Microbial Flora on Operating Room Telephones

Article Outline

• ABSTRACT
• Research Questions
• Literature Review
  • Inanimate surfaces as bacterial reservoirs.
  • Animate reservoirs as transfer agents.
  • Environmental surfaces as fomites.
• Methods
  • Sample and setting.
  • Specimen collection and analysis procedures.
  • Laboratory and equipment.
  • Phenotypic testing agents.
  • Statistical analysis.
• Results
  • Question one.
  • Question two.
  • Question three.
• Discussion
  • Incidental findings.
• Limitations
• Implications and Conclusion
• Notes
• Copyright

ABSTRACT 

Approximately 500,000 surgical site infections (SSIs) occur each year in the United States.¹ Health care-acquired infections (HAIs) contribute to prolonged antimicrobial treatments, increased lengths of hospital stay, and even death.² The Centers for Disease Control and Prevention (CDC) reports that in 1999, the most prevalent causes of SSIs were Staphylococcus aureus (S aureus), coagulase-negative staphylococci, enterococcus species, and Escherichia coli (E coli).², ³ There have been no published changes about the prevalence of these bacteria in relation to SSIs since 1999. A study published in 2003 reports that extremes of costs for SSIs may exceed $92,363 for patients with SSIs caused by methicillin-resistant S aureus (MRSA).⁴

The most common source of SSIs are endogenous flora,⁵ but exogenous flora also are a possible cause.², ⁶ If exogenous flora are causing some SSIs, how are they being transmitted? Could the hands of health care workers be a source? What other surfaces might be involved via direct or indirect contact with patients? One inanimate item in the OR that frequently is in contact with staff members' hands is the telephone. This article describes a study conducted to identify and quantify bacterial contamination on telephones in the OR of a large, teaching medical center.

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Research Questions 

This study attempted to answer the following research questions.

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Literature Review 

Many factors are associated with HAIs, and a chain-of-infection model provides the best framework for depicting the relationships among these factors and SSIs. According to the chain-of-infection model, a causative agent or pathogen survives within a reservoir, exits the reservoir via a mode of transmission, and enters a susceptible host, thereby causing disease.⁷ Intervention in any part of this process can stop disease transmission. Reservoir can be plants, animals, soil, water, and inanimate surfaces.⁸ Of these, the most likely exogenous reservoir in the surgical setting is either an inanimate surface or a human (ie, an animate reservoir). Both reservoirs are capable of becoming transmission agents.

Inanimate surfaces as bacterial reservoirs. 

The evaluation of inanimate surfaces is best categorized by Spaulding's classification system, which classifies items as critical, semicritical, or noncritical.⁹ Critical items present a significant risk of infection if microorganisms are present because these items come in contact with sterile tissue. Semicritical items pose less risk, even though they come in contact with mucous membranes or nonintact skin. Noncritical items only come in contact with intact skin and pose little risk of infection. Noncritical items used in patient care, however, can serve as a mode of secondary transmission by providing a reservoir that can contaminate the hands of health care workers.¹⁰ This mode of transmission (ie, surface-to-hand transfer of bacteria) is well documented in the literature.¹¹, ¹²

Animate reservoirs as transfer agents. 

Proper hand washing is considered one of the most important steps in preventing infections.⁹ Despite several studies documenting hands as carriers of infection,¹³, ¹⁴ hand washing compliance has been shown to be as low as 9% for medical intensive care unit (ICU) health care workers and 3% for cardiac surgery ICU health care workers.¹⁵ As few as 58% of anesthesiologists report that they wash their hands after contact with every patient,¹⁶ and compliance with hand cleansing by postanesthesia care unit (PACU) staff members was shown to be 12.5%.¹⁷ If proper hand hygiene is not performed, items frequently contacted by hands could serve as reservoirs, and those reservoirs could further serve to contaminate hands; thereby increasing the risk of spreading infections to patients during hand-to-patient contact.

Environmental surfaces as fomites. 

