Emergency Room Clean Up
by Karen R. Vallejo, RN, BSN, CIC
Photo courtesy of ER at NW Community Hospital (Arlington Heights, Ill).The methods of handling, transporting, and laundering of soiled linen are determined by hospital policy and any applicable regulations.
Recent changes in health-associated expenditures and health policy have significantly impacted healthcare delivery in the US. As a result, a large number of patients receiving emergency care have limited access to preventive healthcare. This significantly increases their risk for infection and presents an increased infection risk for healthcare workers (HCWs) in emergency center (EC) settings. Furthermore, trauma patients and acutely ill patients often require immediate lifesaving interventions making infection prevention and control measures a lower priority. HCWs must be familiar with and follow standard precautions during all patient care encounters. In addition, the appropriate cleaning of environmental surfaces (housekeeping surfaces and medical equipment surfaces) is critical for maintaining a safe and healthy environment for patients, staff, and visitors. This article focuses on cleaning and disinfection of environmental surfaces in the EC.
Environmental surfaces, including floors, walls, and other surfaces can harbor disease-causing microorganisms. However, these environmental surfaces rarely are associated with transmission of infections to patients or personnel. Therefore, extraordinary attempts to disinfect or sterilize these environmental surfaces are rarely indicated. Cleaning schedules and methods will vary according to the area of the hospital, type of surface to be cleaned, and the amount and type of soil present. In the EC, hard-surfaced flooring should be cleaned on a regular basis, when soiling or spills occur, and when a patient is discharged. At St. Luke's Episcopal Hospital (Houston, Tex), dust mopping is done prior to scrubbing or mopping the floors to remove a large portion of dirt, debris, and dust. Generally, low-level hospital grade disinfectants are appropriate products for floor care disinfection in the EC. The single-bucket procedure for wet mopping is the most common and practical method. When a single-bucket is used, the disinfectant solution must be changed when visibly soiled because of increased bioload or changed every three to four rooms. However, it is imperative that the disinfectant solution be changed immediately after clean up of blood spills such as those associated with trauma, deliveries, or accidental spills. Daily laundering of mop heads in a hot water cycle followed by thorough drying is recommended.
Other horizontal surfaces such as counters and stretcher mattresses and equipment should be cleaned and disinfected with an EPA-registered disinfectant and used in accordance with manufacturer recommendations. The Occupational Safety and Health Administration (OSHA) compliance directive specifies that the disinfectant used for this purpose should be tuberculocidal. This limits choices to a phenolic disinfectant or chlorine solution (i.e. 1:10 dilution of sodium hypochlorite). However, studies have demonstrated that other germicides such as quaternary ammonium compounds can inactivate bloodborne pathogens effectively.1 At St. Luke's Episcopal Hospital a thorough, enhanced environmental "bucket method" is used to clean horizontal surfaces as opposed to the conventional spray bottle method. With the "bucket method," a cleaning rag is dipped into a bucket containing an EPA-registered disinfectant and then used to drench all environmental surfaces. The environmental surfaces are left wet for ten minutes before being wiped dry with a clean towel. The "bucket method" allows for direct and longer contact between the surface and the disinfecting agent. This is particularly important as studies suggest that conventional disinfection (spray bottle method) may be associated with a higher frequency of persistent contamination of environmental surfaces with organisms such as vancomycin-resistant Enterococcus.2 Clean cloths should be used for cleaning each room. Routine changing of the soiled disinfectant solution in the bucket is done every three to four rooms or if the solution becomes visibly soiled. The solution should be changed immediately after clean up of blood spills. If curtains are used in the EC and they become visibly soiled, they should be immediately removed and machine-washed. Finally, walls are spot cleaned of spills and splashes and completely cleaned when they are soiled.
