Environmental Surface Disinfection: Meeting Best Practices for Infection Prevention

All healthcare facilities are faced with the challenges for preventing infection transmission.

Healthcare-associated infections (HAIs) have become a major focus with the emergence of antimicrobial-resistant microbes, e.g., healthcare-acquired and community-acquired methicillin-resistant Staphylo-coccus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and multi-drug-resistant gram-negative bacilli. The rising incidences of healthcare-associated Clostridium difficile infections are also a concern. Meeting best practices for cleaning and disinfection of environmental surfaces and patient care equipment constitutes an important factor in contributing to preventing the spread of these infections. Environmental surfaces and non-critical patient care equipment can serve as reservoirs for microorganisms. Patient-care equipment that come in contact with intact skin and not mucous membranes are considered noncritical. Infection transmission occurs when gloved or ungloved hands of healthcare workers (HCWs) come in contact with a contaminated surface and/ or there is patient contact with contaminated surfaces or medical equipment. Studies have proven that contamination of the environment has likely contributed to the spread of resistant pathogens (MRSA and VRE).1,2

The key to cleaning and disinfecting environmental surfaces and non-critical patient-care equipment is the use of friction. Friction removes visible dirt, organic material, and debris thereby removing microorganisms. Items must be cleaned before disinfection can take place. It is important to note that many disinfectants contain detergents that aid in cleaning. Healthcare facilities should have established protocols and procedures for cleaning environmental surfaces and patient care equipment. One of the biggest challenges in healthcare is assigning who is responsible for items to be cleaned. HCWs are frequently unaware of who is responsible for specific cleaning protocols. Routines for cleaning surfaces and medical equipment in all clinical and non clinical areas need to be established based on the need to frequently clean (e.g., after patient use or at end of the day or shift, and degree of contamination). Items and surfaces that are frequently touched are at a greater risk for cross-transmission than those areas that are less frequently touched or handled less often. Some examples of frequently touched surfaces that are often missed are bed rails, light switches, doorknobs, blood pressure cuffs, stethoscopes, portable X-ray machine handles, cardiac monitor knobs, stretchers, wheelchairs, telephones, IV poles, IV pumps, feeding pumps, utility carts, rehabilitation equipment, computer keyboards, and toys. Disinfection of environmental surfaces may be the responsibility of the housekeeping department, but cleaning and disinfection of patient care items and some clinical department-specific surfaces are usually the responsibility of the clinical department staff. Protocols and procedures should outline who is responsible for disinfection of surfaces and patient care equipment, the frequency of disinfection and product used for disinfection. Infection prevention and control departments should be involved in reviewing cleaning and disinfection practices and protocols and work with housekeeping department and the clinical unit/department management in establishing protocols to ensure best practices. Consistent monitoring of cleaning and disinfection practices should be conducted on a regular basis by department and unit management teams.

Regulatory agencies such as the Occupational Safety and Health Administration (OSHA), the Centers for Medicare and Medicaid Services (CMS), and state departments of health require that certain perimeters must be followed in selecting the right disinfectant for surfaces and patient care equipment. In selecting products for disinfection of environmental surfaces and patient care equipment, use an Environmental Protection Agency (EPA)-registered germicide that is labeled tuberculocidal or specific label claims for HIV or hepatitis B virus (HBV).3 The EPA-registered product must display the EPA number on the product label. Disinfectants should be used in accordance with the manufacturer’s recommendations. A germicide with a label claim for “tuberculocidal” is an intermediate-level disinfectant. Low-level disinfectants are those without a tuberculocidal claim. The guideline from the Association for Professionals in Infection Control and Epidemiology (APIC), Guideline for Selection and Use of Disinfectants by William Rutala, describes a hierarchy of resistance of microbial categories to germicidal chemicals. (see Table 1).4 The hierarchy of resistance is considered a rough guide to general susceptibility of microorganisms to disinfectants. In descending order, bacterial spores show highest resistance to germicidal chemicals and are the hardest to kill, whereas lipid viruses show the least resistance to germicidal chemicals and are the easiest to kill. Bacterial spores require sterilization or high-level disinfection. Sterilization is the complete elimination or destruction of all forms of microbial life and high-level disinfection can be expected to destroy all microorganisms, with the exception of high numbers of bacterial spores. Sterilization is required for critical devices (i.e., surgical instruments, cardiac catheters) and high-level disinfection is required for semi-critical devices (i.e., endoscopes, respiratory therapy items). Intermediate-level disinfection inactivates Mycobacterium tuberculosis, vegetative bacteria, viruses and fungi, but not spores. Low-level disinfection can kill most bacteria, some viruses and some fungi, but not mycobacteria. Intermediate-or low-level disinfection is recommended for non critical patient care items and the environment.