Although the importance of cleaning environmental surfaces is well recognized as a standard of care, little research is available that describes the relationship between the quantity of pathogens present on surfaces and increased HAI rates.¹⁸ Bacteria are capable of transferring antibiotic resistance;¹⁹, ²⁰, ²¹, ²², ²³ therefore, it can be argued that where bacteria are allowed to survive on environmental surfaces, antibiotic resistance could be increased. It is reasonable to question the cleanliness of environmental surfaces in the surgical setting, especially when as much as 32% of anesthesia equipment has been found to have occult blood present.²⁴

The role of inanimate surfaces as fomites (ie, an inanimate object that serves to transmit an infectious agent from person to person) is not well documented. Some recent studies suggest that there is no link between infection rates and surface contamination,²⁵, ²⁶, ²⁷ although other studies demonstrate that environmental surfaces and nursing uniforms have increased contamination from patients known to be infected or colonized with MRSA.²⁸, ²⁹ A wide range of environmental surfaces have been shown to be sources of HAI, including an electronic ear probe,²⁹ a stretcher frame,²⁸ a shower handle,²⁸ and OR surfaces.³⁰

To determine the likelihood of bacterial presence on telephones and subsequent transfer via hands, the literature was reviewed to identify survival times on hands and inanimate surfaces of the bacteria most frequently implicated in SSIs. These bacteria are S aureus, coagulase-negative staphylococci, enterococcus species, and E coli. The literature review also included MRSA and vancomycin-resistant enterococci (VRE), because both of these bacteria are variants of S aureus and enterococcus species. Few studies have examined bacterial growth on telephones; therefore, studies using plastic surfaces also were reviewed.

Table 1 is a compilation of the literature review and is reflective of experimental and quasi-experimental studies dating back to 1989. Although some of the studies are dated, in many cases these studies are either landmark or sole-source references. Each of the studies used different inoculum concentrations and techniques and provides evidence that bacteria might be present on OR telephones. These studies indicate that the passage of time alone will not eliminate bacteria sufficiently. The importance of hand washing, aseptic technique, and surface decontamination is evident.

Table 1. Bacterial Survival on Surfaces

1 R Porwancher et al, “Epidemiological study of hospital-acquired infection with vancomycin-resistant Enterococcus faecium: Possible transmission by an electronic ear-probe thermometer,” Infection Control and Hospital Epidemiology 18 (November 1997) 771–773.

2 AN Neely, M P Maley, “Survival of enterococci and staphylococci on hospital fabrics and plastic,” Journal of Clinical Microbiology 38 (February 2000) 724–726.

3 G ANoskin et al, “Recovery of vancomycin-resistant enterococci on fingertips and environmental surfaces,”

4 C Wendt et al, “Survival of vancomycin-resistant and vancomycin-susceptible enterococci on dry surfaces,”

5 H F Bonilla, M J Zervos, C AKauffman, “Long-term survival of vancomycin-resistant Enterococcus faecium on a contaminated surface,” Infection Control and Hospital Epidemiology 17 (December 1996) 770–772.

6 S I Getchell-White, LG Donowitz, D H Groschel, “The inanimate environment of an intensive care unit as a potential source of nosocomial bacteria: Evidence for long survival of Acinetobacter calcoaceticus,” Infection Control and Hospital Epidemiology 10 (September 1989) 402–407.

7 B Fryklund, K Tullus, LG Burman, “Survival on skin and surfaces of epidemic and non-epidemic strains of enterobacteria from neonatal special care units,” The Journal of Hospital Infection 29 (March 1995) 201–228.

8 S M Smith, R H Eng, F T Padberg, Jr, “Survival of nosocomial pathogenic bacteria at ambient temperature,” Journal of Medicine 27 no 5–6 (1996) 293–302.

In one study conducted to document environmental surfaces and hands of health care workers as reservoirs, 26 telephones were cultured in an ICU, and researchers found S aureus, Acinetobacter calcoaceticus (A calcoaceticus), and Pseudomonas species.³¹ In another study of noncritical items frequently in contact with the hands of hospital staff members, 20 telephones from the OR, ICU, PACU, and emergency department (ED) were cultured; none of the cultures resulted in the identification of gram-negative bacteria.³² One group of researchers cultured 11 telephones in an ICU and identified coagulase-negative staphylococci, coagulase-positive staphylococci, gram-positive rods, and alpha-hemolytic Streptococcus.³³

The literature indicates the potential for bacteria to be present on telephones for varying lengths of time and demonstrates that frequently, there is a lack of both hand washing and decontamination of environmental surfaces by hospital staff members. Additionally, inanimate surfaces have been implicated in infections. One study clearly linked the transfer of bacteria from telephones to hands and from hands to other skin surfaces. It was demonstrated that Micrococcus luteus can be transferred from telephones to hands with approximately 41% efficiency and from hands to mouth at the same rate.³⁴

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Methods 

The purpose of this descriptive study was to determine if the bacteria most frequently involved in SSIs could be found on telephones in the OR of a large teaching medical center. This study focused exclusively on S aureus, coagulase-negative staphylococci, enterococcus species, E coli, MRSA, and VRE.

