Infection Control Today - 10/2002: Fast-Paced EDs Require Speedy Yet Thorough Clean-ups

October 1, 2002

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Fast-Paced EDs Require Speedy Yet Thorough Clean-ups

By Kelly M. Pyrek

departments (ED) often are the busiest parts of a hospital, generating enormous
amounts of foot traffic and dramatically increasing the odds of transmission of
infectious pathogens. A National Hospital Ambulatory Medical Care Survey: 2000
Emergency Department Summary reveals there were 108 million ED visits in 2000,
up 14 percent from 95 million visits in 1997. Because the number of hospitals
providing emergency care decreased from 4,005 to 3,934 between 1997 and 2000,
the number of annual visits per emergency department has increased about 16
percent since 1997, from 24,000 to 27,000, according to the Centers for Disease
Control and Prevention (CDC) report.

EDs also are receiving patients with a more acute degree of illness. Dramatic
changes in healthcare-related policy at the federal, state and local levels have
impacted the number of individuals able to access preventive care. As a result,
many individuals delay seeing a physician until their medical condition worsens
and they require emergency care. This kind of behavior significantly increases
patients' risk for infection and presents an increased infection risk for
healthcare workers (HCWs) in the ED. Opportunities for cross contamination
escalate when ED personnel provide life-saving, therapeutic interventions to
acutely ill and trauma patients. In the rush of tending to squirting arteries,
infection control principles can take a back seat until it's time to clean and
decontaminate the ED.

The thorough cleaning and disinfecting of all surfaces (medical and
housekeeping) is critical in maintaining an aseptic environment. While cleaning
schedules and the kinds of products used will vary from one hospital to another,
industry guidelines dictate that hard surfaces such as floors and counters
should be cleaned regularly and according to the amount and the kind of soil or
body fluid spills present. Dropped packages, spent dressings and other packaging
that may have been dropped to the floor must be collected, and a light mopping
or sweeping to remove initial amounts of dirt and debris can be done prior to a
more labor-intensive wet mopping. Generally, low-level, hospital-grade
disinfectants are appropriate products for floor disinfection in the ED, and the
single-bucket procedure is a common and practical method. The disinfectant
solution must be changed when visibly soiled so that bacteria are not
transferred from bucket to floor and back again. The disinfectant solution must
be changed immediately after clean-up of blood spills, and daily laundering of
mop heads in a hot water cycle followed by thorough drying is recommended.

Other environmental surfaces in the ED that require thorough cleaning include
stretcher mattresses, stretchers, tables, counters and carts. These should be
cleaned and disinfected regularly with a disinfectant registered by the
Environmental Protection Agency (EPA) and used according to the manufacturer's
instructions. Fresh cloths should be used for cleaning each room and if a bucket
method is used, the visibly soiled disinfectant solution must be changed every
three to four rooms. ED curtains should be laundered if visibly soiled and walls
behind them should be spot-cleaned if there is evidence of spills and splashes.

Another safe harbor for bacteria are patient-care items used in the ER.
According to Karen R. Vallejo, RN, BSN, CIC, an infection control practitioner
at St. Luke's Episcopal Hospital in Houston, Texas, 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). Semi-critical 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. Non-critical 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 ED, and a clear understanding of these
categories is essential."

She continues, "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.
Semi-critical 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. Non-disposable, 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