Choosing the appropriate surface disinfectant can be confusing. Disinfectants that are “ready to use” or dispensed in pre-measured amounts are preferred over those that require mixing. “Ready to use” disinfectants eliminate the possibility of human errors in mixing. In choosing a disinfectant for non critical surfaces and patient care equipment, always consider the type of item/surface to be cleaned. For example, caution should be taken with using a spray cleaner on surfaces with nooks and crannies or when liquid could enter the inside of the device (i.e., computer keyboard). Safety is another consideration. Always ask if the disinfectant allows the user to dispense and use the solution in the safest, most efficient way. Aerosols and sprays must be used with caution around patients especially those with history of breathing problems.

Ease of use is another consideration. Does the application of the disinfection consistently provide the correct concentrations to assure proper strength of solution? Also, a busy HCW needs a product that they can access at the point of use. Many times a disinfectant is kept in a closet or inside a cabinet in a utility or work room and not readily available. Also, cleaning cloths are frequently a problem; HCWs will often use a paper towel or wash cloth as a cleaning cloth because designated cloths for disinfection are not available. Costs need to be considered, especially the benefits of using a pre-moistened disinfectant wipe which can be conveniently placed at the point of use for nurses, technicians, and other healthcare personnel who are responsible for cleaning/disinfecting their “own” equipment or wiping down items that have been in isolation rooms. The HCW’s time spent in “looking” for a cleaning product can be example of a non-productive or non-benefit cost.

All healthcare settings should include environmental surface disinfection and disinfection of non critical patient care equipment as part of their protocols and procedures. The frequently touched surfaces and shared patient care equipment require more frequent cleaning and disinfection. These surfaces/items can contribute to spread of pathogenic microorganisms. The importance of understanding the principles of infection prevention and control and reducing disease transmission in the healthcare setting is often misunderstood and this can lead to error or unsafe practice. A busy nursing unit, clinical department, or clinic/office practice may frequently overlook the routine surface disinfection practices that should be performed between patients simply because “we don’t have time” or not recognize that it is necessary. Too often HCWs are faced with the challenge of rapid turnover of patients and need to get the room ready as quickly as possible for the next patient.

Changing procedures to meet best practices in environmental disinfection is a challenge. HCWs must be educated about the importance of an aseptic environment for both employee and patient safety. Create a list of items in the healthcare setting that are frequently touched by patients and HCWs and are contaminated as a result of treatment. Establish a cleaning schedule for these items. Select a surface disinfectant that has a wide antimicrobial spectrum, is fast-acting, has good cleaning and disinfecting properties, is convenient to use, complies with facility’s procedures and is environmentally friendly. Good cleaning and disinfection practices and routines can help fight the battle against the problem pathogens facing the healthcare environment today. Now is the time to evaluate your practices.

References 

1. Muto CA, Jernigan JA et.al. SHEA Guideline for Preventing Nosocomial Transmission of Multidrugresistant Strains of Staphylococcus aureus and Enterococcus. ICHE. 2003; 24: 362-386.

2. Zachary K., et. al. Contamination of gowns, gloves, and stethoscopes with vancomycinresistant enterococcus. ICHE 2001; 22: 560-564.

3. Occupational Safety and Health Administration, Occupational exposure to bloodborne pathogens; final rule (OSHA 29 CFR 1910.1030). Federal Register 1991; 56: 64003-182. [memorandum] February 28, 1997; compliance document [CPL] 2-2.44D [11/99].

4. Rutala W. APIC guideline for selection and use of disinfectants. Association for Professionals in Infection Control and Epidemiology. Am J Infect Cont 1996; Vol. 24 No. 4: 313-342.