Environmental Services Personnel Can Help Break the Chain of Infection
By Kelly M. Pyrek
When it comes to closing the infection control loop in a healthcare facility, the staff members of the environmental services or housekeeping department play a critical role; they can either undermine clinicians' efforts or support the institution-wide goal of preventing the transmission of pathogens.
"In an acute care setting, housekeeping is second only to hand hygiene in importance in this infection control loop," acknowledges Paul Webber, director of research and education for Maunco Sanitation and Safety Supplies in Belleville, Ontario, Canada. "There is no surgical technique, no wound-care strategy and no antibiotic prescription regime that can offset the impact of a dirty hospital. A hospital that pays attention to the cleanliness of (not necessarily disinfection of) above-floor surfaces is a healthy hospital. Although shiny floors are the most visible and yet the least clinically significant task of the housekeeping department, they do serve as a motivator for staff and psychosomatic healing aid for patients."
According to Kentucky-based infection control consultant Raymond B. Otero, PhD, nosocomial infections are seldom caused by contaminated surfaces in the environment, but he says hospitals must still be vigilant in their cleaning efforts.1
"Housekeeping practices, if performed correctly, will create an area suitable for patient, visitor and healthcare worker (HCW) to enter and be comfortable within the confines of the environment," he says. "The proper maintenance of a healthcare facility increases the awareness of other employees of the necessity of good sanitary practices. Good housekeeping practices increase morale and public relations. No one wants to work in an area that smells or is dirty."
The infection control manual at the Yale-New Haven Hospital states that environmental surfaces such as walls, floors and countertops, as well as other patient-care surfaces in the hospital, should be cleaned routinely with EPA-approved disinfectants according to manufacturers' directions. Horizontal surfaces such as countertops, over-the-bed tables and bedside tables, should be damp-cleaned daily. Uncarpeted floors should be cleaned daily and carpeted floors should be vacuumed daily, using a vacuum cleaner that does not expel airborne organisms into the environment. Vacuum cleaner filters should be regularly maintained and replaced as needed. Waste receptacles should be emptied daily or as needed, and the liners of the receptacles replaced whenever waste is removed. Cleaning of vertical surfaces such as walls and curtains is needed periodically or whenever soiling is visible.
Bathrooms must be cleaned daily and special attention should be paid to the sink, faucet handles, commode and door handles. Thorough cleaning is necessary due to the high concentration of body fluids that may be present on surfaces, says Otero. Soap dispensers should be checked daily for function and replenished as needed.
Not all surfaces are created equal, Webber says, explaining that some areas of the hospital pose greater challenges to cleaning and disinfecting.
"Areas of concern include handrails that run along hallways, the strings attached to bedside call bells, the bed-surround curtains that hang close to the floor and other high-touch areas like door handles, doorframes and bathrooms," Webber adds. "In most cases I would support thorough cleaning of these surfaces. In my opinion we disinfect way too often and that this may someday be our downfall. Shared toilets and sinks, and isolation rooms are appropriate places for cleaning and disinfection."
Webber adds that carpets and other fabrics require ongoing, special attention from environmental services staff.
"For several years there was a trend toward carpeting floors in hospitals," Webber says. "They carpeted hallways and stairs, patient rooms, clinics ... they even carpeted intensive care units and emergency rooms. Generally the floor is not a concern for infection control (except in pediatric units) but all of the bacteria, viruses and fungi that would normally be swept up and mopped away have to be vacuumed and extracted. The vacuuming and the steam cleaning would aerosolize the potentially pathogenic organisms, thereby creating an airborne infection hazard, not to mention a chronically wet floor in some places. How do you disinfect a chair that has vomit or diarrhea on it, even in minute quantities? For example, if there are Norwalk viruses in the vomit or feces a quat disinfectant won't do it, and bleach will take the color out of the fabric. Imagine a fabric chair in which hundreds of people sit, and on which they rub their hands in nervous anticipation. Hundreds of thousands of Norwalk viruses are on and in that fabric and we know that it takes as few as just one to make people very sick, but we have no way to get the Norwalk out. Many Canadian hospitals will use products made with accelerated hydrogen peroxide that are safe on fabrics and effective at killing viruses and bacteria, but I don't think that they are available in the United States yet."
