SPECIAL REPORT: A Perspective on the Year in Surgical Site Infection Prevention
Optimal Infection Control
Practices in the OR Environment
DONNA ARMELLINO, DNP, RN, CIC
T he Centers for Disease Control and Prevention’s
most recent National and State Healthcare-
Associated Infections Progress Report describes
reductions in nearly all health careeassociated infections
(HAIs) when compared with baseline data: central linee
associated bloodstream infections decreased by 50%, surgical site
infections (SSIs) decreased by 17%, Clostridium difficile infections
decreased by 8%, and methicillin-resistant Staphylococcus aureus
bloodstream infections decreased by 13%.1 Despite these positive
changes, patients are still at risk. An estimated 1 in 25 patients
contract at least one HAI during their hospitalization.1
To modify intrinsic and extrinsic risk factors in the OR
environment, perioperative personnel have focused on
performance improvement methodologies and implementa-
tion of care bundles.2-7 Surgical care bundles, combined with
quality improvement practices, can increase the care team’s
attention to improving surgical outcomes (eg, reducing HAIs)
through awareness of the problem, development and align-
ment of practice standards based on current literature and
guidelines, and continuous assessment and implementation of
improvement strategies based on practice compliance and
outcomes data. Regardless of the efforts, gaps remain in actual
practice when compared with standards of practice; this
emphasizes the urgent need to accelerate practice improvement
in the OR setting to decrease a patient’s risk of HAI.7,8
The OR environment is a complicated setting that contributes
to the likelihood of an HAI because of the disruption of the
patient’s primary defensive barrier, the skin. In addition to
disrupting one of the innate immune elements, patient risk is
also increased because of characteristics such as advanced age,
diabetes mellitus, obesity, and other comorbidities such as
immunosuppressive disorders.9 Surgical patients are also at
high risk for infection because of extrinsic factors such as the
type of procedure being performed, operative time, and
516 j AORN Journal
surgeon skill. Decreasing the burden of microorganisms in the
OR environment can decrease the risk of surgical incision
contamination and SSIs.10,11 Sources of environmental
contaminants could be health care professionals’ (HCPs’) skin,
hair, and hands, or the physical environment such as the OR
bed or anesthesia machine. Health care personnel must strive
to create an environment that is free of microorganisms,
especially in the OR setting.
Today’s perioperative standards of practice are guided by
AORN. AORN’s Guidelines for Perioperative Practice,
periodically revised based on evidence supported by research,
provide guidelines for optimal patient safety practices in the
perioperative setting.12 The standards for the profession are
outlined; the difficulty is in operationalizing these standards
with routine adherence by all staff members in the OR
environment. This article focuses on new discoveries blended
with existing knowledge on C difficile and environmental
contaminants, surgical attire, surgical hand scrub, and terminal
cleaning in the perioperative setting.
C DIFFICILE IN THE PERIOPERATIVE
SETTING
C difficile is a commonly reported cause of HAIs and is an
anaerobic, spore-forming, gram-positive bacterium that causes
diarrhea ranging from self-limiting to life threatening.1 The
organism is spread via the fecal-oral route and may be acquired
through the ingestion of spores spread from patient to patient
via HCPs’ hands or from the environment. Surgery or anti-
biotics can alter a patient’s colonic microbiome and allow for
the proliferation of ingested spores. The patient will have
diarrhea, and a confirmatory test for C difficile and treatment
for the infection will follow. The likelihood of infection
depends on risk factors related to the host (ie, immune status,
comorbidities), exposure to the spores (ie, frequent hospitali-
zations, long length of hospitalization, long-term care), and
http://dx.doi.org/10.1016/j.aorn.2016.09.019
ª AORN, Inc, 2016
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December 2016, Vol. 104, No. 6
factors that disrupt the normal colonic microbiome (ie, anti-
biotics, certain medications, surgery).13 Health care professionals
can hypothesize that if the perioperative patient avoids anti-
biotics related to an HAI and the patient’s environment is clean,
exposure to C difficile and the risk of development can
be reduced.
