Infection control professionals know the numbers all too well. Each year, almost 2 million patients are affected by healthcare-acquired infections (HAIs), costing hospitals an estimated $35.7 billion to $45 billion nationwide. These costs result from direct medical costs, absenteeism and loss of productivity along with other indirect costs such as loss of reputation from negative press.
While environmental surfaces throughout a healthcare facility offer only one possible source of transmission for potential HAIs, experts consistently recommend better surface sanitation and handwashing as the two most significant environmental controls to reduce HAIs. However, in some situations, the wrong level of disinfectant is used, or the disinfectant is not properly used. Both of which can cause a surface not to be properly disinfected.
Another significant issue to be discussed in HAI control is the disconnect between infection control staff and environmental services (EVS) staff when it comes to infection control. Many infection control personnel generally accept that EVS personnel are performing their due diligence to keep high-touch, off-floor areas such as doorknobs, restroom surfaces and light switches clean and disinfected. In reality, EVS managers understand the importance of infection control but focus on turning patient rooms over quickly and achieving budget goals, which can reduce actual compliance.
The average HAI costs a patient-care facility an estimated $10,000 per incident. By connecting with EVS and assuring the right disinfectants are being properly used on all the appropriate surfaces, infection control staff can limit the opportunity for a nosocomial infection to occur, protecting patients and reducing potential costs.
A Closer Look at Disinfectants and Common Healthcare Pathogens
A first step in addressing the risk of HAIs from environmental surfaces is to work with EVS to determine what organisms need to be killed and review kill-claims for the disinfectant technology being used. Based on the Spaulding classification scheme, there are three levels of disinfection. Each level kills specific common healthcare organisms. (To access figure 1, consult the July 2009 issue of ICT.) Historically, EVS staff would use an intermediate-level disinfectant capable of killing tuberculosis for all high-touch surfaces. However, many intermediate-level disinfectants, such as phenolics, have significant issues related to their use — ranging from the need for proper personal protective equipment (PPE) to protect EVS staff from health effects, such as bleaching of the skin, to strong odors and toxicity. Many EVS departments switched to using low-level disinfectants to clean and disinfect high-touch environmental surfaces. This standard was reinforced by OSHA’s Bloodborne Pathogen Standard, which only requires use of a low-level hospital-grade disinfectant known to kill HIV and hepatitis B.
In recent years, there has been increased focus on tough to kill, small, non-enveloped viruses, such as norovirus, polio and rhinovirus. Killing these organisms requires an intermediate-level disinfectant, but the same intermediate-level disinfectant that can kill these small non-enveloped viruses may not be capable of killing tuberculosis (TB). Recognizing that TB can not be transmitted through environmental surfaces, there is a growing point of view that TB should not be the determining factor when selecting a hard-surface disinfectant. While some standard operating procedures still include Tb as the standard of performance, as it was previously required for bloodborne pathogens, it has generally been replaced with a low level disinfectant that meets Bloodborne pathogen requirements.
When considering which disinfectant to use, infection control personnel should first determine the appropriate level of disinfection for high-touch, off-the-floor surfaces. They should establish which types of bacteria or viruses are likely to be present, whether they are potentially communicable through environmental surface contact, and then work with EVS personnel to find the right disinfectants that target the specific organisms that could be a potential source of an HAI, rather than defaulting to using a disinfectant that kills TB. Newer intermediate-level disinfectants are available with better safety profiles, shorter contact times, and better sustainability stories than those historically available, which focused on killing TB.
The Dynamics of Disinfectants
In addition to identifying the organisms of concern, infection control staff can also reduce the risks of HAIs by understanding how disinfectants work. In the past, standard disinfectants required a 10-minute contact time on a wet surface in order to work properly. However, in most situations, surfaces dry after the first three to four minutes, rendering the disinfectant ineffective unless reapplied so that the surface remains wet for the entire contact time. In practice, EVS workers do not have the time to reapply the disinfectant, so an appropriate contact time should be a key concern in selecting a disinfectant.
