Beyond Hand Hygiene: The 5 Critical Moments for Environmental Disinfection in Health Care

(You can also listen to this interview on our ICTalk: Infection Control Today Podcast on Spotify or Apple Podcasts, or wherever you listen to podcasts)

Infection prevention has long focused on hand hygiene, but what about the surfaces patients and health care workers touch throughout the day? Jim Gauthier, MLT, CIC, alongside coauthors Carol Calabrese, BS, RN, CIC, and Peter Teska, MBA, introduced the concept of Targeted Moments of Environmental Disinfection (TMED)—a structured approach identifying 5 critical moments for cleaning high-touch surfaces in patient care areas, published in The Joint Commission Journal on Quality and Patient Safety.¹

In this interview with Infection Control Today (ICT), Gauthier discusses the importance of real-time disinfection, the hidden dangers of overlooked surfaces, and practical strategies to integrate TMED into daily health care practices, aiming to reduce health care–associated infections and enhance patient safety.

“TMED is a heuristic, risk-based model proposing additional cleaning and disinfecting within the patient zone modeled on a similar concept developed by WHO [World Health Organization] for hand hygiene,” the authors wrote. “TMED identifies and suggests when disinfection should be conducted by [health care workers], either after or before certain procedures or events that may leave organisms on high-touch surfaces, or to remove organisms that may have been deposited during other care procedures.”

ICT: Please explain to me what your commentary covered.

Jim Gauthier, MLT, CIC: What [the commentary] boils down to is that we told health care workers back in the 2000s when to wash or sanitize their hands, and WHO published the 5 Moments for Hand Hygiene [guidance],² which boils down to these are 5 critical moments [when] we need you to make sure your hands are clean: before you have contact with the patient, before you do anything very, very clean or aseptic, after contact with blood or body fluids, before you leave the patient’s room, if you’ve touched the patient’s environment.

When I look at cleaning and disinfection, we go into the patient’s room, hopefully once a day, clean high-touch surfaces, and that’s about it. [Environmental services (EVS) goes] in and [cleans] well once a day, and then care occurs for the other 23.5 to 23.75 hours of that day with no other targeted cleaning being done based on the care we did. So that’s where the genesis of this commentary came from.

ICT: What was your goal for the commentary?

JG: The point of the paper is care happens all day. There is not an EVS [technician] standing behind the door every time somebody comes in the door to perform some form of care for the patient or the resident, if we’re talking long-term care. As I put the paper together with my peers, and as I’ve talked about it to different infection control groups and to [EVS] groups, I always get this feedback of, well, what do you think we should clean and what’s not in the article, and I should probably do a follow-up to it. But what it boils down to is if, during care, you’ve touched it or used it, clean. But we [broke it down] into 5 moments.

As a microbiology technologist, I understand the movement of microorganisms. I know what they look like, what they smell like, and where they can hide. When [my coauthors and I] start looking at papers that are trying to figure out an outbreak and where these organisms came from, the 2 dirtiest surfaces in the hospital, when I looked at the papers, were the over-bed table and the bed rails. When I started looking at what you can find on the over-bed table and the bed rails, we thought, “Well, those are also high-touch surfaces. They get touched a lot, and we probably need to clean those more than just once a day.”

ICT: What are the 5 moments you are recommending?

JG: What we’re suggesting is disinfecting the over-bed table.

Moment 1: Before placing food or drink on the over-bed table, it must be disinfected.

Moment 2: Before and after aseptic practices. For instance, if health care workers come in to change a dressing, insert a line, or perform catheter care, they need to disinfect before establishing a clean space and disinfect after.

Moment 3: Involves anything related to feces or respiratory secretions within the patient’s bed space. For example, if the patient is expectorating for you, they’re coughing up something. If you need to assist a patient with their incontinence products and help them into a clean product, you’ll need to disinfect something when you’re done.

Moment 4: After any patient bath within the patient bed space, if you give the patient a basin and a washcloth and say, “Here, clean yourself up. Breakfast is on its way,” you’re likely going to need to disinfect afterward. If you’re using the prewetted wipes that are quite common in health care today, you can warm a small package of wipes, wipe the patient down, or allow [them] to clean themselves; you have 1 wipe for each part of the body. In my experience, they often end up on the over-bed table. So again, after any patient bathing, you need to disinfect something.

Moment 5: Does anything used on or used by a patient that touches the floor need to be disinfected? We all have experiences where somebody will come into a room and see the cell phone charger on the floor, pick it up, and hand it back to the patient. That will fall, hit the floor, and return to the patient without being disinfected.

As these moments arose, much of this came from reading the literature and addressing issues, whether through outbreaks or discussing topics such as what we should do with floors. It doesn’t matter too much what you do with a floor; if anything touches the floor, which will be used by or on a patient, it is infected when it hits the floor. [Our] paper has 51 references as commentary to support each of these points.

The over-bed table that the patient eats off—none of us eat in our restrooms, I hope, at home or in our bathrooms. Well, people probably do. But patients are somewhat trapped there, so they might use a urinal if they’re bedridden and place it on the over-bed table if they don’t use the one on the side. All of us can recall what we’ve seen on over-bed tables if we’ve been in health care. That’s where I found evidence of bacteria, and I suggested that we disinfect that over-bed table before placing anything on it. The same applies to all the other moments mentioned in the paper. One of the main pieces of feedback we receive is, “Don’t give me anything else to do.” Especially for registered nurses trying to care for too many patients, don’t add more tasks to their load.

We designed a little table [with] the 5 moments across the top and looked at different kinds of patients. A ventilated patient in the intensive care unit is going to require a lot more wiping if someone tries to follow these 5 moments than a medical-surgical patient who is able to ambulate, look after themselves, use the toilet. You may only be using 3 or 4 wipes just because they eat in bed, so it’s not as onerous as what we were looking at.

We also realized that for this concept to work, the health care provider doing the care can’t take the time to look for a wipe because there are disinfectant wipes that you don’t want near the patient. They’re either caustic or they are poisonous. You don’t want to leave them near a patient. So the staff know where they are, but if they’re not right at the bedside, you’re going to have this issue of staff not completing the 5 moments.

We learned this with hand hygiene, and we developed something called point of care [for] hand hygiene products, where the point of care is the patient and the care provider and the care all meeting together, and you want the hand sanitizer so that the care provider only has to reach out the hand sanitizers there. They can sanitize their hand per moment 2 before they move on to another moment.

We propose in the paper that you need to have a safe disinfectant wipe that can be kept where the care will occur. You need to look at the safety data sheet around the wipe to find a wipe that works quickly so that surfaces aren’t wet around the patient for 3 to 5 minutes. Find a product that doesn’t require personal protective equipment to touch it. Staff always use their gloves because of the care that they provide and other things like that. But if you can find a safe-enough product that’s [kept at the] head of bed, you may also have the visitors or family helping to keep the environment cleaner around the patient. There will take some education because we run into the problem of people flushing wipes—not only family, but we’ve got care providers who, if they have a wipe that is grossly soiled with feces, they may go and flush it, and that causes problems down the road. But with a bit of education, I don’t see this as a huge problem.

References

1. Gauthier J, Calabrese C, Teska P. Targeted Moments of Environmental Disinfection. Jt Comm J Qual Patient Saf. 2020;46(3):167-172. doi:10.1016/j.jcjq.2019.11.009
2. Five moments for hand hygiene. World Health Organization. Accessed February 4, 2025. https://www.who.int/publications/m/item/five-moments-for-hand-hygiene