All 17 hospitals transferred information on the quality of structure. Process quality was obtained through direct observation during cleaning and disinfection of rooms and their plumbing units. Result quality was gained using the fluorescent method, i.e. marking surfaces with a fluorescent liquid and testing if this mark has been sufficiently removed by cleaning.

RESULTS

Structure quality: in all hospitals the employees were trained regularly. In 12 of them, the foremen had the required qualifications, in 6 hospitals unclarity as to the intersection of the cleaning and care services remained. In 14 hospitals only visible contamination was cleaned on the weekends, whereas complete cleaning was reported to take place in 12 hospitals on Saturdays and in 2 hospitals on Sundays. The contractually stipulated cleaning (observations specified in brackets) averaged 178 m(2)/h (148 m(2)/h) per patient room and 69 m(2)/h (33 m(2)/h) for bathrooms. Process quality: during process monitoring, various hand contact surfaces were prepared insufficiently. Result quality: 63 % of fluorescent markings were appropriately removed.

CONCLUSION

The need for improvement is given especially in the area of the qualification of the foremen and a in a clear definition of the intersection between cleaning and care services, as well as in the regulations for weekends and public holidays.

Determining high touch areas in the operating room with levels of contamination

BACKGROUND

The Centers for Disease Control and Prevention put forth the recommendation to clean areas considered high touch more frequently than minimal touch surfaces. The operating room was not included in these recommendations. The purpose of this study was to determine the most frequently touched surfaces in the operating room and their level of contamination.

METHODS

Phase 1 was a descriptive study to identify high touch areas in the operating room. In phase 2, high touch areas determined in phase 1 were cultured to determine if high touch areas observed were also highly contaminated and if they were more contaminated than a low touch surface.

RESULTS

The 5 primary high touch surfaces in order were the anesthesia computer mouse, OR bed, nurse computer mouse, OR door, and anesthesia medical cart. Using the OR light as a control, this study demonstrated that a low touch area was less contaminated than the high touch areas with the exception of the OR bed.

CONCLUSIONS

Based on information and data collected in this study, it is recommended that an enhanced cleaning protocol be established based on the most frequently touched surfaces in the operating room.

Quantifying the rambunctious journey of the anesthesia provider's hands during simulated, routine care

BACKGROUND

The role of anesthesia providers in dispersing potentially pathogenic material from one patient to another during intraoperative care needs further study. In this study we aimed (1) to quantify the dispersion of a surrogate pathogen from a simulated patient's mouth to the anesthesia workstation during routine anesthetic induction, (2) to test the hypothesis that there would be fewer contamination sites by providers who used a double-gloving technique, and (3) to examine the effectiveness of between-case anesthesia apparatus disinfection.

METHODS

Twenty subjects were randomized to a single pair of gloves group (group 1) or a double-gloved group (group 2) and completed a simulated general anesthesia induction, completing a standardized set of interventions. Dispersion of a surrogate pathogen dye placed in the oral cavity of the simulated patient was tracked by a blinded observer and photography. Standard cleaning of the workstation was performed, and residual dye was quantified. Group performance was plotted using regression analysis and rate of contamination compared using parametric statistics.

RESULTS

Group 1 contaminated an average of 16.0 (SEM = 0.89) sites compared with group 2, who contaminated an average of 7.6 (SEM = 0.85). The cart drawers, gas flow dials, medication vials, and ventilator controls were significantly contaminated by group 1, but not by group 2 (P < .05 in all cases). There were similar rates of contamination in both groups for the airway equipment, breathing system, intravenous access ports, and the roll of tape used to secure the endotracheal tube. Once the airway management phase of the induction ended, new site contamination continued at a high rate in group 1 but not group 2.

CONCLUSIONS

A double-gloving technique was associated with less spread of an oral inoculum to the workstation but was not uniformly protective. Between-case cleaning was ineffective in removing the contaminant, indicating that biologic material from one patient may be present when subsequent patients are cared for. This suggests risks for the current patient (eg, skin or oral site transfer to an intravenous site) and also may place future patients at risk. Importantly, using models that simulate actual clinical events can inform clinical practice and decipher challenging areas of ergonomics.

Influence of pulsed-xenon ultraviolet light-based environmental disinfection on surgical site infections

This study evaluates the influence of nightly pulsed-xenon ultraviolet light disinfection and dedicated housekeeping staff on surgical site infection (SSI) rates. SSIs in class I procedures were reduced by 46% (P = .0496), with a potential cost savings of $478,055. SSIs in class II procedures increased by 22.9%, but this was not significant (P = .6973). Based on these results, it appears that the intervention reduces SSI rates in clean (class I), but not clean-contaminated (class II) procedures.

