 is a senior perioperative practice specialist at 

. A registered nurse for more than 30 years, she is certified in both perioperative nursing and infection prevention and control, and has led system-wide initiatives to standardize surgical and sterile processing practices. She serves as lead revision author for several guidelines, including the current update to the 

, and represents the organization on national infection prevention committees.

Karen deKay, MSN, RN, EBP-C, CNOR, CIC, FAPIC

A brightly lit Hospital operating room, a surgical team wearing gowns and masks.

Five back-to-back cases. A full waiting room. An urgent add-on that just landed on the schedule. Every operating room (OR) team knows what turnover pressure feels like, and I’ve spent enough time studying environmental hygiene to know exactly where that pressure does its damage: in the small cleaning steps that get skipped when the next case is already waiting.

As lead author of the recent update to the Association of periOperative Registered Nurses’s (AORN’s) 

), I’ve looked closely at how that pressure plays out in real turnovers, and where the process can be strengthened.

My top recommendation isn’t a product or a checklist. It’s a team approach. Environmental hygiene is everyone’s responsibility, because any missed surface is a chance for the OR to become a vector for infection transmission. That team is bigger than the surgical staff alone. Guidance on OR cleaning programs generally calls for a 

, including perioperative leadership, infection prevention, environmental services (EVS), and facilities, all working from the same expectations for what gets cleaned, when, and by whom. Without that shared ownership, cleaning steps become “someone else’s job,” and that’s exactly when they get missed.

Turnover pressure can undermine OR cleaning.

 Missed surfaces, shortened disinfectant contact times, and premature restocking create gaps between cases.

Clear responsibilities support consistent practice.

 Perioperative staff, infection prevention, environmental services, and facilities need shared expectations for who cleans what and when. 

Ongoing training helps sustain improvement.

 Repeated education and competency checks reinforce cleaning practices when busy schedules put them under pressure.

Where Turnover Pressure Causes the Most Misses

Here’s what I see slip most often when a room is turning over fast:

Reaching for a single cloth or wipe and using it across several different surfaces.

Skipping cleaning and disinfection altogether on items or areas that had contact during the case.

Setting sterile packages or sheets down on a surface before the disinfectant has had its full contact/dwell/kill time (the duration required to actually achieve disinfection).

Wiping fast enough that part of the surface never gets covered or stays visibly wet with disinfectant.

Working on “dirty” areas before “clean” ones, or bouncing between the 2 instead of moving in 1 direction.

Rushing past high-touch items without giving them the same disinfection attention as larger surfaces.

Restocking clean or sterile supplies before environmental hygiene is fully finished.

The stakes behind this list are higher than they might look. Some pathogens associated with surgical site infections, including 

, and research on hospital fomites has found that high-touch surfaces 

 even when they receive more frequent cleaning than low-touch surfaces. A missed step during one turnover isn’t an isolated lapse; it leaves a surface contaminated until the next cleaning cycle catches it.

If a team can only focus on a few things during a fast turnover, these 3 practices are where that focus pays off most.

1. Follow the disinfectant label, down to the minute.

The disinfectant’s manufacturer’s instructions for use (

 specifies the wet contact time required to kill the specific microorganisms it targets, such as viruses, 

, other bacteria, and that time only counts if the surface remains visibly wet for the entire duration. If it starts to dry, add more product rather than letting the clock run on a surface that is no longer wet.

Contact times vary by product and target organism, ranging from roughly 30 seconds to 10 minutes or more. For organisms like 

 used for its full labeled contact time, since standard disinfectants aren’t effective against spores. Building a few extra seconds into the turnover workflow for reapplication is a smaller cost than reworking a surface that was cleared before it was actually disinfected.

