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A Shield of Protection: Unmet Needs in COVID-19 Prevention and Control

Paul G. Auwaerter, MD, MBA; Paul P. Doghramji, MD, FAAFP; Aruna Subramanian, MD

Cases and Conversations™: Applying Best Practices to Prevent Shingles in Your Practice

From unsterilized surgical tools in Colorado to a years-long methicillin-resistant Staphylococcus aureus (MRSA) outbreak in Virginia and a surging measles crisis in Canada, recent headlines reveal the fragile front lines of infection prevention and the high stakes when systems fail.

Pathogen Pulse: Facilities Need the SPD, Yersinia Enterocolitica Outbreak, and More

Take 5 minutes to catch up on Infection Control Today’s highlights for the week ending March 23, 2025. 

Weekly Rounds: Candida auris in Burn ICU, Updates on Long COVID, and More

Health care-associated infections pose a global threat. In the op-ed, experts advocate for Far-UVC light as a safe, effective tool to reduce airborne pathogens, enhancing infection control in hospitals and public spaces.


Far-UVC Is a Public Health Tool We Need Now

From advanced sterilization methods to combating antimicrobial resistance, Infection Control Today’s top articles of 2024 delivered actionable strategies for safer healthcare environments and improved patient outcomes.

The Heavy Hitters: Three Essentials for Exam Room Infection Prevention

Inconsistent cleaning and disinfection practices continue to pose significant risks to patient safety in health care environments. Despite broadly aligned guidelines from agencies like the CDC, the World Health Organization, the Association for Professionals in Infection Control and Epidemiology (APIC), and the Association of periOperative Registered Nurses (AORN), critical operational differences and accessibility barriers persist. 

This article examines the need for internal standardization, the role of professional memberships, regulatory frameworks from The Joint Commission, Centers for Medicare & Medicaid Services (CMS), The Occupational Safety and Health Administration (OSHA), and US Environmental Protection Agency (EPA), and the vital importance of viewing cleaning as a clinical service, not a commodity. Grounded in both personal experience and real-world examples, it emphasizes that 

 and offers a blueprint for health care facilities to lead with safety, consistency, and trust.

Introduction: Why Standardization Matters

Environmental cleaning and disinfection are foundational pillars of infection prevention. Yet, while the clinical community emphasizes protocols and stewardship, the healthcare environment itself remains vulnerable to inconsistencies. Even among recognized leaders like the CDC,¹ WHO,² APIC,³ and AORN,⁴ guidance varies enough to create confusion on the front lines.
In today's environment of emerging and reemerging pathogens, 

, and heightened regulatory oversight, internal standardization of cleaning and disinfection practices is not optional. It is a foundational investment in patient safety, staff confidence, and organizational resilience. Simply stated, 

all surfaces matter in the war on pathogen transmission in health care and community settings

A Landscape of Best Intentions—and Missed Alignment


Even minor inconsistencies around cleaning frequency, chemical selection, training expectations, and auditing methods can lead to operational drift, unless a facility sets and enforces its own consistent standard.

Access to Standards Is Always Best Practice, Not a Barrier

While foundational guidelines from agencies like the CDC¹ and WHO² are freely accessible, health care-specific cleaning standards often require membership or purchase:

AORN’s perioperative cleaning guidelines

⁴: membership or purchase required, updated annually.

¹³: surface safety, materials compatibility, validated cleaning protocols.

Disclosure: The author serves on the Healthcare Surfaces Institute Advisory Council under ISSA.


Membership isn’t a hurdle; it’s a strategic investment.
Direct access connects facilities to validated education, best practices, and peer collaboration critical for resilient infection prevention programs.

Real-World Consequences (with HealthPlus Case Study and National CMS Deficiency Data)

Case Study: HealthPlus Surgery Center, Saddle Brook, New Jersey⁹

In 2018, HealthPlus Surgery Center temporarily closed after the NJ Department of Health found critical lapses in sterilization and infection prevention protocols. Over 3,700 patients were notified of potential exposure to HIV, Hepatitis B, and Hepatitis C. While sterilization was a primary issue, inadequate environmental hygiene also surfaced as a major breakdown.


Failure to verify and enforce infection control protocols, including cleaning and disinfection, can escalate rapidly into a patient safety crisis.

National Trends: CMS Data on ASC Deficiencies⁸

CMS data from 2023 to 2024 shows infection prevention failures are the most frequently cited deficiencies across ambulatory surgical centers.

Failure to follow standardized cleaning protocols

Lack of documentation for terminal and between-case cleaning

Improper disinfectant use and dwell time compliance


Infection prevention lapses, including improper cleaning, are systemic risks, not isolated mistakes.

Agencies Advancing Health Care Cleaning Standards

Recognizing environmental hygiene as a pillar of patient safety, national and global organizations lead initiatives to close gaps:

: Certifications (CHEST, CSCT, CHESP) advancing healthcare cleaning competence.