Sample and setting. 

The researchers intended to take a quota-based convenience sample of 30 cultures from telephones within the ORs; however, only 26 cultures were obtained from telephones in 14 ORs and two substerile rooms. Two control cultures and two double cultures also were collected. Specimen collection was divided between two days that were separated by 19 days to decrease the likelihood that perioperative personnel might alter hand washing, aseptic technique, and environmental disinfection practices because they were aware of the study and data collection.³⁵ This research protocol was approved by the institutional review board of the medical center and the Uniformed Services University of the Health Sciences, Bethesda, Md.

Specimen collection and analysis procedures. 

To ensure precision in data collection, the laboratory officer oriented the researchers to the medical center's laboratory and familiarized them with testing supplies and procedures. With the assistance of the microbiologist, the researchers developed a guideline, depicted in Figure 1, for all testing procedures. This bacteria-identification algorithm was adapted from algorithms found in The Textbook of Diagnostic Microbiology.³⁶ The guideline was incorporated into a standardized specimen data collection and analysis sheet for use in recording the identification and interpretation of bacteria. The data collection sheet was used to capture data related to

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• Figure 1. 

  Bacterial Identification Algorithm¹, ²

The researchers' basic laboratory skills were evaluated during a practical examination using eight known bacterial isolates. Cultures were taken from OR telephones at the end of surgical procedures and before the surgical suites were cleaned to eliminate unnecessary traffic through the surgical area.

Cultures were taken in the same manner by three researchers wearing sterile gloves. All four sides of the telephone hand piece handles were swabbed. The posterior swab path included one vertical pass from ear piece to mouth piece; the researcher held the swab on its side, rotating or rolling it across the surface. Swabs with non-nutritive modified Stuart's medium were used to obtain bacterial sampling. Validity and reliability testing was obtained by random double-culturing and random control-culturing techniques. The double-culture technique included swabbing the telephones in the manner described previously with two consecutive culturettes, attempting to eliminate path over-run. These culturettes were labeled so that one researcher was blinded to the source. One control culture was randomly selected for each culture batch. The control culturettes were opened and resealed without exposure to contaminants.

After the samples were obtained, the swabs were returned aseptically to their cases, labeled, and numbered sequentially. Swabs were delivered to the laboratory within 15 minutes of the samples being taken. All samples were streaked for isolation onto trypticase soy agar with 5% sheep blood agar, chocolate agar, and MacConkey agar, respectively. The agar plates were incubated at 35° C (95° F) for 24 hours. Chocolate and blood agar plates were incubated in 4% carbon dioxide (CO₂) while MacConkey agar plates were incubated in 1.2% CO₂. After the first 24 hours, all of the bacterial flora were quantified visually into the number of colonies present. If no colonies were present at 24 hours, confirmation was performed again at 48 hours.

Although blood agar plates would support the growth of S aureus, MRSA, coagulase-negative staphylococci, enterococcus species, VRE, and E coli, there was an ethical obligation to rule out other bacteria capable of causing HAIs. Chocolate and MacConkey agar were used to rule out Acinetobacter species, Pseudomonas aeruginosa (P aeruginosa), Haemophilus influenza, and Neisseria gonorrhoeae.

Staphylococcus aureus, enterococcus species, MRSA, VRE, coagulase-negative staphylococci, and E coli were identified by shape—spherical (ie, coccus), rod-like (ie, bacillus), or spiral (ie, spirochete); and cell wall—gram-positive or gram-negative as seen with gram stain. Spiral-shaped bacterial were not considered in this study because they typically are not associated with HAI. Gram-negative rods were further tested for oxidase and indole reactions. Positive oxidase and negative indole results ruled out E coli and were tested further to rule out Acinetobacter calcoaceticus-Acinetobacter baumannii (A calcoaceticus-baumannii) and P aeruginosa.