Randomized Crossover Study Evaluating the Effect of a Hand Sanitizer Dispenser on the Frequency of Hand Hygiene among Anesthesiology Staff in the Operating Room

Forty anesthesia providers were evaluated with and without hand sanitizer dispensers present on the anesthesia machine. Having a dispenser increased the frequency of hand hygiene only from 0.5 to 0.8 events per hour (P = .01). Other concomitant interventions are needed to further increase hand hygiene frequency among anesthesia providers.

Infect Control Hosp Epidemiol 2014;35(6):717–720

Propionibacterium in Shoulder Arthroplasty: What We Think We Know Today

➤ Propionibacterium is a slow-growing gram-positive rod that is part of the normal skin microbiome but can be found on culture of specimens from a large number of patients having revision shoulder arthroplasty performed for pain, stiffness, and component loosening. ➤ Propionibacterium infections do not present with obvious signs of infection, such as swelling, erythema, drainage, or tenderness, but rather are of the so-called stealth type, presenting with unexplained pain, stiffness, or component loosening months to years after the index arthroplasty. ➤ Not all propionibacteria are the same: certain subtypes of Propionibacterium are enriched with virulence factors that may enhance deep infection. ➤ Because propionibacteria typically reside in the pilosebaceous glands of the oily skin of the chest and back, standard surgical skin preparation solutions and even perioperative intravenous antibiotics are often inadequate at sterilizing the incision site; therefore, other prophylactic measures such as meticulous implant handling to avoid contact with dermal structures need to be considered. ➤ Recovery of Propionibacterium from the surgical wounds requires that multiple specimens for culture be taken from different areas of the shoulder to reduce sampling error, and cultures should be held for two weeks on multiple culture media. ➤ Future research efforts can be focused on reducing the risk of implant infection and point-of-care methods for identifying Propionibacterium infections.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation

BACKGROUND

Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation.

METHODS

Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment.

RESULTS

Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001.

CONCLUSIONS

The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

Influence of a total joint infection control bundle on surgical site infection rates

Quality improvement initiatives combined with pulsed xenon ultraviolet room disinfection were implemented to reduce surgical site infections (SSIs) in patients undergoing total joint procedures. After 12 months, knee SSIs were reduced from 4 to 0 (P = .03) and hip SSIs were reduced from 3 to 0 (P = .15) for a combined prevention of 7 SSIs (P = .01) and a savings of $290,990.

Surface contamination in operating rooms: a risk for transmission of pathogens?

BACKGROUND

The role of surface contamination in the transmission of nosocomial pathogens is recognized increasingly. For more than 100 years, the inanimate environment in operating rooms (e.g., walls, tables, floors, and equipment surfaces) has been considered a potential source of pathogens that may cause surgical site infections (SSIs). However, the role of contaminated surfaces in pathogen acquisition in this setting generally is considered negligible, as most SSIs are believed to originate from patients' or healthcare workers' flora.

METHODS

A search of relevant medical literature was performed using PubMed to identify studies that investigated surface contamination of operating rooms and its possible role in infection transmission.

RESULTS

Despite a limited number of studies evaluating the role of surface contamination in operating rooms, there is accumulating evidence that the inanimate environment of the operating room can become contaminated with pathogens despite standard environmental cleaning. These pathogens can then be transmitted to the hands of personnel and then to patients and may result in SSIs and infection outbreaks.

CONCLUSION

Contaminated surfaces can be responsible for the transmission of pathogens in the operating room setting. Further studies are necessary to quantify the role of contaminated surfaces in the transmission of pathogens and to inform the most effective environmental interventions. Given the serious consequences of SSIs, special attention should be given to the proper cleaning and disinfection of the inanimate environment in operating rooms in addition to the other established infection control measures to reduce the burden of SSIs.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room

BACKGROUND

Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk.

METHODS

Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score.

RESULTS

The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001).

CONCLUSIONS

The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

An Ounce of Prevention Saves Tons of Lives: Infection in Burns

BACKGROUND

Modern day burn care continues to wage an uphill battle against an enemy that evolves faster than we can develop weapons. Bacteria (bioburden) are everywhere and can infiltrate anywhere within our susceptible population of burn patients. This is why prevention of infection is key to improving their survival and outcome.

PURPOSE

To reduce the incidence of infection in the burn patient population.

MATERIALS

Review of pertinent recent literature regarding infection prevention and control in the intensive care unit setting.

RESULTS

We propose that bioburden is one of the central elements in the infectious cycle that is ever-present in burn units. The mechanism of bacterial entry into the unit and subsequent transmission and infection are delineated. Recommendations for mitigating this risk are provided to guide future clinicians in their care of burn patients.

CONCLUSIONS

The treatment of infection and sepsis against highly adaptable bacteria is often insurmountable by ill patients. In this process, bioburden needs to be corralled to have any success. Thus, preventing organisms from entering the unit and transferring onto other patients, and eliminating the bacteria dwelling in the unit are all necessary actions in this battle. Ultimately, maintaining a culture that is constantly wary of this risk only can achieve this goal.