International Sanitary Supply Association (ISSA) + Healthcare Standards Institute (HSI) + International Executive Housekeepers Association (IEHA)

: Interdisciplinary surface safety and facility leadership training.

: STAR Facility Accreditation, outbreak preparedness and response.

: International collaboration for health care hygiene research and advocacy.


Active participation with these agencies represents a strategic investment in health care excellence and resilience.

Regulatory Standards Reinforce the Need for Consistency

Regulatory agencies shape health care cleaning requirements:

: Mandates cleanliness validation under the Environment of Care standards.

: Requires safe, sanitary environments under Conditions of Participation.

: Bloodborne pathogens, PPE, and chemical handling safety.

: Disinfectant registration (List N, List K) ensuring efficacy against health care pathogens.


Compliance fulfills the fundamental obligation to protect patients, staff, and the community.

Facilities must own their environmental hygiene processes:

: Use EPA-registered, pathogen-appropriate disinfectants (tuberculocidal, fungicidal, sporicidal as needed).

: Implement two-step cleaning, validated dwell times, and clear Standard Operating Procedures (SOPs).

: Certification, annual competencies, ongoing education.

: Membership and direct access to standards ensure adherence to current best practices.

: Regular inspections benchmarked against internal SOPs, not industry averages.

Collaborative relationships with a medical laboratory

 for microbiological sampling and understanding of the pathogen burdens with the facility.


Standardization empowers staff, strengthens infection prevention, and builds operational resilience.

In-House or Outsourced, Cleaning Is Patient Care

Whether environmental services are in-house or contracted, cleaning is a 

Are staff health care-certified (CHEST, CSCT)?

Are SOPs aligned with the CDC, AORN, and CMS?

Is association engagement (ISSA, AHE, HSI) maintained?

Are outbreak response protocols established?


Having worked as both a customer and a provider, we’ve seen firsthand that too often, facilities contract cleaning services to the lowest bidder, overlooking the real costs: increased health care-associated infections, surgical site infections, readmissions, reputational damage, and patient harm.


Environmental cleaning is not a commodity. It is patient care.


Outsourcing does not outsource responsibility for patient safety.
Facilities that treat environmental hygiene as clinical care will achieve stronger outcomes, safer environments, and greater community trust.

Environmental cleaning must be recognized as a frontline health care service—essential to infection prevention, patient outcomes, and healthcare resilience.

Standardization is not bureaucracy.
Standardization is protection.

Facilities that invest in clear, accessible cleaning protocols, supported by training, membership, and strategic partnerships, will lead in safety, innovation, and patient trust.

Outsourcing does not absolve responsibility.
Internal teams do not guarantee readiness.
Only a culture of continuous education, accountability, and excellence sustains real infection prevention.

We have spent our careers on both sides: as customers and now as service providers.
The lesson remains clear:

Cleaning is not ancillary to patient care.
Cleaning is patient care.

https://www.cdc.gov/healthcare-associated-infections/media/pdfs/environmental-cleaning-rls-508.pdf

Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level

. World Health Organization. 2016. Accessed May 12, 2025. 

https://www.who.int/publications/i/item/9789241549929

Infection prevention: a perioperative nurse’s

guide to preventing infections in surgical settings

https://www.aorn.org/article/infection-prevention--a-perioperative-nurses-guide-to-preventing-surgical-site-infections

Association of periOperative Registered Nurses. 

Guidelines for Perioperative Practice: Environmental Cleaning

https://aornguidelines.org/guidelines/content?sectionid=173715702&view=book

Occupational Safety and Health Administration. 

. 29 CFR §1910.1030. U.S. Department of Labor. Accessed May 12, 2025. 

https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030

List N: Disinfectants for Emerging Viral Pathogens (COVID-19)

https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19

List K: EPA’s Registered Antimicrobial Products Effective Against Clostridium difficile Spores

https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium

Centers for Medicare & Medicaid Services. 

Ambulatory Surgical Center Top Deficiencies Report, 2023–2024

. CMS. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/surveycertificationgeninfo. Accessed May 12, 2025.

NBC News, Time Magazine, New Jersey Department of Health. 

. Various media sources. Accessed May 12, 2025. 

https://www.nbcnews.com/health/health-news/n-j-surgery-center-possibly-exposed-thousands-hiv-had-rusty-n952971

https://gbac.issa.com/gbac-star-facility-accreditation/

CHEST, CSCT, and CHESP Certifications and Resources

HSI Programs under ISSA Partnership Initiatives

. Healthcare Surfaces Institute. Accessed May 12, 2025. 

https://www.healthcaresurfacesinstitute.org

Lybert L. & Rohde RE. Why Surface Materials Matter in Health Care Settings American Society for Microbiology, 

January 25, 2024. Accessed May 13, 2025. 

https://asm.org/Articles/2024/January/Why-Surface-Materials-Matter-in-Health-Care-Settin

Inconsistent cleaning practices continue to jeopardize patient safety. Experts urge health care leaders to treat cleaning as clinical care—essential, standardized, and foundational to infection prevention.









