Procedure Room - Infection Control

The procedure suite will provide a clean environment for 
procedure patients.
Attention: Products used for disinfecting and environmental 
cleaning are appropriate to the task and EPA rated as 
germicide; antimicrobial, antibacterial, antiviral, 
antifungal, and tuberculocidal.
    1. Daily prior to first case, all flat surfaces of 
       tables, equipment, lights, and counter tops in 
       procedure room and utility room are damp dusted with 
       germicide.  Assure that the germicide is left on the 
       surfaces for the proper amount of time to achieve low 
       level disinfecting; see the manufacturer's 
    2. Throughout the procedure:
       a. Traffic is kept to a minimum and doors are closed
       b. Proper attire shall be worn by all persons. 
       c. Procedures shall be performed utilizing the 
          appropriate level of aseptic technique.
       d. Gloves are worn when handling contaminated objects
       e. Visibly and potentially soiled gloves are not worn 
          when handling clean items.

       f. Goggles are available for all personnel, 
    3.  Following the procedure:
       a. Disposable gowns and gloves are removed prior to 
          leaving the procedure room.
       b. All contaminated equipment is placed in one area 
          for processing in the routine manner.
       c. Sharps are disposed of in the routine manner
       d. Housekeeping:  Standard precautions must be 
          strictly adhered to.  Use of facility accepted 
          germicidal for cleaning between cases as per 
          routine.  Linen will be placed in laundry bag, 
          trash discarded in routine manner. Regulated waste 
          discarded in routine manner.
Operating Room:
Cleaning should be performed on a regular basis to reduce the 
amount of dust, organic debris and microbial load in surgical 
environments.  Operating rooms should be cleaned before and 
after each surgical procedure and the end of each day.  
Cleaning also may be necessary during any surgical procedure. 
 The ultimate responsibility for ensuring a clean surgical 
environment rests with the peri-operative personnel. 
The staff working within cleans the operating room.  All 
horizontal surfaces in the OR should be damp dusted before 
the first scheduled surgical procedure for the day with a

clean lint free cloth moistened with an approved 
disinfectant/germicide. Equipment from other areas brought 
into the OR must be cleansed in the same manner.  
For subsequent surgical procedures, between-procedure 
cleaning is performed.  The floor, if contaminated, is mopped 
with 10% bleach solution or appropriate germicide, with a 
clean mop head.  The operating room tables, back tables, 
Mayo, stand, OR lights and all equipment brought into the 
operating room are cleansed with a lint free cloth damped 
with organization approved germicide. Assure that the 
germicide is left on the surfaces for the proper amount of 
time to achieve low level disinfecting; see the 
manufacturer's instructions. The same method is used for 
dusting other electrical equipment and surfaces.  If 
contamination occurs, the equipment within the operating room 
is decontaminated following the manufacturer' instructions.  
Suction bottles are emptied into the regulated waste system. 
All used disposable sharps are considered infectious waste.  
They must be placed in designated puncture resistant 
containers that have a biohazard label.
All instruments must be transported to the utility area in 
covered boats, trays or closed washable carts.
Spills of contaminated debris in areas outside the surgical 
field should be removed as promptly as possible.  Gloves and 
other personal protective equipment should be utilized as 
appropriate.  Small spills (less than 10 ml) should be 
cleaned and disinfected with organization approved germicide

chlorine bleach in a 1:100 dilution.  Large spills (greater 
than 10 ml) must be disinfected with a 1:10 chlorine bleach 
solution.   Bleach solutions must be prepared daily.  
Contaminated disposable patient care items should be 
discarded in a leak-proof, tear resistant regulated waste 
container.   Staff handling contaminated items should wear 
gloves, gowns, and/or other protective attire as appropriate 
to the task.
Preparation of the OR should include visual inspection for 
cleanliness before anything is opened or brought in for the 
next case.
Patient transport vehicles including straps and attachments 
should be cleaned after use with a cloth moistened with an 
organization approved germicide. 
Recovery Rooms:
The recovery rooms are cleansed in the same manner as above. 
Instruments are transferred to the decontamination area in 
covered boats, trays, or washable carts. 
The instruments are soaked in an enzymatic detergent, 
brushed, flushed, etc and then rinsed.  The sets are wrapped 
with sterilization indicators and autoclaved according to the 
settings for the individual autoclave.
The exam room instruments are washed and sterilized in the 
same manner as above.
Patient Bathroom:
The toilet and walls should be wiped with a germicidal wipe 
or 10% bleach solution as needed.  The floor may be mopped 
with a dilute Clorox solution (1:10).
Personal Protective Equipment
The use of heavy gauge vinyl gloves during all cleaning 
procedures is standard practice.  Since there is a 
possibility of splashing while cleaning, the use of goggles 
and mask are mandatory.
All areas and equipment in the surgical practice setting 
should be cleaned according to an established schedule.
Areas and equipment to be cleaned should include, but are not 
limited to:
        a. Ducts and filters, 
        b. Air-conditioning equipment
        c. Return ventilation and heating grills
        d. Recessed ceiling racks for overhead lighting
        e. Closets, cabinets, and shelves
        f. Storerooms
        g. Sterilizers and refrigerators,
        h. Walls, ceilings and 
        i. Offices, lounges, lavatories

Approved By Governing Board    
Control #298.2