The challenge continues in areas containing water sources. "Bathtubs with circulating water jets are troublesome, too," Webber says. "Organisms along the walls of the tub can usually be simply wiped off with a detergent. In the pump, piping and jets of the circulating system, however, exist a biofilm that can be very dangerous. The biofilm will consist of a sampling of every disgusting bacteria, feces and body soil of every person who has ever used the tub. Ordinary disinfectants won't clean out that biofilm, even those that are marketed specifically for those tubs. An oxidizing solution such as bleach (at 5,000 ppm) or accelerated hydrogen peroxide must be circulated through the pump and jets to clean out that slimy and potentially very dangerous film."
Webber says another troublesome area in the hospital is the flooring. "In infection control circles it is a common mantra that floors are not an issue but I think that they might have a larger impact than we give them credit for," he emphasizes. "When hospital floors are buffed and/or burnished, a little bit of the floor coating is sanded off and then allowed to become airborne. Some pieces of equipment have filters to reduce the amount of dust that is released. I am concerned that whatever microorganisms might be living happily on the floor will also be vortexed up into our breathing space or at least onto surfaces that will have hand contact. Certainly the filters used to trap the dust are not sufficiently fine to catch bacteria or viruses." Webber adds he is not aware of any body of research that has addressed this specific issue. "The studies that are available look only at the particulate level as an IAQ issue, not at the microbial content of the particulate."
Given the risk of airborne transmission of bacteria, environmental services personnel must follow standard precautions and don personal protective equipment (PPE), according to the Yale-New Haven Hospital infection control manual. The type of barrier protection required is dependent on the procedure performed and the environmental conditions encountered. Handwashing should be performed in the following circumstances:
- Just prior to the start of cleaning procedures
- Following contamination of the hands by blood or body substances
- After removing a pair of gloves and before donning a new pair
- After completing cleaning activities
Non-sterile, disposable gloves should be worn during all cleaning procedures, and they should be discarded if there is evidence of deterioration or if they are punctured, cut or torn. The should also be changed between each patient room or area in the healthcare facility, as well as after contact with grossly or visibly contaminated items or surfaces.
Fluid-impervious gowns should be worn for any cleaning task that involves large amounts of blood or other body fluid that may splash or splatter or be difficult to contain. Masks must be worn for any cleaning procedures that involve:
- The management of blood or body fluids that may contaminate the mucous membranes of the mouth and nose or which may become aerosolized, such as during trash removal or emptying suction canisters
- The cleaning of rooms of patients on airborne precautions or for suspected/confirmed pulmonary TB; in these cases an N-95/HEPA respirator must be worn
- The cleaning of rooms of patients on droplet precautions only if personnel are within 3 feet of the patient
Protective eyewear should be worn if environmental services personnel will be cleaning large amounts of blood or body fluids that may splash.
Environmental services personnel should be familiar with how to safely and properly handle and dispose of sharps and infectious medical waste, and make sure that containers for holding such items are emptied and processed according to facility protocol and mandates by the state health department and the Occupational Safety and Health Administration (OSHA).
Communication about policies and procedures is essential to ensuring environmental services personnel follow aseptic technique. Webber acknowledges that as budgets are stretched and HCWs are expected to multi-task, this communication and structured education can sometimes fall through the cracks.
"Housekeepers are becoming multi-skilled workers and are being used to do many other jobs, and this has its good side and its bad side," Webber says. "On the good side, more relationships are being formed between people in different departments who might never get the opportunity to work together and who are much more likely to understand the other's challenges and point of view. On a grander scale, setting the multi-skilled issue aside, the key is education and awareness. The housekeeping department is low profile; if there is to be a sense of teamwork in the hospital to address infection control issues, the housekeeping department must be highlighted for the important role it plays. By necessity this would involve departmental horn blowing and positive publicity from administrators. Housekeeping has a critically important role, but is typically the entrance point into employment in other areas of the hospital, or the exit point to which one is demoted just before being shuffled out the door."
Webber continues, "To ensure housekeeping staff members know the purpose of their job, a supervisor can do several things. He or she can invite nursing staff, medical staff, infection control professionals and administrators to speak to the workers to let them know how important their contribution is and how exactly it helps to break the chain of infection."