Patients with severe fulminant colitis caused by C difficile may
require a surgical intervention for a resection of the entire
colon or diverting loop ileostomy with colonic lavage followed
by high doses of vancomycin orally or via an enema, possibly
in combination with IV metronidazole. Although surgery is a
treatment option for C difficile, it appears to increase the risk
of infection.14 Saeed et al15 retrospectively analyzed SSIs and
C difficile and reported a correlation coefficient between SSI
and C difficile of 0.65. The five surgeries with the highest
prevalence of subsequent C difficile infection were liver
transplants (9.61%), above-the-knee amputations (8.86%),
heart transplants (7.45%), below-the-knee amputations
(5.80%), and pancreas surgery (5.49%).15 Other studies have
reported similar rates after surgical procedures, which draws
attention to the high risk in the surgical patient popula-
tion.16,17 This cycle can be broken by reduced exposure to
C difficile through improved environmental cleaning, perhaps
supplemented with the use of innovative technology such as
ultraviolet (UV) light and hydrogen peroxide vapor disinfec-
tion when the patient is known to have C difficile.18,19
Environmental cleaning with and without technology
continues to be explored in the literature. Ghantoji et al20
reported disinfection with pulsed xenon UV light after manual
cleaning with a nonbleach solution versus manual cleaning
with a 10% bleach solution and described no significantly
different results between the two groups in final contamina-
tion levels. The researchers assessed mean contamination level,
measured in colony-forming units, in rooms previously
occupied by a patient with C difficile. There were fewer
colony-forming units in the rooms cleaned with bleach
compared with the UV-cleaned rooms (0.71 versus 0.80,
respectively); however, UV light resulted in a larger percent
reduction in colony-forming units (95% reduction, P ¼
.0017).20 This study supports that UV light is at least
equivalent to bleach in reducing C difficile spores after cleaning
an isolation room previously occupied by a patient with C
difficile. Bleach is still a practical method for cleaning a room
after use by a patient with C difficile, and HCPs should assess
the benefits and limitations of both methods.
Another innovative method for cleaning is to disperse
hydrogen peroxide vapor onto surfaces after manual room
cleaning. The current systems on the market aerosolize
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Special Report: The OR Environment
hydrogen peroxide, which falls onto surfaces in the environ-
ment. This method has been shown to reduce spores and
microorganisms on porous and nonporous surfaces.21 Weber
et al19 evaluated outcomes in several studies using hydrogen
peroxide vapor, and all reported a decrease in C difficile.
A 2016 study conducted by McCord et al18 reported a
decrease in C difficile from 1.0 to 0.4 cases per 1,000 patient
care days after using hydrogen peroxide vapor (P < .001).
However, the length of time that the solution needs to remain
on the surfaces is lengthy and may interrupt patient care.18
Limitations and benefits of hydrogen peroxide vapor in
the OR specifically are unknown because most studies have
been performed in hospital rooms rather than ORs. It is
unknown if the air handling system (positive pressure and
high air exchange rate) will decrease the efficacy of hydrogen
peroxide vapor.
To reduce the transmission of spores in the health care envi-
ronment, HCPs must place patients with C difficile on contact
precautions in a private room with a hand hygiene sink and
toilet facilities. At minimum, health care personnel should
wear a gown and gloves for contact with the patient and the
patient’s environment. The HCP should remove his or her
gown and gloves before exiting the room and perform hand
hygiene. Spores are removed more effectively when hands are
washed with soap and water rather than alcohol-based hand
rubs.22 Using alcohol-based hand rubs may only displace
C difficile spores along the skin rather than remove them
because C difficile is highly resistant to alcohol.23 The patient’s
environment should be cleaned with an Environmental
Protection Agencyeregistered sporicidal solution (eg, bleach-
based product)24,25 daily and after the patient is transferred
or discharged. All equipment that is dedicated to the room
when the patient is on contact precautions or is used on
multiple patients should also be cleaned before use on another
patient.23,26 As with any protocol for patient management,
facility leaders need to assess HCPs’ compliance with protocols
and embed these protocols into practice to ensure repeat-
ability. A recent study found staff member adherence to
contact precautions to be low, at only 7% (n ¼ 237) and 22%
(n ¼ 51) when assessed in two acute care hospitals.27 When
HCPs do not comply with protocols intended to contain
microorganisms, the potential for transmission increases.