Patient-Care Equipment and Articles
The rationale for cleaning, disinfecting, or sterilizing patient-care equipment can be better understood if medical devices, equipment, and surgical materials are divided into three categories. Critical items are instruments or objects that are introduced into normally sterile areas of the body (e.g., surgical instruments, cardiac catheters). Semicritical items generally do not penetrate body surfaces but are in contact with mucous membranes. Such items include respiratory therapy equipment (e.g., laryngoscopes) and gastroscopy equipment. Noncritical items are those that do not touch the patient or touch only the intact skin. Such items include stethoscopes, blood pressure cuffs, crutches, and other medical accessories. All these items are used routinely in the EC, and a clear understanding of these categories is essential.
Since it is neither necessary nor possible to sterilize all patient-care items, hospital policies can identify whether cleaning, disinfecting, or sterilizing an item is indicated to decrease the risk of infection. For example, critical medical devices or patient-care equipment should always be sterilized as any microorganisms, including bacterial spores, that come in contact with normally sterile tissue can cause infection. Semicritical medical devices or patient-care equipment should be introduced to a disinfection process that kills all microorganisms (e.g., viruses and tubercle bacilli) but resistant bacterial spores. This disinfection should always be done between uses to reduce the risk of transmission of microorganisms to other patients. It is important that reusable items be cleaned thoroughly before processing because organic material (e.g., blood and proteins) may inactivate chemical germicides and protect microorganisms from the disinfection or sterilization process. Nondisposable, noninvasive items (i.e., antishock trousers, blood pressure cuffs) contaminated with blood or other body fluids should be cleaned and disinfected thoroughly with an EPA-registered disinfectant agent after each use. Patient care equipment intended for single use should not be reprocessed and used. These disposable items usually cannot be cleaned and sterilized adequately or are made of materials that may be damaged by chemical or heat disinfection or sterilization. HCWs performing these procedures should demonstrate knowledge of and proficiency in proper technique. In addition, appropriate attire (e.g., gloves, goggles, and gowns) must be worn during cleaning procedures. HCWs should understand the limitations of gowns, how to remove a gown that becomes grossly contaminated, and how to dispose of such gowns.
Sharps and Linen
Disposable items that can cause injury such as scalpel blades and syringes with needles should be placed in puncture-resistant containers. Used needles should not be recapped, bent, broken, or cut before disposal. The container should be available for sharps disposal at point of use. If possible, the person performing the procedure should place all items with the potential for puncture wounds in the sharps container. Proper disposal of filled sharps containers (three quarters full) are essential. They should be identified with the proper OSHA required labeling.3
Linens on stretchers in the EC should always be changed between patients. If the linen becomes soiled with blood or other potentially infectious materials (e.g. vaginal secretions, semen, spinal fluid), it should be placed in a linen bag at the location where it was removed to prevent leakage. Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms to patients, personnel, and environments. Hygienic and common sense storage and processing of clean and soiled linen are recommended by the Centers for Disease Control and Prevention (CDC). The methods of handling, transporting, and laundering of soiled linen are determined by hospital policy and any applicable regulations.
Adherence to basic infection control practices must be in the minds of all personnel working in the EC. Although the risk of infection cannot be eliminated completely, the appropriate cleaning and disinfection of environmental surfaces can minimize this risk. Each member plays a vital role in maintaining a clean, attractive, and safe environment for patients, staff, and visitors. In addition, a review of current infection control policies and practices should be an ongoing process in the EC.
Karen R. Vallejo, RN, BSN, CIC, is an Infection Control Practitioner at St. Luke's Episcopal Hospital (Houston, Tex).
1 Bond WW, Favero MS, Petersen NJ, et al. Inactivation of hepatitis B virus by intermediate to-high-level disinfectant chemicals. J Clin Microbiol. 1983;18:535-538.
2 Byers K, Durbin L, Simionton B, Anglim A, Ada K, Farr B. Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium. Infect Control Hosp Epidemiol. 1998;19:261-264.
3 Occupation Safety and Health Administration: Occupational exposure to bloodborne pathogens: final rule, 29 CFR part 1910.1030, Washington DC, Dec. 6, 1991 U.S. Department of Labor.
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