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Environmental Surface Disinfection in the Healthcare Environment
By J. Hudson Garrett Jr., PhD, MSN, MPH, APRN, CIC
One of the most critical interventions that can be routinely performed to decrease the risk for cross transmission and development of healthcare-associated infections (HAIs) is routine cleaning and disinfection of the healthcare environment. This includes both medical equipment and environmental surfaces. To maximize the efficacy of the chosen disinfectant product, thorough cleaning must be performed prior to disinfectant use.
Cleaning, as defined by the latest CDC Guideline for Disinfection and Sterilization in Healthcare Facilities released in 2008, is “the removal of foreign material (e.g., soil and organic matter) from objects, and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.” Cleaning removes bioburden from the affected surface by reducing the number of microorganisms that must be inactivated. Removing bioburden from the surface prior to application of the disinfectant solution will result in increased disinfectant efficacy. It is also important to also apply friction to the area being cleaning and disinfected in order to remove more resistant forms of microorganisms such as spores (i.e., Clostridium difficile) from the surfaces that may not be readily inactivated by the disinfectant. This will decrease the risk for development of multidrug-resistant organisms (MDROs).
The use of an Environmental Protection Agency (EPA)-accepted product with proven efficacy claims is also crucial to selection of the appropriate product. In addition, the infection preventionist should refer to the facility’s risk assessment and ensure that the disinfectant selected has efficacy claims for microorganisms that are routinely found within the facility. Efficacy claims are readily available through the product’s manufacturer, and should be carefully reviewed prior to introduction of the product into the facility. A thorough cleaning and disinfection program combined with careful selection of the most appropriate hospital-grade disinfectant will dramatically improve the healthcare professional’s daily fight against HAIs.
J. Hudson Garrett Jr., PhD, MSN, MPH, APRN, CIC, is director of clinical affairs at PDI Healthcare.
By Dale Grinstead, PhD
Before looking at ways to fight HAIs in a patient-care facility, we should first look at the contributing factors and trends. One such trend is the reduction of disinfectant use to limit costs. As environmental services (ES) departments experience pressure to control budgets, many workers try to extend the amount of product available by not properly diluting it or neglecting to disinfect some surfaces that need to be disinfected. Another trend is the increased emphasis on throughput. ES workers face unprecedented pressure to turn patient rooms over quickly. As a result, they may neglect to clean high-touch areas, which are higher risk surfaces for HAIs. The sustainability movement is also having an adverse effect on disinfection and environmental cleaning. In an effort to become more “green,” some healthcare facilities compromise the level of a disinfectant’s performance for products that are less effective but have an enhanced environmental profile, or replacing the use of disinfectants with cleaners that have no disinfectant properties.
As we have seen with the recent H1N1 influenza outbreak, microorganisms are evolving. To address this risk, disinfectants with a broad efficacy range should be used. Using the right disinfectant properly is the primary cleaning practice that will help reduce the risk of HAIs from environmental surfaces. It is imperative that infection control staff promotes the role of EVS in controlling HAIs, so limited resources are not an issue. In addition, infection control staff should work with EVS staff to develop a disinfection program that focuses on off-the-floor surface disinfection to ensure surfaces are properly disinfected.
When deciding what disinfectant to use, first consider what organisms are likely sources of an HAI and how they can be transferred. For example, small, non-enveloped viruses such as norovirus and rhinovirus can be the source of an HAI and are communicable through environmental surfaces that are not properly disinfected. Therefore, use of disinfectants that can kill these pathogens is best practice. Many facilities use disinfectants not capable of killing these small non-enveloped viruses, which doesn’t address the risk from the surfaces. Other intermediate-level pathogens, such as TB, are not transmittable through surface contact, so it is not necessary to use disinfectants with this kill claim.