When managing a patient with C difficile, HCPs should
consider how workflow will be affected. If a patient is sched-
uled for an elective procedure, the patient’s diarrhea should be
resolved. If diarrhea persists, the procedure should be post-
poned. If it is an emergency procedure, HCP circulators
should adhere to contact precautions. The environment and
equipment should be thoroughly cleaned with an appropriate
AORN Journal j 517
Armellino
solution, and the patient should recover in a single room
recovery area, recover in a private room on the receiving unit,
or as a last resort be placed in a remote area of the post-
anesthesia care unit with an empty bay between patients.
CURRENT STATE OF INFECTION
PREVENTION IN THE OR SETTING
The presence of microorganisms in the OR environment de-
pends on HCPs’ practices and adherence to evidence-based
practices. As with any best practice, standards are available
and HCPs are expected to follow the standards. To enhance
HCPs’ practice adherence in the OR environment, all staff
members involved with patient care and maintenance of the
environment need to be aware of the standards, demonstrate
competency, and support repeatability of the standards to
achieve desired outcomes (eg, decreased HAIs); otherwise,
changes in outcome will not occur.5,28,29 Unfortunately, there
are reported gaps between expected practice and observed
practice in the literature.7,8,27
There has been increased interest in AORN practice guidelines
because of reported SSIs and benchmarks established by the
National Healthcare Safety Network, the nation’s infection
surveillance system for data collection. Personnel at some fa-
cilities voluntarily report SSI data or are required by regulatory
agencies to report data. Facilities must publicly report specific
SSIs for select infections (ie, SSIs for colon, hip, and hyster-
ectomy procedures), and this is required for participation in
the Centers for Medicare & Medicaid Services reimburse-
ment.30 Surveyors are also reporting more immediate jeopardy
situations for the Centers for Medicare & Medicaid Services
Infection Control Condition of Participation.31 Immediate
jeopardy is a situation in which the health care facility’s
practices are noncompliant with one or more of the Centers
for Medicare & Medicaid Services requirements of participa-
tion and have caused or are likely to cause patient injury,
harm, impairment, or death. The question is whether
noncompliance is related to lack of alignment of facility pro-
tocols with AORN guidelines, lack of HCPs’ knowledge and
awareness of standards, or lack of OR leaders’ expectations and
enforcement of the standards.
The ramifications of noncompliance can be modified with a
structured approach that engages all HCPs to increase the
awareness of SSI risk and incidence.5 Standards can be out-
lined in a protocol that can be reasonably implemented, are
simplified with minimal rules or steps to follow, and are
integrated into HCPs’ workflow. Leadership must be clear on
the expectation, provide initial training and ongoing training
when warranted, and possibly initiate disciplinary action for
518 j AORN Journal
December 2016, Vol. 104, No. 6
those who choose to resist transformation from noncompli-
ance to compliance. Health care professionals must follow
regulatory requirements, which may result in financial impli-
cations that could threaten the financial viability of the orga-
nization. However, we must minimize sources of microbial
contamination and transmission at any cost to align with our
goal to keep patients free from harm, including HAIs.11
Surgical Attire
AORN provides guidelines for garments and cover apparel to
minimize environmental contamination related to shedding of
HCPs’ squamous cells, hair, and hair dandruff (Figure 1).32
A recent statement on OR attire was released by the American
College of Surgeons,33 which differs slightly from the rec-
ommendations in the AORN guidelines and, in contrast to
AORN, recommends that
 scrub attire and hats worn during a dirty or contaminated
procedure should be changed before subsequent procedures
even if not visibly soiled,
 scrub attire should not be worn in the hospital facility
outside the OR area without a clean laboratory coat or
appropriate cover over them, and
 leaving ears or a small amount of hair exposed during
invasive procedures is acceptable.33
Several articles on surgical attire have been published recently
that challenge current recommendations and should be stud-
ied further. Chow et al34 reported no difference in SSIs among
13,302 procedures one year before implementing the use of
cover jackets compared with 12,998 procedures one year after
the policy was implemented; the SSI rate was 2.42% versus
2.76% (P ¼ .199). The authors recommended the cover
jacket requirement be discontinued. Vincent and Edwards35
conducted a systematic review of the literature on surgical face
masks and SSIs in clean surgery that reported no clear benefit
of wearing a face mask to prevent SSIs.
