By Kelly M. Pyrek
Numerous studies have demonstrated that contaminated environmental surfaces in healthcare facilities can contribute to the transmission of infectious pathogens and that the cleaning and disinfection of these high-touch surfaces has been suboptimal. As Carling, et al. (2008) notes, "It has now been well documented that pathogens such as methicillinsusceptible S. aureus, MRSA and VRE, are readily transmitted from environmental surfaces to healthcare workers hands. Recently, the link between environmental contamination and patient acquisition has been more convincingly demonstrated. Epidemiologic studies have shown that patients admitted to rooms previously occupied by individuals infected or colonized with MRSA, VRE or Acinetobacter baumanii are at significant risk of acquiring these organisms from previously contaminated environmental sites."
"There is no doubt in my mind that contamination of the environment (surfaces in patient care areas and mobile medical equipment) play a major role in the transmission of potential pathogens," says Michael Phillips, MD, the hospital epidemiologist at New York University Langone Medical Center. "There are well-designed studies which show patients who occupy the bed of a patient previously infected with a resistant pathogen are at greater risk of acquiring that pathogen. The key to convincing healthcare workers of the importance of the environment is data posting unit or service specific rates of C. difficile infections, for example."
"There is no debate as to the role that contaminated surfaces play in the transmission of MDROs in the healthcare delivery setting," says Irena L. Kenneley, PhD, APRN-BC, CIC, assistant professor at Case Western Reserve University's Frances Payne Bolton School of Nursing. "There are many compelling studies that point to an environmental cause in outbreak situations, but one study regarding the impact of environmental MRSA and VRE contamination was conducted that really underscores the role of contaminated fomites (Huang, Datta and Platt, 2006). In this study it was found that after retrospective review of 10,000 ICU patients they found patients had significantly higher risk for acquiring MRSA or VRE if the most recent previous occupant of the same room had tested positive for the organisms. These results (and numerous other studies) point directly to an environmental reservoir and provide an explanation for transmission, the links to the chain of infection, and healthcare-associated infection."
The Centers for Disease Control and Prevention (CDC) recommends that environmental services personnel "pay close attention to cleaning and disinfection of hightouch surfaces in patientcare areas," and that hospitals must "ensure compliance by housekeeping staff with cleaning and disinfecting procedures." The challenge for infection preventionists is to continue to convey this message to environmental services managers and personnel so that variations in cleaning methods can be addressed and a better system of monitoring can be implemented.
The key to establishing better communication and collaboration between infection preventionists and hospital environmental services professionals, according to Phillips, is "establishing better communication is incorporating environmental services into the patient care unit team and they are a critical member of the team." Phillips adds, "Our 'Clean Team' includes representatives from nursing, environmental services and infection prevention and control. This type of collaboration enhances problem solving and reduces infections."
Kenneley advises infection preventionists to provide continuous training to environmental services and housekeeping personnel. "First and foremost is fundamental education of staff about infection prevention and control basics such as hand hygiene, clean and dirty are located in separate areas, standard precautions/isolation, proper cleaning, disinfection, and sterilization to name a few. But there is so much more that needs to happen to establish better communication and a spirit of camaraderie supporting teamwork."
Kenneley adds that in order to improve communication and collaboration among hospital environmental professionals and the staff and clinicians, successful infection prevention programs must:
- Develop an integrated program for infection prevention and control
- Build multi-modal interventions
- Take a team approach
- Have mentors available for new staff
- Convince administrators of value and cost-effectiveness of infection control and prevention
- Figure out appropriate strategies for healthcare worker behavior control taking into account the setting, cultural differences, and the climate of the institution
Kenneley reminds infection preventionists that "Adult learners learn best by 'doing' rather than being lectured to," she says. "One of the most compelling methods to convey an educational message is to present a real-life scenario and then troubleshoot the problems as a team. Also, for adult learners many times presenting the facts goes a long way. Some of the facts from environmental studies can be used to highlight the reasons for high touch surfaces to be cleaned while linking appropriate methodologies for optimal cleaning."
Kenneley suggests sharing the following facts from pertinent studies with environmental services personnel:
1. Contamination rates of various surfaces and equipment associated with the medical environment across the continuum of care have been more than 80 percent (Shigehar et al., 2005; Lankford et al., 2006; Gavin et al., 2002; Zwanziger and Roper, 2002; Larson and Duarte, 2001).