Consider the following scenario: Susan from EVS has exactly 11 minutes to clean and disinfectant a discharge room. She works from one end of the room to another, applying disinfectant to all required surfaces. After the first three minutes, she returns to the first disinfected surface to reapply solution and continues to reapply to each disinfected surface until the 10-minute dwell time is achieved. Noting that there are many other tasks that must be completed in the room such as changing curtains, linens and cleaning floors with a microfiber flat mop, it is unlikely that Susan will be able to focus all of her attention on ensuring the required dwell time is reached.
As a result of the limitations of a 10-minute dwell time presented by these disinfectants, new disinfectants with reduced contact times have become available. By properly using disinfectants that only require one to five minutes to kill the desired microorganism, it has been shown that overall infection rates substantially decrease in a hospital.
A study conducted by Suburban Hospital in Bethesda, Md., and the Food and Drug Administration (FDA) showed that the introduction of an eight-hour training program and a broad-spectrum, reduced-contact time disinfectant decreased use of antibiotics rates by as much as 10.1 percent. The study concluded that use of a structured, comprehensive occupational safety and health and environmental management training program for EVS personnel with the addition of a cleaning product that requires less contact time, but still kills the pathogens of concern, can have a statistically significant impact on the HAI rate in hospitals.
Aligning Goals with EVS
The ultimate goal for an infection control professional is to have zero HAIs. While an EVS director might have a similar goal, his or her performance is often tied to the department’s budget. As a result, an EVS director is not likely to spend more money than is allocated in the budget. This presents an inherent conflict between the two departments as the goals are misaligned with one party looking to reduce infections and the other group looking to reduce costs. There are several tactics infection control staff can deploy to better align the goals of each department:
1. Champion EVS with hospital administration
To assist EVS in focusing on the greater goal of reducing infections, infection control staff needs to become advocates for EVS staff. Because the infection control department maintains more weight and broader representation with C-level personnel and hospital administrators, staff can use their clout to show the importance of environmental surface cleaning to reduce infection rates. Lower infection rates protect the hospital’s brand, reputation and ultimately save it from potential lawsuits.
2. Work with EVS to establish cleaning requirements
Infection control personnel should participate in walk-throughs with EVS directors to review cleaning programs and identify which surfaces need to be routinely cleaned and disinfected and how often they should be cleaned. They also should identify which surfaces are less critical, such as a lobby floor. Is it specified that high dusting should be performed on a daily basis or just at discharge? These walk-throughs will enable staff to reduce cleaning frequency in some areas so greater focus can be placed on surfaces that are a higher risk for causing an HAI.
3. Work with EVS to establish time standards
In addition to helping establish which surfaces need to be cleaned, infection control and EVS staff must work together to determine the amount of time needed to clean and disinfect areas. There is no magic number — each hospital is different and poses a unique set of requirements. For example, some hospitals might have just small patient rooms while others might have multi-patient rooms mixed with larger single-patient rooms with sitting areas.
To establish time standards, infection control and EVS should perform a time study. Using a stopwatch and a checklist of the surfaces to be cleaned, they should measure the amount of time it takes for an EVS employee to clean and disinfect the necessary surfaces in the room. If enough time is not allocated for staff to perform the required duties, they can engage upper management to find a way for workers to clean fewer rooms, or to remove low risk surfaces from daily cleaning so adequate time remains to clean all the high risk surfaces.
4. Empower EVS
Recognizing the important role the EVS department plays in the control of infection, it is important for infection control staff to reward individuals who demonstrate significant reductions in infection control rates. For instance, they can track rates by ward and work with the EVS director to provide recognition programs for those personnel who best ensure surfaces are properly disinfected. Rewards can be tied into performance-based pay incentives.
Investing in EVS
There are new rules for intermediate-level disinfectants and surface disinfection within a healthcare facility. Phenolic-based disinfectants with Tb kill claims and/or disinfectants with 10-minute contact times are a thing of the past. By identifying the organisms of concern, understanding how disinfectants work and working with the EVS department to ensure infection control goals are aligned, infection control professionals can develop a program that can help reduce risk to hospital patients and costs.
Dale Grinstead, PhD, is an infection control fellow for JohnsonDiversey.
Parekh A. HHS Efforts to Reduce Healthcare Healthcare-Associated Infections. HICPAC
PowerPoint presentation, Nov. 13, 2008.
Smith R, et al. Effects of an environmental services professional training course and cleaning products on the rates of infection seen at suburban hospital. Suburban Hospital/FDA poster.