Gram-positive bacteria initially were tested using 3% hydrogen peroxide for catalase testing, which was used to differentiate group 1 bacteria—catalase-positive bacteria (ie, MRSA, micrococcus, S aureus, coagulase-negative staphylococci) from group 2 bacteria—catalase-negative bacteria (ie, enterococcus species, other streptococceae). Group 1 bacteria then were tested with a rapid latex agglutination test to rule in S aureus. Bacteria that were negative for the rapid latex agglutination test then were tested with the microdase test to differentiate coagulase-negative staphylococci from micrococcus species. The hydrogen peroxide catalase-negative bacteria were analyzed using the phadebact D test to differentiate potential enterococcus from other streptococcus species.

An automated microbiology laboratory testing system was used for gram-positive identification and gram-negative identification to identify Agrobacterium radiobacter /tumefaciens (A radiobacter /tumefaciens), A calcoaceticus-baumannii complex, and nine of the 43 isolates of coagulase-negative staphylococci. A single double-culture of coagulase-negative staphylococci also was analyzed via gram positive identification card. Identification of P aeruginosa was based on

These methods are in compliance with standard culture techniques.³⁷, ³⁸

Two researchers counted the colonies individually and took digital photographs. Additionally, the surface area of the four vertical swab paths was calculated to determine colony-forming units (CFU)/cm². The maximum swab path width was measured at 3 mm. The length or distance of this path was measured at 95.6 cm. To find the surface area in cm², length (ie, 95.6 cm) was multiplied by width (ie, 0.3 cm) for a total of 28.7 cm², which is nearly equivalent to the surface area of a replicate organism direct agar contact plate with a 6-cm diameter (ie, 3.14 × 32 = 28.26 cm²). Two researchers each entered the data into a spreadsheet individually, using the completed specimen data collection and analysis sheet. A test of interrater reliability revealed 100% agreement between the two researchers on all data entered into the two separate spreadsheets.

Laboratory and equipment. 

The laboratory used was accredited by the Commission of Laboratory Accreditation of the College of American Pathologists (CAP) in 2004. The reliability and validity of the automated microbiology laboratory testing system used is well established among medical laboratories.³⁹ Quality controls were conducted on all identification card lots used in this study. Photographs were taken using a digital camera with 2.0 megapixels and five-times digital zoom.

Proficiency testing for the microbiology testing system was performed three times during the year of this study. At the time of preparation of this article, test results were available for only two of the three proficiency tests. These proficiency tests showed greater than or equal to 86% accuracy of bacterial identification and greater than or equal to 92% performance satisfaction with 100% antigen detection. This level of testing is in accordance with CAP accreditation.⁴⁰ The microbiology testing system is approved by the US Food and Drug Administration for both gram-positive and gram-negative bacterial identification and sensitivity testing.⁴¹, ⁴²

Phenotypic testing agents. 

Several phenotypic testing agents were used in conducting this study. None of the agents used were beyond their expiration dates. The same lot numbers among agar plates, culturettes, gram-positive and gram-negative identification cards, and all other supplies were used. The only exception to this was the microdase test, for which lot numbers changed during the second batch of testing. A brief literature review of the testing agents is presented in Table 2 to demonstrate reliability and validity.

Table 2. Phenotype Testing Agents

N M Burdash et al, “Group identification of streptococci. Evaluation of three rapid agglutination methods,”American Journal of Clinical Pathology 76 (December 1981) 819–822.

1 Remel Staphaurex Plus (Lenexa, Kan: Remel, Inc, 2004).

2 M Wilerson et al, “Comparison of five agglutination tests for identification of Staphylococcus aureus,”

3 bioMerieux, Inc—Gram-negative identification+ card for in vitro diagnostic use (Rev 0402/L) (Durham, NC: bioMerieux, Inc, 2002).

4 bioMerieux, Inc—Gram-positive identification card for in vitro diagnostic use (Rev 0402/AU) (Durham, NC: bioMerieux, Inc, 2002).

5 AFaller, K H Schleifer, “Modified oxidase and bensidine tests for separation of staphylococci from micrococ-ci,” Journal of Clinical Microbiology 13 (June 1981) 1031–1035.

6 JS Baker, “Comparison of various methods for differentiation of staphylococci from micrococci,” Journal of Clinical Microbiology 19 (June 1984) 875–879.

7 LM Teixerira, R R Facklam, “Enterococcus,” in Manual of Clinical Microbiology, vol 1, eighth ed, P R Murray et al, eds (Washington, DC: American Society for Microbiology, 2003) 422–431.