2. Move clean to dirty, never dirty to clean.

Work outward from the cleanest surfaces toward the most contaminated ones, never the reverse, so contaminants don’t ride along from a dirty surface onto one that’s already been cleaned. The same logic applies vertically. Gravity pulls dust, debris, and disinfectant runoff downward, so tackling high surfaces first keeps that fallout from landing on areas still waiting for their turn.

the CDC generally tiers the cleaning risk

 of health care surfaces. Low-touch surfaces such as floors and walls carry lower transmission risk than high-touch surfaces like OR tables, equipment controls, and light handles. Those high-touch surfaces are exactly the ones a cloth or mop head should reach last, once it’s no longer carrying contamination picked up earlier in the room. A sequence like this only holds up if everyone cleaning the room follows the same order. One person skipping ahead undoes the logic for the whole team.

3. Give every room its own clean material.


A cloth, wipe, or mop head that’s already touched one room shouldn’t touch another. Carrying it over from bay to bay carries contaminants along, and used material can’t disinfect as reliably as fresh material.

The risk here isn’t theoretical. A study on hospital cleaning practices found that reused cloth towels carried 

 even after standard laundering, and that towels can interfere with the disinfectants they’re soaked in. Laundering alone isn’t a reliable safeguard, which is why the workflow itself has to be built around a clean material at the start of every room, not a laundering or restocking process that’s assumed to catch what the workflow misses.

Building the Habit, Not Just the Awareness

Perioperative nurses and environmental services professionals should start preparing now for what the updated guideline will ask of them, because how we approach cleaning and disinfection in the perioperative environment is changing. But awareness of a new guideline only goes so far. The real goal is to engage staff, support a genuine culture shift, and raise the profile of the people doing this work: EVS, who is too often an afterthought in how OR personnel think about infection prevention.

Ongoing education is what makes that culture shift hold. Cleaning steps that get taught once tend to erode under the same turnover pressure that causes the misses described above, and knowledge of a guideline update doesn’t change practice unless it’s revisited regularly. One hospital’s 

repeated training initiative for nursing and EVS staff

 found that the percentage of surfaces cleaned to standard rose from 20% after the first training session to 49% after the second and 82% after the third, with corresponding drops in 

, surgical site, and central line-associated infection rates over the same period.

A single in-service isn’t enough to change behavior at that scale; it’s the repetition that closes the gap between knowing a step and reliably doing it under pressure. Recurring competency checks, especially ones that revisit the specific misses a team already struggles with, keep environmental hygiene from sliding back into old shortcuts once the initial push around a new guideline fades.

Before the updated guideline is released, it’s worth getting the whole team into the same room to walk through current turnover practices together. Half the value of a guideline update comes from the conversation it forces a team to have about where its own process actually breaks down.

For teams that want to get ahead of the update, AORN’s 

Guideline Essentials for Environmental Hygiene

 (exclusive member content) offers a set of implementation tools worth working through together. That includes checklists for general environmental hygiene, multidrug-resistant organism cleaning, sterile processing, and OR/preop/postop turnover, along with guidance on differentiating cleaning procedures for high-touch objects and worked examples of between-patient cleaning in both surgical and preop/postop areas.

Articles

Turnover pressure can leave critical OR cleaning steps unfinished. Karen deKay, MSN, RN, EBP-C, CNOR, CIC, FAPIC, examines common gaps in environmental hygiene and how shared responsibilities, attention to disinfectant contact time, and ongoing education can help teams strengthen practices between cases.

How Can OR Teams Improve Environmental Cleaning Between Surgical Cases?

When patients enter the operating room, they expect the environment to be tightly controlled for safety. What they may not realize is that the clothing and personal items worn by perioperative staff can influence their outcomes as much as sterile instruments or surgical technique.

 makes it clear that attire choices are not simply about maintaining a professional appearance. What staff wear and how those items are cared for can directly influence the risk of spreading microorganisms in and beyond the operating room. From proper laundering of scrubs to cleaning identification badges and personal devices, the guideline positions attire as an essential part of an overall infection prevention strategy.

The 2025 AORN Guideline for Surgical Attire reinforces attire’s role as a core component of infection prevention across perioperative settings.

Evidence from acute and intensive care settings indicates that health care uniforms frequently harbor pathogenic microorganisms, underscoring the need for consistent laundering practices.

Updated recommendations extend beyond the operating room to include hallways, changing areas, and shared spaces where contamination can occur.