A synthesized literature review on surgical attire found that
tightly woven, tucked in, polyester fabrics minimized con-
taminants in the OR environment.36 In a small study
comparing reusable scrub attire made of cotton, polyester, and
carbon fiber with reusable scrub attire made of woven poly-
propylene, and single-use attire with nonwoven spunbonded
polypropylene, the researchers measured bacterial counts on
sterile blood agar plates and reported that single-use poly-
propylene clothing yielded reduced bacterial counts when
compared with reusable attire.37
Surgical attire for some procedures goes beyond surgical
scrubs, head cover, surgical mask, scrub jacket, or sterile
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December 2016, Vol. 104, No. 6
Figure 1. Proper surgical attire should minimize envi-
ronmental contamination from the health care pro-
vider’s skin and hair. Reprinted with permission from
the “Guideline for surgical attire.” In: Guidelines for
Perioperative Practice. Denver, CO: AORN, Inc; 2016.
surgical gown and sterile gloves if scrubbed. During some
procedures (eg, total joint replacements), surgeons and scrub
personnel wear special filtered-exhaust helmet airflow systems
with a hood and suit to minimize environmental contamina-
tion. A small, simulated study using powder detectable by UV
light focused on the timing of turning on the filtered-exhaust
system related to accumulated powder on the surgical drapes.
Environmental contamination was higher when the system
was turned on before initiation versus completion of gowning
(P < .05).38 Young et al39 reviewed the literature on surgical
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Special Report: The OR Environment
helmet systems and exhaust suits in relation to the reduction
of environmental contamination and arthroplasty SSIs.
Evidence from this systematic review revealed reduced intra-
operative contamination and deep SSIs when using negative
pressure body exhaust suits but no studies supporting benefit
from using the positive pressure helmet system. Reducing
contaminants in the OR environment is an ongoing process.
Some practices may be easy to implement (eg, turning on the
filtered-exhaust system after completion of gowning self and
others), yet additional evidence is still needed before recom-
mendations for practice on surgical attire are made or relaxed.
Surgical Scrub
The hands of scrubbed HCPs can serve as a source of
contamination. Surgical hand antisepsis is the first line
of defense against SSIs, and sterile gloves are the second line of
defense.22 Holes or tears in sterile gloves expose the patient to
HCPs’ hands and therefore provide a potential for incision
contamination8,40 and an increased risk of SSI.41 There may
be a role for antimicrobial surgical gloves with an internal
chlorhexidine gluconate coating to reduce contamination
when gloves are punctured, but the benefit requires more
research to evaluate the efficacy.42 AORN provides guidance
on when and how to perform a surgical scrub to reduce
transient and residential flora and prevent contamination of
the surgical site when gloves are perforated or torn.22 The two
surgical hand scrub options are the waterless alcohol-based
surgical hand rub and the traditional surgical hand scrub
with water.
A systematic review of the literature compared the traditional
scrub with the waterless scrub and reported that both were
effective in reducing hand flora.43 Shen et al44 also reported
that the waterless hand rub has several favorable factors such as
immediate rapid and prolonged action; decreased time to
complete; and less hand irritation, skin damage, and dermal
intolerance. Unfortunately, compliance with the surgical hand
scrub among OR HCPs is suboptimal.4 Controlling contam-
inants at the source (ie, HCPs’ hair, skin, hands) is one
approach; the other is removing and minimizing environ-
mental contaminants with proper cleaning and disinfection of
the OR environment.