Staphylococcus (S) lentus, S sciuri, and S vitulus can give a false positive microdase reaction. The impact probably is minimal because in an evaluation of coagulase-negative staphylococci infections, 86 cultures revealed one S sciuri and no S lentus or S vitulus.⁴³ In one study, the phadebact D test was found to be 100% effective in identifying group D Streptococcus.⁴⁴ Only 80% of enterococcus, however, can be identified by group D antigen testing.³⁸ The catalase, Kovac's indole, modified oxidase, and oxidase tests are standard testing agents for the identification of bacteria.³⁸

Statistical analysis. 

Data analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 12.0.⁴⁵ Descriptive statistics (ie, frequencies, means) were used to summarize and describe the data variables.

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Results 

After the bacteria were identified and analyzed, the results were quantified. Following is a brief description of how the study findings relate to the three research questions.

Question one. 

In what quantity are bacteria present on OR telephones? The mean number of colonies found on telephones in the sample set of this study was 23.3 CFU or 0.81 CFU per cm² per telephone. The quantity of bacteria needed to cause disease is unclear. The only relevant surface contamination data stated that floors with microbial contamination greater than 50 colonies per plate relate to poor cleanliness.⁴⁶ This number is lower than the 23.3 CFU found in the present study.

Question two. 

Are the bacteria most frequently involved in SSIs present on telephones in the OR? Of the bacteria frequently involved in SSIs, coagulase-negative staphylococci were found to be present on telephones in the OR whereas S aureus, enterococcus species, and E coli were not. Figure 2 summarizes the types and percentages of bacterial isolates discovered. Only the first culture results for telephones that were double-cultured are included to avoid over-representation of isolates.

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• Figure 2. 

  The percentage of bacteria cultured from telephones in the OR.

Question three. 

Are independent variables such as surgical service, time of day, culture location, number of surgical procedures performed before sampling, and temperature or humidity associated with bacterial quantities on telephones? Based on the small sample size of this study, correlations or conclusions could not be drawn from the independent variables in the study. The small sample obtained in this study allowed for descriptive statistical analysis only. Additionally, caution should be taken when drawing conclusions based on a convenience sample from only one medical center in which housekeeping services are performed by the surgical technologists and circulating nurses.

Table 3 summarizes the five variables that remained in the study after removal of the temperature and humidity variables. The humidity and temperature data were not included because of a lack of standardized measuring instruments.

Table 3. Variable Data Summary

Specimen collection was performed on two separate days separated by 19 days. Specimen numbers 9914, 9915, 9916, and 9917 were intended for collections that researchers were unable to complete on day one.

* Sequential culturing of the same telephone during the same time period.

** One control culture was selected randomly for each culture batch.

† Room was cleaned before swab was obtained.

The majority of samples were collected in the morning (ie, 61.5%) versus evening (ie, 38.5%). The largest numbers of specimens were obtained from the first surgical procedure of the day (ie, 65.4%), followed by the second procedure (ie, 30.8%), and the third procedure (ie, 3.8%). The top five surgical services operating in the rooms where the telephone cultures were obtained were

Double cultures from data collection days on one and two revealed coagulase-negative staphylococci of similar quantities, and on data collection day two, testing with the automated microbiology testing system and gram-positive identification cards revealed the same genus and species, S epidermidis. One telephone (ie, specimen #9910) was cultured after the room had been cleaned. This specimen had the second highest number of CFU per cm² (ie, 2.16 CFU per cm²).

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Discussion 

During this study, S aureus, enterococcus species, and E coli were not detected on telephones in the OR. The inability to find enterococcus species may be related to the limitations previously described for the phadebact D test. Thus, in each of the three isolates recorded as nongroup D Streptococcus, enterococcus may have been missed. Additionally, colony counts for bacteria were low in comparison to levels recorded for horizontal surfaces in ORs (ie, 5.86 CFU per cm² to 6.98 CFU per cm²),²⁷ stethoscopes (ie, 158 CFU),¹² hospital pagers (ie, 39 CFU to 153 CFU),⁴⁷ and telephones in the ICU (ie 7 CFU to 282 CFU).³³ The mean number of colonies found on telephones in the sample set of this study was 23.3 CFU or 0.81 CFU per cm² per telephone.

The only environmental surface contamination guidelines that were found are based on the use of replicant organism direct agar contact plates. The guidelines state that floors with microbial contamination greater than 50 colonies per plate relate to poor cleanliness.⁴⁶ In this study, only four samples exceeded that amount. Those four samples did not contain isolates of Acinetobacter, Pseudomonas, or Agrobacterium. The inability to find S aureus parallels similar difficulties in another study that were remedied by using broth to support environmental cultures, which led to increasing MRSA findings by a factor of two.⁴⁸ Similarly, one group of researchers were only able to isolate S aureus twice out of 114 specimens.³² The inability to find E coli on telephones is consistent with that study, which found no gram-negative bacteria on 20 telephones in the OR, ICU, PACU, and ED.³² Additionally, the literature review determined that E coli has a relatively short life span on environmental surfaces,⁴⁹, ⁵⁰ which may explain its absence.

The bacterium most frequently isolated in this study was coagulase-negative staphylococci. Both coagulase-negative staphylococci and S aureus are the most commonly implicated bacteria in SSIs (ie, 20% and 14% respectively).² Subsequently, coagulase-negative staphylococci is one of the most frequently isolated bacteria in the laboratory.⁵¹ These bacteria are of little virulence⁵² but are frequently implicated as the cause of infections in patients who are either immunocompromised or have medical implants.⁵³, ⁵⁴, ⁵⁵, ⁵⁶ A high prevalence of coagulase-negative staphylococci on telephones is consistent with a study by one group of researchers who isolated coagulase-negative staphylococci on all the telephones that they cultured.³³

Incidental findings. 

In a similar study, researchers found no gram-negative bacteria.³² In the current study, there were three gram-negative bacteria present on telephones in the OR (ie, A calcoaceticus-baumannii complex, P aeruginosa, A radiobacter/tumefaciens). Similarly, another group of researchers also was able to find Acinetobacter and Pseudomonas, in addition to three isolates of S aureus from 26 telephone cultures using replicant organism direct agar contact plates.⁵⁷ The use of these plates eliminate the number of times that bacteria are transferred because they use a direct transfer technique. Undoubtedly, some bacteria collected from the telephones in the current study remained in the culture swabs and were not accounted for. Had replicant organism direct agar contact plates been used, bacterial counts might have been higher.

Acinetobacter, P aeruginosa, A radiobacter/tumefaciens, and micrococcus have been implicated in HAIs,⁵⁸, ⁵⁹, ⁶⁰, ⁶¹, ⁶², ⁶³, ⁶⁴, ⁶⁵, ⁶⁶, ⁶⁷ but these bacteria predominantly are involved in infections of an immunocompromised host.³⁸, ⁵⁸, ⁵⁹, ⁶⁸, ⁶⁹, ⁷⁰ It is likely that the transmission of these bacteria could have been avoided with simple hand washing, surface disinfection, and use of basic aseptic techniques.

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Limitations 

The limitations of the study included the following.

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Implications and Conclusion 

Based on the findings of this study, there is a need for heightened awareness of cleaning procedures and standard precautions. Cleaning is paramount; however, it must be performed correctly to be effective. When bacteria are subjected to sublethal levels of disinfectants, they can become resistant to antibiotics.⁴⁸, ⁶³ AORN provides recommended practices for environmental cleaning that includes terminally cleaning telephones at the end of the day.¹⁸ Additionally, AORN recommends that such cleaning should occur when equipment is visibly soiled.⁷³

In this study, one telephone (ie, specimen #9910) was cultured after the room had been cleaned between procedures. This specimen had the second highest number of colony forming units at 2.16 per cm². This finding is particularly disturbing and raises the question, “Should telephones and other objects frequently contacted by staff members' hands in the perioperative environment be cleaned between procedures rather than only at the end of the day?” More important, it is the initial contamination of telephones rather than the cleaning that is of concern. Standard precautions require workers to wear gloves when the possibility of exposure to body fluids exists. On removing gloves, hands should be washed.⁶⁹ The obvious conundrum for OR personnel is that a circulating nurse frequently touches soiled materials and must leave the room in order to wash his or her hands. Leaving the room decreases the room's positive air pressure and places the patient at risk for infection.¹⁸ A possible solution may be to provide waterless alcohol-based hand hygiene products in the individual ORs.

Ultimately, the cleanliness of the surgical suite is the responsibility of perioperative nurses.¹⁸ Perioperative managers in concert with facility infection control officers must ensure that US Environmental Protection Agency-approved hospital disinfectants are both appropriate for emerging resistant bacteria and are being used correctly. Close attention must be applied to these key processes and focused to include aseptic principles and standard precautions. Future research may seek to

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Notes 

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