Another step to developing a successful surface-level disinfection program is using products with an appropriate contact time. Most disinfectants require a 10-minute dwell time, which would require rewetting surfaces to keep the surface wet for the duration of the dwell time as most surfaces dry in 3 to 5 minutes. However, the pressure of enhanced throughput limits the amount of time an EVS worker is able to spend in the room, so it is beneficial to use a disinfectant with a contact time of 5 minutes or less, so that the surface stays wet for the entire dwell time, thus ensuring the disinfectant is used in compliance and that the surface is properly disinfected.
Training is another key to reducing HAIs. Multi-language online training can teach ES about the importance of contact time and maintaining a wet surface in the disinfection process. This is also an easy way to test staff and ensure comprehension. Training should be regularly scheduled and include a thorough review of all high-touch surfaces that must be cleaned on a regular basis. Infection control staff should follow up and work with EVS management to monitor the work performed and reward those who follow protocol.
Partnerships are the key to winning the battle against HAIs. Infection control staff needs to look at ES as a partner in controlling pathogens on environmental surfaces. They should also look for suppliers that can provide the broad-spectrum disinfectant technology and training resources necessary to ensure staff are properly using the disinfectants.
Dale Grinstead, PhD, is an infection control fellow for JohnsonDiversey.
By Bill Slezak
Clean and “shiny” floors -- it’s often the first impression one has when they enter a facility. If you can see reflections in the shine on the floor, many assume it is clean. If the floor is dull, then it must be dirty. This same premise holds true in healthcare facilities and unfortunately, is extended unfairly to the patient care areas. Why is there so much attention given to the floor? Do clean and shiny floors reduce infection rates? While maintaining clean (and dust-free) floors is important, properly cleaning, and where appropriate, disinfecting, high-touch surfaces are possibly the most important aspect of cleaning patient-care areas. And combined with other basic strategies, like proper hand-washing, may be one of the most important ways to reduce hospital infections.
In an often-quoted 2006 study by Axel Kramer, gram positive bacteria such as VRE and MRSA, and spore-forming bacteria including Clostridium difficile, can survive on surfaces for months.1 Yet these surfaces are often not cleaned consistently.2 If we know surfaces can harbor and facilitate transmission, why is there such a challenge in keeping them clean and pathogen-free? Part of the challenge is the sheer number of items that need to be properly cleaned. A typical patient room contains a myriad of high-touch surfaces such as bed rails, telephone, remote controls, cabinet drawers, patient charts, etc. There is also an often overlooked challenge that has been imposed on ES; patient room design. There are still a large number of facilities where patients share a bathroom and others where the room contains only one sink, which is located in the patient care area. In these environments, high-touch surfaces can be highly contaminated even before a patient is able to wash their hands. Are we facing a losing battle? Absolutely not! In order to properly clean and disinfect high-touch areas, there are two important strategies that must be employed; implementing the right process while utilizing the right tools. In addition to having the right process, it’s critical for staff to execute it on a daily and consistent basis. Due to the aforementioned challenges, combined with the need to turn over rooms quickly, it’s easy for cleaning professionals to become distracted, hurried or miss a step. That’s why cleaning teams need ongoing training supplemented with training aids. Industry groups like ASHES, IEHA, APIC and AORN have detailed practice guidelines that can provide you with the proper “how to’s” in cleaning and infection control.
The launch of microfiber has had a significant and positive impact on the cleaning industry, yet utilizing microfiber cloths to clean and disinfect high-touch areas has only recently gained significant exposure and momentum. Due to their relative higher initial cost compared to cotton rags and disposable wipes, microfiber cloths need to be both used correctly and cared for in order to maximize their effectiveness. For optimum cleaning performance, demand split microfiber, which is chemically and mechanically split apart from the polyester to create microscopic crevices and openings within the filaments. Darrel Hicks, BA, REH, CHESP, director of ES at St. Lukes Hospital in St. Louis, utilizing the right type of microfiber will provide you with numerous benefits: “The guiding principle is always to remove germs if possible rather than kill them, and then when necessary, use the least amount of the mildest chemical that will do the job because stronger often means more toxic to people. Therefore, the best way to remove pathogens in spore or vegetative form is with the use of a high-quality split microfiber cloth which can remove up to 99.9 percent of the organic soil. And with the soil goes the microbes.”