It was found that Enterococci can survive for seven days on countertops, for 24 hours on bedrails and telephone handpieces, for 60 minutes on stethoscope diaphragms, and for at least 60 minutes on gloved and ungloved hands (Noskin et. al., 1995; Bonilla, Zervos and Kauffman, 1996; Boyce et. al., 1994; Wilcox and Jones, 1995). These microorganisms have been isolated from blood pressure cuffs, dietary trays, intravenous pumps, stethoscope bells, utility room sinks, bathroom doors and sink drains in patient rooms (Karanfil, 1992; Boyce, et al., 1994).
2. Contamination of the inanimate environmentespecially bedrails, bed sheets and patient gowns has been most closely associated with methicillin-resistant Staphylococcus aureus (MRSA), C. difficile and vancomycin-resistant Enterococcus (VRE).
In its 2003 guideline the CDC outlines the interventions relating to proper surface decontamination, and urge healthcare professionals to consider that the number and types of microorganisms present on environmental surfaces are influenced by the following factors: number of people in the environment, amount of activity, amount of moisture, presence of material capable of supporting microbial growth, rate at which organisms suspended in the air are removed, and type of surface and orientation [i.e., horizontal or vertical]. The guidelines further reminds practitioners that strategies for cleaning and disinfecting surfaces in patient-care areas take into account the following factors: potential for direct patient contact, degree and frequency of hand contact, and the potential contamination of the surface with body substances or environmental sources of microorganisms (such as soil, dust, and water).
Kenneley emphasizes that there are two major considerations related to proper surface decontamination to bear in mind:
1. The cleaning products
- Many factors are important to consider when choosing an appropriate cleaning product such as how caustic is it, and what is the surface material of the item to be cleaned?
- Considerations include the nature of the disinfectant, how the patient care items are to be used and what they are made from, and always follow the manufacturers recommendations
- What to clean: environmental surfaces, such as bedside tables, if soiled, could become a source of contamination to hands or other objects which may have contact with the patient
- The CDC recommends therefore, environmental surfaces (especially high-touch surfaces) should be cleaned regularly with an EPA-approved, hospital-grade disinfectant
2. The bugs, taking into account the types of organisms commonly found on surfaces where healthcare is delivered.
- Different types of microorganisms vary in how easy they are killed by disinfectants
- Some are very hard to kill, while others can easily be killed by many disinfectants, even simple soap and water
Kenneley provides a list of the pathogens that are ranked in order from the hardest to kill to the easiest to kill:
1. Bacterial spores such as Clostridium difficile the cleaning agent must be sporicidal (this includes bleach-based institutional cleaning agents)
2. Mycobacteria such as M. tuberculosiscleaning agent must be marked tuberculocidal
3. Non-lipid or small viruses such as polio virus or hepatitis A virus
4. Fungi such as Aspergillus
5. Vegetative bacteria such as Pseudomonas or Staphylococcus aureus
6. Lipid or medium-sized viruses such as herpes simplex virus, hepatitis B virus or HIV
It cannot be emphasized enough that surfaces with minimal hand-contact (such as floors and ceilings) and those with frequent hand-contact ("high-touch surfaces") require different approaches to cleaning. While the methods, thoroughness and frequency of cleaning and the products used are determined by healthcare facility policy, according to the CDC guideline, "However, high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patients room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff," according to the CDC guideline.
Phillips underscores the importance of monitoring cleaning performance as the next step. "We are focused on the daily disinfection of frequently touched surfaces within the patient room," Phillips explains. "On high-intensity units, this disinfection is conducted twice daily. It is important to assess cleaning and disinfection efficacy we measure protein levels (ATP) using a bioluminescent assay. This data is collected systematically and reported back to our environmental service colleagues similar to surveillance for surgical site infections or central line associated bacteremia. This type of surveillance is just as important, in our assessment."
Carling PC, Parry MM, Rupp ME, Po JL, Dick B and Von Beheren S. Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals. Infect Control Hosp Epidem. Vol. 29, No.11. November 2008.
Centers for Disease Control and Prevention (CDC). Guidelines for Environmental Infection Control in HealthCare Facilities. Recommendation of CDC and the Healthcare Infection Control Advisory Committee (HICPAC), 2003. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf