Environmental surveillance in the operating room

AORN Journal , July, 2005 by Janice A. Neil, Pamela F. Nye, Lisa Ann Toven

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Perioperative nurses have an ethical obligation to provide patients with safe, effective care during surgical interventions. (1) A guiding principle of perioperative nursing care is surgical asepsis. Regulatory agencies monitor and evaluate OR environments, and
AORN's "Recommended practices for environmental cleaning in the surgical practice setting" provide guidelines for a safe, visibly clean environment to minimize patients' and health care workers' exposure to potentially infectious microorganisms. (2) These
recommendations state that, ultimately, it is the responsibility of perioperative RNs to ensure that the surgical environment is clean and eliminate environmental hazards to reduce the risk of surgical site infections that may be related to environmental
contamination. (2) This article describes the results of a pilot test of an instrument that was developed to help nurses conduct environmental surveillance of ORs after terminal cleaning has been performed, identify problem areas, and correct deficiencies before
patient care is affected adversely.

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TERMINAL CLEANING

Terminal cleaning of ORs should be performed once every 24 hours even if no procedure has been performed in the room. (2) Registered nurses should monitor the OR environment to ensure that terminal cleaning processes have been carried out effectively
according to the Centers for Disease Control and Prevention infection control guidelines. (3)

Terminal cleaning is performed in surgical procedure rooms and scrub and utility areas at the completion of daily surgery schedules. It includes cleaning

* surgical lights and external tracks;

* fixed and ceiling-mounted equipment;

* all furniture, including wheels and casters;

* equipment;

* handles of cabinets and push plates;

* ventilation faceplates;

* horizontal surfaces (eg, countertops, autoclaves, fixed shelving);

* the entire floor;

* kick buckets; and

* scrub sinks.

Both ongoing and terminal cleaning are extremely important because they not only decrease microorganisms and contamination risks but also may contribute to control and prevention of infection in patients. Cleaning solutions used for terminal cleaning are
institution-specific but must be bacteriocidal. This is of paramount importance because of the virulence of some organisms, including those that are medication resistant. An instrument that allows perioperative nurses to monitor the OR environment may contribute
to patient safety and positive outcomes and, ultimately, may contribute to a reduction in surgical infection rates.

SURVEILLANCE INSTRUMENT

The environmental surveillance monitor is a checklist of surfaces found in every OR (Table 1). The OR quality coordinator in one facility developed this instrument to track and trend terminal cleaning of the OR suite based on her observations of a general lack of
attention to detail in terminal cleaning processes. A score of one is assigned for each contamination event (ie, dust, paper, suture, blood spatter) found in a room, and the total is noted for each room each day. Data obtained from the instrument can be used to
identify and correct problem areas, and, in collaboration with environmental services personnel, improve terminal cleaning processes.

PILOT TEST

A pilot test of the instrument was conducted at a large academic medical center serving patients from 27 rural counties in a southeastern state. The interior of 22 operating suites currently in use at the medical center served as the setting. A nonexperimental,
descriptive design was used to compare the number of contamination events in rooms and on room surfaces daily during a six-month period.

Data collection was performed by an RN and the environmental services team leader or a designee on a daily basis Monday through Friday between 6 AM and 6:45 AM, using the following procedure.

* The entire room was inspected from the door.

* Monitors, booms, hanging equipment, ledges above cabinets, white boards and doors, light fixtures, casings holding monitors, desks, radios, shelves, overhangs, doors, counters, telephones, and floors were inspected individually.

* If dust or debris was found, it was removed immediately using the hospital approved cleaner and cloth, and this action was noted on the environmental surveillance monitor.

* Personnel coming into the room were notified and educated about the deficiencies noted in the room.

* A log was completed for each room, and a total score was calculated for each room.

* A daily report was submitted to relevant nursing, infection control, plant operations and environmental services managers.

Data were coded, and frequency distributions, means, and standard deviations were calculated for each item.

RESULTS

Figure 1 shows the total number of events by month. In January, the total number of dust, suture, blood, and paper events noted in all rooms was 1,217. In February, there was a 4% (54event) increase over January. This increase may have occurred because of
personnel changes in the environmental services department and the data collectors' increased familiarity with the instrument.