Controlling Environmental Contaminants
AORN outlines recommendations for comprehensive terminal
cleaning practices to minimize the risk of environmental
contamination.24 The fundamental task is to clean the OR
environment at the end of each day with an Environmental
Protection Agencyeregistered disinfectant.45 Surfaces in the
AORN Journal j 519
Armellino
OR should be cleaned from the area that is the cleanest to the
dirtiest.24 Personnel assigned to terminal cleaning and super-
visors who oversee personnel performing this task should be
educated and deemed competent at the time of hire and
periodically thereafter assessed for competency, particularly if
there are practice changes or observed practices that breach
protocol, or if the OR does not visually pass inspection at the
beginning of the day. When cleaning the OR, personnel
should be particularly attentive to high touch surfaces (eg, the
computer mouse and keyboard, OR bed, door, anesthesia cart,
phone, IV pole, computer keyboards).46,47
Options for monitoring the quality of cleanliness include
microbiologic methods, fluorescent markers, and adenosine
triphosphate assays.47,48 Microbiologic methods entail collecting
specimens from surfaces and measuring the colony counts on
select culture media based on the targeted type of pathogen.
Another method is placing invisible fluorescent markers on room
surfaces before the cleaning and disinfection process. After
cleaning, personnel use a UV light to inspect the room to see if
the fluorescent mark was effectively removed. If there are no
visible signs of the marker, then a thorough room cleaning was
performed. Bioluminescence-based adenosine triphosphate as-
says measure bioburden on a surface, but the results do not
necessarily indicate viable pathogens.48 All three methods allow
for establishment of a room cleaning threshold, categorization as
pass versus fail, and information that can be used for feedback to
environmental services personnel.
Researchers are studying how to improve environmental
cleaning with novel solutions and technology that can enhance
cleanliness. In a study conducted in four ORs after routine
terminal cleaning, an antimicrobial isopropyl alcohol/organo-
functional silane solution was placed on select surfaces and
then evaluated with adenosine triphosphate assay. The surfaces
treated with the silane solution had lower surface bioburden
after treatment.49 Catalanotti et al50 reported that there may
be an added benefit to supplementing manual environmental
cleaning with UV light to decrease SSIs. The study reported a
46% decrease (P < .05) in SSIs after class I procedures and a
22.9% increase (P ¼ .697) in SSIs after class II procedures
when UV light was used nightly after manual cleaning. The
investigators hypothesized that the microbial load at the sur-
gical incision is greater in a class II procedure and therefore
environmental disinfection is less effective than for class I
procedures. Other innovative technology to enhance cleaning
such as hydrogen peroxide vapor disinfection can be consid-
ered for use in the OR with additional research.18,21 Well-
designed studies examining cleaning methods, disinfection,
and cleanliness monitoring are still needed to link environ-
mental cleaning and reduced risk of HAIs.51
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December 2016, Vol. 104, No. 6
Technology such as hydrogen peroxide vapor or UV light may
be supplements used to reduce contaminants after thorough
manual room cleaning. Before implementing these emerging
technologies or altering OR policies, facility leaders must have
a system in place to evaluate the effect implementation may
have on the unit and the facility as a whole. When adding
additional cleaning methods, there is a cost for the equipment,
a need for specialized HCP training on the equipment and
procedure, and increased operational cost because of the added
time to use the technology after room cleaning. Decisions to
incorporate supplemental cleaning methods could be based on
the prevalence of infection in the facility, type of surgery
performed, and availability of support (eg, financial, leader-
ship) provided to the department that will use the technology.
The evidence-based standard related to these emerging tech-
nologies has not yet been decided; at a minimum, cleaning
with Environmental Protection Agencyeregistered products
remains an acceptable standard for cleaning the OR
environment.24,25,45
CONCLUSION
The focused attention on preventing HAIs can be attributed
to leaders who are motivated to improve the quality of care
with evidence-based practices, patient expectations of an
uncomplicated surgical procedure, an awareness of reported
SSIs, and an organization’s focus on the financial implications
related to HAIs. Evidence continues to emerge on how con-
taminants can be minimized, and current recommended
practices provide good guidance on efforts to reduce con-
taminants. Until studies refute the benefit of reduced OR
environment contaminants and the relationship with HAIs,
HCPs should follow the current AORN guidelines to keep

patients safe from harm and provide effective, patient-
centered, timely, equitable, and efficient care.
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Donna Armellino, DNP, RN, CIC, is the vice presi-
dent of Infection Prevention at Northwell Health, Lake
Success, NY. Dr Armellino has no declared affiliation that
could be perceived as posing a potential conflict of
interest in the publication of this article.
www.aornjournal.org