Bill Slezak is the national healthcare segment manager for Rubbermaid Commercial Products, LLC.
1. Kramer et al. BMC Infectious Diseases 2006 6:130.
By Kirsten M. Thompson
The most important environmental cleaning practice hospitals can adopt to help fight infections is a multi-modal approach with a focus on cleaning the high touch areas of the hospital. Research performed by Philip Carling, MD, and others has demonstrated that the high touch areas of patient rooms such as doorknobs, light switches, sink handles, bed rails etc. are not always cleaned but can be improved with the use of targeted education and monitoring resulting in lower transmission of pathogens from these surfaces. Although taking a multi-modal approach sounds complex, there are a few basic elements that underpin a successful program including continually monitoring cleaning activities and measuring efficacy, using the right tools and products for the job, and creating and sustaining a culture of responsibility and education within environmental services staff.
Monitoring cleaning activities is critical in effectively managing and correcting any deficiencies and allowing a facility to set and maintain optimal process controls. For example, Carling’s monitoring tool is simple, yet elegant: a fluorescent marker applied to a surface before cleaning is checked after cleaning with a black light to verify whether the mark had been disturbed. This method has been very successful in improving compliance to the hospital protocol in cleaning patient areas.
Fundamental to an effective strategy for environmental cleaning is the use of the appropriate products, cleaning tools and process to disinfectant correctly and eliminate the chance of cross-contamination between patient areas. EPA registered quaternary ammonium disinfectants are frequently used on hospital surfaces and are considered very effective antimicrobials according to product labeling. Recently, concern has arisen around the discovery that the active ingredient (quat) has a tendency to become attracted to and absorbed into the fabrics used in cleaning tools. Because quaternary ammonium chlorides (quats) are cationic, or positively charged surfactants, they are attracted to fabric surfaces which are anionic, or negatively charged. There was some concern that the portion of the quats absorbed by the fabric may not adequately kill the microorganisms present. However, our research has shown that quat absorption occurs in cotton terry cloth as well as in microfiber cloth and that microfiber is superior to cotton terry cloth accounting for quat absorption, cleaning and disinfection efficacy, and preventing organism transfer to clean surfaces. To ensure that products are disinfecting correctly, environmental staff should be trained on correct use and dilution and best practices such as soaking clothes to achieve the proper solution saturation and using new clothes for each patient room.
Finally, creating a sense of responsibility as part of the patient care team in ES staff is key. We’ve found that most staff believe that the job they perform is very important, but also desire more education. Frequently reinforced education with a focus on adult learning and behavioral change using a learn-practice-do model insures that the knowledge of critical content is sustained. Also, a certification program based on demonstrating best practices and outcome monitoring helps environmental services staff take pride in their work and its role in keeping patients healthy.
Kirsten M. Thompson, BS, is technical affairs expert for Ecolab.
Carling PC, Briggs JL, Perkins J, Highlander D. Improved cleaning of patient rooms using a new target method. Clin Infect Dis 2006;42:385-8.
Carling PC, et al. Improving cleaning of the environment surrounding patients in 36 acute-care hospitals. Infect Control Hosp Epidemiol 2008; 29:1035-1041.
Datta R, Platt R, Kleinman K, Huang S. Impact of an environmental cleaning intervention on the risk of acquiring MRSA and VRE from prior room occupants. SHEA Annual meeting presentation, March 20, 2009.
US2006/0223731 A1 Monitoring Cleaning of Surfaces. Inventor: Philip C. Carling.
Eder AR, Brown ER, Carbone HL, Thompson KM. Evaluation of the use of ATP in auditing patient room cleanliness. APIC annual meeting presentation, June 9, 2009.
MacDougall KD, Morris C. Optimizing disinfectant application in healthcare facilities. Infect Control Today 2006;June: 62-7.