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 MEDICAL SURVEILLANCE

Top of Form
Purpose

The purpose of medical surveillance is for the early identification of conditions, if any, that could present an increased risk of adverse
Key Word Search Go health effects related to the task being performed.

Based on the type of work being performed, including consideration of factors such as the duration of the task, the materials being used,
and the potential for exposure, medical surveillance is either recommended or required for the job.

Specific test results and other personal medical information generated by these exams will be kept confidential between the employee
Bottom of Form and the physician. The physician will determine the scope of the exam, then inform the supervisor of their recommendations based on the
exam results. The supervisor will discuss these recommendations, if any, with the employee. The employee can contact the physician
• Purpose who performs the exam with any questions regarding the test results.

According to federal law, employees have the right to request copies of their medical or exposure records at any time by contacting their
• Objective supervisor or Human Resources.

Should you have any concerns or questions regarding this procedure, please contact EH & S at 515-6860.
• Scope
Objective

• Funding The primary purpose of the medical surveillance program is to identify medical conditions that could lead to an occupational disease.
The secondary objective is to assure compliance with federal and state regulations which require medical monitoring when employees
use certain materials.
• Responsibility
Scope

○ Supervisor's Responsibilities
○ HR, Academic Personnel, or Ag.
This section pertains to medical surveillance of University employees and students related to the use of chemicals, physical agents
(noise, radiation), or animal contact. Medical surveillance, as described in this section, does not include discussion of fitness for duty
exams (e.g. Campus Police Officer, Emergency Responder, etc.), although these exams must be conducted through the approved NCSU
medical provider.

Extension Personnel Reference in this section to use the NCSU approved medical provider (currently Student Health Services) does not pertain to drug
Responsibilities screening or exams conducted after work related injuries or illnesses (workers compensation cases) since these programs are currently
handled under separate arrangements.

○ Environmental Health and Funding

Safety Center Responsibilities Charges for appropriate medical surveillance exams, tests and consultations, as of September 1, 2000, will be handled at the college
level. Supervisors will no longer be billed directly for the employee's medical costs. However, medical cost will be billed to the
• Medical Surveillance Criteria individual departments, as usual, for nonacademic (Finance and Business and receipts supported) departments. For questions concerning
applicability contact Roger Lewis, 515-6862.

• Access to Medical Services and Consultation Non-Employees and NCSU Students

It is the responsibility of the supervisor to notify the individual about his/her responsibility to comply with N.C. State’s occupational
medicine program requirements. For a description of required medical exams and tests, please refer to section entitled ‘Medical
Surveillance Criteria’. In addition, there is also a Medical Surveillance Chart that can be used to assist the supervisor in determining
what vaccinations and medical services are recommended when handling animals. Individuals are required to submit documentation to
their NCSU supervisor that they have fulfilled the medical program requirements. Upon termination of duties, the supervisor shall
forward any personnel medical documentation to the Occupational Medicine Program Administrator, Student Health Center, Box 7304.

If an individual arrives without having met the appropriate occupational medicine requirement, they must receive their required tests and
exams through the NCSU Occupational Medicine program by submitting an Exam Request Form and/or other applicable forms or
questionnaires to the Occupational Medicine Program Administrator. All costs of exams, questionnaire reviews, vaccinations, etc. will be
charged to the particular college.

If a respirator is required and not received prior to arriving at the University, respiratory protection training and fit-testing will be
provided by the EHSC. Please refer to the section, Respirator Approval Exams for information concerning medical approval for
respirator use. Respirator training and fit-testing may also be billed back to the college..

Special requirements may apply depending upon the individual’s status as described below:

Unsupported Individuals:

Individuals, who are not sponsored by a host institution, who receive medical services through the Occupational Medicine Program, may
request copies of medical records to be provided to their own personal physician.

Unsupported individuals with special medical conditions or concerns, whose health is affected by their work or workplace, should be
sent to their personal physician for work-related medical review.

Supported Individuals:

Supported individuals who receive services through the Occupational Medicine Program, should have copies of medical records sent to
their host institution’s medical office. It is the responsibility of these individuals to confirm that the occupational medicine exams, tests
and approvals, as well as training for respirator use, as required for NCSU employees are also in accordance with their own institutional
health and safety policies.