Attire management offers a practical, evidence-based opportunity to reduce the risk of surgical site infections and protect patients and staff.

Evidence from intensive care settings shows just how contaminated uniforms can become. A 2019 study in Clinical Nursing Research analyzed 305 uniform cultures from 115 staff and found high levels of bacterial contamination across all roles. Physicians’ uniforms showed contamination in 

, while about 79% of nurses’ uniforms tested positive. In total, 24 different microorganisms were identified, with 

 present in more than 60% of positive cultures.

Research in the emergency department environment showed that personally owned, home-laundered uniforms carried 

 than freshly laundered hospital-issued scrubs, highlighting the infection prevention risks tied to inconsistent laundering practices.

The burden of surgical site infections remains significant. According to the CDC, on any given day, about 1 in 31 hospital patients has at least one 

 (HAI), and a national survey from 2015 estimated 687,000 HAIs in US acute care hospitals in a single year, with 72,000 patient deaths linked to these infections. More recent data also show worrying trends, with surgical site infections (SSIs) following abdominal hysterectomy procedures increasing by 8% between 2022 and 2023. Addressing risks tied to attire is one practical step perioperative teams can take to help reduce these preventable infections.

One of the clearest updates in the 2025 guideline is how contaminated attire should be handled. Scrub apparel or personal clothing that has been contaminated with blood, body fluids, or other potentially infectious materials must be removed immediately and left at the health care facility for laundering. Contaminated attire should not be rinsed or sorted; instead, it must be bagged or containerized at the site of use. This approach minimizes the risk of spreading pathogens to other areas of the hospital or the community.

The guideline emphasizes that scalp and hair should be fully covered in semirestricted and restricted areas. Beards also require coverage, given that facial hair of varying lengths has been shown to shed microorganisms at high rates, including drug-resistant species. Properly fitted head covers improve containment and comfort, particularly for staff using surgical equipment like headlights and loupes.

Protective footwear must meet safety requirements outlined by the Occupational Safety and Health Administration and ASTM standards. In addition, fluid-resistant shoe covers or boots are required when gross contamination can be reasonably anticipated. Shoe covers used as personal protective equipment must be removed and discarded immediately after use, followed by hand hygiene.

The updated guideline calls out a common yet often overlooked source of contamination: personal devices and accessories. Cell phones, tablets, stethoscopes, identification badges, backpacks, and briefcases can all harbor microorganisms. Studies have confirmed that these items are highly contaminated and, in some cases, contain multidrug-resistant organisms. Regular cleaning, paired with consistent hand hygiene before and after use, reduces the risk of pathogen transmission from staff to patients.

For these updates to succeed, attire must be reframed as a patient safety practice rather than a dress code requirement. Staff education is key, along with visible leadership support. Leaders can reinforce culture by modeling safe behaviors, ensuring access to cleaning supplies, and supporting standardized processes across departments.

True adherence requires collaboration. Infection preventionists, perioperative nurses, surgeons, and administrators each play a role in establishing consistent practices. Facilities that bring these groups together are better positioned to address challenges such as workflow adjustments or supply availability.

A tool for prevention and a cultural shift

 positions attire as a clinical safeguard essential to infection prevention. When clothing and personal items are consistently managed as part of the broader infection prevention strategy, hospitals can better protect patients, safeguard staff, and reduce the risk of surgical site infections.

What might seem like a minor detail in the fast-paced environment of surgical care is, in fact, a critical safeguard. With evidence-based practices guiding everyday choices, attire becomes not just a uniform requirement but a foundation for patient safety.

Could a badge, cell phone, or home-laundered scrub top contribute to infection transmission?
AORN's updated 2025 Guideline for Surgical Attire reinforces that surgical attire is much more than a uniform. From laundering practices and beard covers to cleaning personal devices, the recommendations position attire as a key component of infection prevention and patient safety across the perioperative environment.


Karen deKay, MSN, RN, EBP-C, CNOR, CIC, FAPIC

Articles

How Can OR Teams Improve Environmental Cleaning Between Surgical Cases?

AORN’s Updated Surgical Attire Guideline Strengthens Infection Prevention In Every Care Space