The Case for Standardizing Cleaning and Disinfection: Why Consistency Is Critical to Patient Safety

Pharmaceutical waste challenges

 in Angola, Indiana, faced significant challenges managing pharmaceutical waste, from excessive disposal quantities to unclear waste segregation practices. With a budget-conscious approach and commitment to sustainability, the hospital implemented effective strategies to simplify and improve its waste management processes.

One of the primary issues was the hospital's classification as a large pharmaceutical waste generator, with over 1,200 pounds of waste annually. This designation came with higher fees and highlighted inefficiencies. A breakthrough occurred in 2021-2022, when the hospital partnered with the pharmacy and laboratory departments to identify key areas for improvement. One early success was reducing biohazard container use from 15 to 6, with further consolidation saving costs and streamlining workflows.

Signage played a critical role in the transformation. Clear, strategically placed labels helped staff identify appropriate waste streams, reducing errors. “It’s amazing what ends up in pharmaceutical waste bins—regular trash, specimen cups, even lunch leftovers,” said Darren Goff, executive director of hospitality services. By educating staff and emphasizing proper segregation, pharmaceutical waste was nearly halved to 656 pounds in 2022, keeping the hospital under the small generator threshold.

Training and accountability were equally vital. Staff participated in competency evaluations tied to annual and biannual assessments, reinforcing proper waste disposal practices. These evaluations not only ensured compliance but also fostered a culture of continuous improvement. “We want our frontline workers to feel informed and involved in decisions,” Goff noted.

Looking ahead, the hospital aims to explore alternative disposal companies and methods to further enhance sustainability. With plans extending to 2025, Cameron Royal is dedicated to finding innovative solutions to reduce costs and environmental impact.

This initiative not only improved pharmaceutical waste management but also inspired broader changes in departmental budgeting and accountability. “It’s about simplifying processes, saving money, and empowering our team to make informed decisions,” Goff concluded.

Cameron Memorial Community Hospital streamlined pharmaceutical waste management through signage, training, and collaboration, cutting waste nearly in half and saving costs while boosting staff competencies and accountability.

Video Series

Reducing Pharmaceutical Waste: Challenges and Innovations at Cameron Memorial Community Hospital

Dr. Danielle Zehr explains her presentation at SHEA 2024 on pediatric and patient-centered care

Exploring Strategies Into Environmental Pathogen Control and Patient-Centered Care

Facilities require innovative strategies and key insights to handle challenges, promote patient—and family-centered care, and mitigate environmental risks. In pediatric settings, it is also important to have infection control measures that are centered around the family. 

These are 2 topics for presentations at the Society of Epidemiology of America (SHEA) in Houston, Texas, held from April 16 to 19, 2024.

To discuss these presentations and more, Danielle Zerr (“Zair”), MD, MPH, spoke to 

). She is the division head and professor of pediatric infectious diseases and adjunct professor of epidemiology at the University of Washington School of Medicine; affiliate investigator at Fred Hutchinson Cancer Research Center; and medical director of infection prevention at Seattle Children’s Hospital.

She will present “Reducing The Risk of Environmental Pathogens: Strategies for Environmental Surveillance and Enhanced Cleaning within Healthcare Settings” and “Family-Centered Infection Control Precautions for Respiratory Viruses in Pediatric Settings“ at the Society of Epidemiology of America (SHEA) in Houston, Texas, held from April 16 to 19, 2024.

“I will be focusing on environmental pathogens within health care settings,” Zerr told 

. “And I decided to sort of focus the talk on 3 different types of environmental areas. So environmental surfaces, water, and air. And I'll talk about the organisms that might exist in those spaces that can cause infection in humans, and then what we might do to mitigate the risk to patients.”

Zerr continued, “If we take, for example, water. What I do during the talk is recognize the importance of Legionella and certain resistant gram-negative bacterial organisms like Pseudomonas. And these are organisms that can carry significant morbidity and mortality in our patients, especially immunocompromised hosts. And regarding mitigation, I'll talk about the importance of having a water management program and plan. We'll review the strategies around mitigating the risk of problems that might arise as you're performing surveillance following the plan of your water management program. And then also, I'll talk about mitigating the risk of splashback that happens with sinks and health care settings.”

For her second presentation on respiratory viruses in pediatric settings, Zerr said, "I will be reviewing the history, the goals, and the requirements for patient or family-centered care and the importance of family-centered care; there are many benefits that have been shown with family and patient-centered care,” 

However, there is "an inherent little bit of conflict between those 2 things because patient-centered care calls for flexibility whenever possible, Zerr explained. "Sometimes, in the interest of keeping everyone safe, infection can be prevented, and we tend to like our rules. So, I'll be exploring those opportunities where we can really practice family-centered care and patient-centered care.”

Danielle Zerr, MD, MPH, explains her presentations at SHEA 2024 about strategies for environmental pathogen control, the significance of patient-centered care in health care settings, and respiratory viruses in pediatric settings.

Surface Disinfection

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