Decreasing Operating Room Environmental Pathogen Contamination Through Improved Cleaning Practice

L. Silvia Munoz-Price, MD; David J. Birnbach, MD, MPH; David A. Lubarsky, MD, MBA; Kristopher L. Arheart, EdD; Yovanit Fajardo-Aquino, MD; Mara Rosalsky, RN; Timothy Cleary, PhD; Dennise DePascale, MT; Gabriel Coro, MD; Nicholas Namias, MD; Philip Carling, MD


Infect Control Hosp Epidemiol. 2012;33(9):897-904. 

In This Article

Abstract and Introduction


Objective. Potential transmission of organisms from the environment to patients is a concern, especially in enclosed settings, such as operating rooms, in which there are multiple and frequent contacts between patients, provider's hands, and environmental surfaces. Therefore, adequate disinfection of operating rooms is essential. We aimed to determine the change in both the thoroughness of environmental cleaning and the proportion of environmental surfaces within operating rooms from which pathogenic organisms were recovered.
Design. Prospective environmental study using feedback with UV markers and environmental cultures.
Setting. A 1,500-bed county teaching hospital.
Participants. Environmental service personnel, hospital administration, and medical and nursing leadership
Results. The proportion of UV markers removed (cleaned) increased from 0.47 (284 of 600 markers; 95% confidence interval [CI], 0.42–0.53) at baseline to 0.82 (634 of 777 markers; 95% CI, 0.77–0.85) during the last month of observations (P <. 0001). Nevertheless, the percentage of samples from which pathogenic organisms (gram-negative bacilli, Staphylococcus aureus, and Enterococcus species) were recovered did not change throughout our study. Pathogens were identified on 16.6% of surfaces at baseline and 12.5% of surfaces during the follow-up period (P =.998). However, the percentage of surfaces from which gram-negative bacilli were recovered decreased from 10.7% at baseline to 2.3% during the follow-up period (P = .015).
Conclusions. Feedback using Gram staining of environmental cultures and UV markers was successful at improving the degree of cleaning in our operating rooms.


During the past decade, there has been an increasing awareness of the role of the hospital environment as a reservoir of multidrug-resistant organisms. These organisms include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile, and Acinetobacter baumannii.[1–7] However, the interactions between healthcare worker's hands, patients, objects, and the hospital environment has, to our knowledge, thus been studied only in intensive care units and wards.[1,5,8,9] There is evidence that the hospital environment, including the operating rooms, is often not cleaned thoroughly or in a manner consistent with relevant hospital policies.[10,11] Nevertheless, regular objective performance feedback can lead to improved cleaning rates. Earlier studies have shown an improvement in cleaning thoroughness from 47% at baseline to almost 80% after instituting structured ongoing monitoring and feedback programs in almost 40 hospitals.[11]

Until recently, no objective evaluation of disinfection has been performed in operating rooms. In a recent study, Jefferson et al[10] evaluated 71 operating rooms in 6 acute care hospitals and found a mean daily cleaning rate of 25% of the objects monitored. This finding is of particular concern, because studies by Loftus and collaborators have shown a correlation between contamination of anesthesia machines and contamination of intravenous stopcocks[12] as well as an association between hand contamination among anesthesia providers and contamination of intravenous stopcocks.[13] As part of interventions put in place to control an outbreak of endemic A. baumannii infection primarily involving our surgical and trauma intensive care units, we implemented an evaluation of environmental contamination and cleaning practices. As reported elsewhere, this evaluation started in our intensive care units and later expanded to include our operating rooms.[14] The evaluation of environmental contamination and cleaning practices in our operating rooms was achieved by objectively evaluating preintervention cleaning effectiveness and the degree to which improvement in the thoroughness of cleaning influenced bacterial contamination of operating room surfaces.