Fast-Paced EDs Require Speedy Yet Thorough Clean-ups
By Kelly M. Pyrek
Emergency 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 gowns."