Supported individuals in need of respiratory protection should get the necessary training, fit testing and equipment at their host
institution. If respiratory protection training is to be provided by the University, permission must first be obtained from the host
institution.

Supported individuals with special medical conditions or concerns, whose health is affected by their work or workplace, should be sent
to their host institution’s medical provider.

NCSU Students serving as volunteers, trainees and observers

NCSU Students will receive all occupational medicine services through SHS Occupational Medicine Program. Students may be referred
to EHSC for respirator training and fit testing. Students are to complete the required Occupational Medicine forms or questionnaires and
submit to SHS Occupational Medicine Administrator for review. Expenses from form review and services are billed to the college.

Responsibility

Supervisor's responsibilities:

1. Review employee job tasks against the Medical Surveillance Criteria listed below.

2. Contact EH&S at 515-6862 if medical surveillance is indicated for an employee. Medical

surveillance is determined to be appropriate based on input from the supervisor, EH&S, and
the medical provider.

3. Use the approved NCSU medical provider. Currently, this is Student Health Services.
(Nonacademic departments are to bear the cost of employee's exam.)

○ Note: Refer to Access to Medical Services and Consultation for guidelines on

making medical appointments or consulting with a Student Health Services'
medical provider.
 4. Prior to receiving a medical screening exam, the supervisor must review the following "Medical
Surveillance Statement" with the employee:

"Based on the type of work you are performing, including considerations of factors such as the duration of your task,
the materials being used, and the potential for exposure, medical surveillance is either recommended or required for
this job. The purpose of this medical surveillance is for the early identification of conditions, if any, that could present
an increased risk of adverse heath effects related to the task you are performing. NOTE: Information on the disclosure
of private health information is described in the NCSU Notice of Privacy Practice.

Specific test results and other personal medical information generated by those exams will be kept confidential
between you and the physician. The physician will determine the scope of the exam, then inform your supervisor of
their recommendations based on your exam results. Your supervisor will discuss those recommendations, if any, with
you. You can contact the physician who performs your exam with any questions regarding your test results.

According to federal law, you have the right to requests copies of your medical or exposure records at any time by
contacting your supervisor or Human Resources.

Should you have any concerns or questions regarding this procedure, please contact the Human Resources
Department."

5. The supervisor will discuss the physician's recommendations with the employee. Note: The
supervisor will not receive the employee medical exam results. Rather, they will receive a
"Health Recommendation Form," which contains the examining physician's recommendations
based on his/her findings.

6. Assure employees report to the physician on time for the medical exam. Continued work
performance is contingent on completion of medical exams. Annual exams not completed
within 3 months of the due date will require the employee to stop the task until completion of
the exam.

7. Where department employees are required to receive medical exams/tests based on specific
tasks and conditions, supervisors are to ensure that students performing these same tasks
under the same working conditions obtain this medical screening. All students, paid or
volunteer, will have exams paid for in the same manner as full time employees. Students may
be referred to EHSC for respirator training and fit testing. Students are to complete the
required Occupational Medicine forms or questionnaires, including the Animal Contact
Questionnaire and submit to the Occupational Medicine Program for review. Expenses from
form review and services are billed to the college.

8. Maintain any physician's reports in a confidential manner. Keep this information with the
departmental records for the employee.

9. Maintain the physician's report for the duration the employee works for you. Transfer these
and other employee records to Student Health Services.

10. Immediately contact Human Resources, Academic Personnel or Ag Extension Personnel when
an employee requests access to their medical records or exposure records.

11. Reexamine medical surveillance criteria versus job task should job duties change.

12. It is the responsibility of the supervisor to notify visitors, trainees and other non-NCSU
employees (referred to collectively as “visitors”) about their responsibility to comply with N.C.
State’s occupational medicine program requirements. Individuals who fall under a requirement
of the program are required to inform their NCSU supervisor that they have fulfilled N.C.
State’s medical program requirements. Upon termination of duties, the supervisor shall
forward any personnel medical documentation to the Occupational Medicine Program
Administrator, Student Health Center, Box 7304.

If a visitor arrives without having met the appropriate occupational medicine requirement, they must receive their
required tests and exams through the NCSU Occupational Medicine program by submitting an Exam Request Form
and/or other applicable forms or questionnaires to the Occupational Medicine Program Administrator. All costs of
exams, questionnaire reviews, vaccinations, etc. will be charged to the particular college.

If a respirator is required and not received prior to arriving at the University, respiratory protection training and fit-
testing will be provided by the EHSC. Please refer to the section, Respirator Approval Exams for information
concerning medical approval for respirator use. Respirator training and fit-testing may also be billed back to the
college.

Of particular note, for a visitor, an Animal Contact Questionnaire is not required before handling animals. In addition
to the information provided in the Medical Surveillance Criteria section, there is aMedical Surveillance Chart that can
be used to assist the supervisor in determining what specific vaccinations and medical services are recommended when
handling animals. For questions concerning this chart, the supervisor may contact the Occupational Medicine Program
Administrator at 919-513-0277. For additional information concerning animal contact please refer to the Animal
Contact Program.

Special requirements may apply depending upon the visitor’s status as described herein. Unsupported Visitors, i.e.
those who are not financially sponsored by a host institution, who receive medical services through the Occupational
Medicine Program, may request copies of medical records to be provided to their own personal physician. These
visitors with special medical conditions or concerns, whose health is affected by their work or workplace, should be
sent to their personal physician for work-related medical review. Supported Visitors, who receive services through the
Occupational Medicine Program, should have copies of medical records sent to their host institution’s medical office.
It is the responsibility of these visitors to confirm that the occupational medicine exams, tests and approvals, as well as
training for respirator use, as required for NCSU employees are also in accordance with their own institutional health
and safety policies.

Supported visitors in need of respiratory protection should get the necessary training, fit testing and equipment at their
host institution. If respiratory protection training is to be provided by the University, permission must first be obtained
from the host institution. Supported visitors with special medical conditions or concerns, whose health is affected by
their work or workplace, should be sent to their host institution’s medical provider.

Human Resources, Academic Personnel, or Ag. Extension Personnel responsibilities:

Brief appropriate departmental representatives on the Departmental Responsibilities listed above.

Environmental Health and Safety Center responsibilities

1. Coordinate medical management program for the University.

2. Act as NCSU liaison with the medical provider, Student Health Services.

3. Work in cooperation with contract medical provider to improve efficiency and effectiveness of
medical management program.

4. Work in cooperation with contract medical provider to determine tasks where medical
surveillance is appropriate. Provide feedback to supervisors on medical surveillance inquiries.

Medical Surveillance Criteria

NCSU Environmental Health and Safety developed these criteria with the assistance from occupational health physicians. The criteria
are subject to modification upon periodic review.

1. OSHA requires medical surveillance for employees who:

a. Have exposure to noise levels exceeding 85 dBA in an 8 hour time weighted

average exposure. Refer to section 100-20, NCSU Health & Safety Manual for
additional information. Refer to Hearing Conservation Requirements for
additional information.

b. Wear a respirator. Note: Refer to Guidelines for Respirator Wear for an

explanation on annual medical approval.

c. Have exposure to asbestos above the permissible limit or excursion limit for 30
days/year; perform Class 1,2, or 3 asbestos work for 30 days/year.

d. Use any of the following 13 OSHA regulated human carcinogens as "authorized

employees" and those entering "regulated" areas. Note: You must have
approval from EH&S to use any of these materials.

4-Nitrobiphenyl
Alpha-Naphthylamine

Methyl Chloromethyl Ether

3,3' Dichlorobenzine (and its salt)

Bis-Chloromethyl Ether

Beta-Naphthylamine

Benzidine

4-Aminodiphenyl

Ethyleneamine

Beta-Propiolactone

2-Acetylamino Fluorine

4- Dimethylaminoazobenzine

N-Nitrosodimethylamine

e. Use Vinyl Chloride and are exposed above the action level. (The "action level" is
typically one half of the permissible exposure level for the chemical.)

f. Use Inorganic arsenic and are exposed above the action level for at least 30
days/year and based on previous exposure.

g. Use Metallic Lead, Inorganic Lead, or Organic Lead Soaps and are exposed
above the action level for greater than 30 days/year

h. Use Benzene and are exposed above the action level for greater than 30
days/year and based on additional requirements.

i. Have "occupational exposure" to Blood borne Pathogens, refer to NCSU

Biological Safety Manual, Appendix C, for information.

j. Are exposed to Cotton Dust and are engaged in yarn manufacturing, slashing
and weaving operations, or work in waste houses for textile operations

k. Use 1,2 - Dibromo-3-Chloropropane, working in a regulated area or may be

exposed in an emergency situation

l. Are exposed to Acrylonitrile above the action level

m. Are exposed to Ethylene Oxide at or above the action for at least 30 days/year

n. Are exposed to Formaldehyde greater than the action level or greater than the
short term exposure limit.

o. Are exposed to Methylenedianiline greater than or equal to the action level for
30 days/year.

p. Are exposed to Cadmium greater than or equal to the action level for 30
days/year.

2. In addition, employees will need medical surveillance for the following jobs. Note: Medical
surveillance may NOT be needed where adequate engineering controls or protective
equipment are in use, or when there are no reliable medical tests.

a) All employees having a potential for significant exposure to cholinesterase inhibiting organophosphate chemicals
should participate in periodic monitoring of cholinesterase levels. Refer to Pesticide Exposure Prevention for additional
information on exposure reduction, and Cholinesterase Biomonitoring Program for Cholinesterase activity
determination.

b) Maintenance operations that creates airborne particles of lead, cadmium, arsenic, or other systemic toxins where
local exhaust is not used.

c) Significant and prolonged use of mercury, chlorinated solvents, heavy metals, or other solids and liquids with
 chronic toxicity and:

- enclosure and local exhaust ventilation are not available or ineffective or

- prolonged glove contact is necessary and material is capable of rapid absorption through the skin or;

- oral uptake is possible from contaminated surfaces and the material used is a systemic poison.

d) Use of radioactive material under specific conditions described in NCSU Radiation Protection

e) Use of Class 3b and 4 lasers - ophthalmology exam required prior to use

f) As specified by department or committee requirements

Note: Various advisory groups (e.g. Biosafety Committee) or colleges (e.g. CVM) may recommend/require medical
exams, biological monitoring, immunizations, or titers based on the nature of the work activity. Refer to Animal
Contact for information concerning vertebrate animal exposure.

Environmental Health & Safety Center personnel will assist supervisors in determining whether medical monitoring is necessary or
appropriate for their employees. Call 515-6860 or 515-6862-for information.

Access to Medical Surveillance Services and Consultation

In order to contact Student Health Services for advice or to make an appointment to receive a medical service, you will need to complete
the following steps:

For medical appointments:

For Respirator Approval Exams, complete and send the following forms in a sealed envelope to: Occupational Medicine Coordinator,
Student Health Services, Box 7304

1. Exam Request Form

2. Confidential Medical Evaluation & Workplace Exposure Questionnaire

Be sure to check on the exam request form what medical service you are requesting; fill out the form completely, use space on form to
explain your answers. Respirator exams for using SCBA equipment for emergency response activities will be scheduled by Student
Health. Employees requesting an annual SCBA medical for emergency response should fill out only an Exam Request form and send to
Student Health. Please refer to Respiratory Protection Program for program guidelines.

For Vaccinations please complete and send the following forms in a sealed envelope to: Occupational Medicine Coordinator, Student
Health Services, Box 7304

1. Exam Request Form

For audiograms please complete and send the following forms in a sealed envelope to: Occupational Medicine Coordinator, Student
Health Services, Box 7304. Please refer to Hearing Conservation Requirements for program information.

1. Exam Request Form

2. Hearing Log

For Animal Handler questionnaire review and Animal Handler Physicals please complete and send the following form in a sealed
envelope to: Occupational Medicine Coordinator, Student Health Services, Box 7304 Please refer to Animal Contact for program
guidelines.

1. Animal Contact Form

For All Other Exams, such as blood lead determinations and cholinesterase inhibitor checks please complete and send the Exam
Request Form in a sealed envelope to: Occupational Medicine Coordinator, Student Health Services, Box 7304. Please refer to Pesticide
Exposure Prevention for program guidelines.

Once the form is received by Student Health, the Occupational Medicine Coordinator will e-mail you appointment information. Please
allow for a period of two weeks to schedule an appointment.

Contact Points

• Medical Advice: 513-2380

• Billing and appointment scheduling: 513-0277

• Non-medical advice (e.g. program requirements, chemical exposure monitoring): 515-6862

• NCSU Notice of Privacy Practice: 513-3267