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By Kelly M. Pyrek
Whenit comes to closing the infection control loop in a healthcare facility, thestaff members of the environmental services or housekeeping department play acritical role; they can either undermine clinicians' efforts or support theinstitution-wide goal of preventing the transmission of pathogens.
"In an acute care setting, housekeeping is second only to hand hygienein importance in this infection control loop," acknowledges Paul Webber,director of research and education for Maunco Sanitation and Safety Supplies inBelleville, Ontario, Canada. "There is no surgical technique, no wound-carestrategy and no antibiotic prescription regime that can offset the impact of adirty hospital. A hospital that pays attention to the cleanliness of (notnecessarily disinfection of) above-floor surfaces is a healthy hospital.Although shiny floors are the most visible and yet the least clinicallysignificant task of the housekeeping department, they do serve as a motivatorfor 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 theenvironment, but he says hospitals must still be vigilant in their cleaningefforts.1
"Housekeeping practices, if performed correctly, will create an areasuitable for patient, visitor and healthcare worker (HCW) to enter and becomfortable within the confines of the environment," he says. "Theproper maintenance of a healthcare facility increases the awareness of otheremployees of the necessity of good sanitary practices. Good housekeepingpractices increase morale and public relations. No one wants to work in an areathat smells or is dirty."
The infection control manual at the Yale-New Haven Hospital states thatenvironmental surfaces such as walls, floors and countertops, as well as otherpatient-care surfaces in the hospital, should be cleaned routinely withEPA-approved disinfectants according to manufacturers' directions. Horizontalsurfaces such as countertops, over-the-bed tables and bedside tables, should bedamp-cleaned daily. Uncarpeted floors should be cleaned daily and carpetedfloors should be vacuumed daily, using a vacuum cleaner that does not expelairborne organisms into the environment. Vacuum cleaner filters should beregularly maintained and replaced as needed. Waste receptacles should be emptieddaily or as needed, and the liners of the receptacles replaced whenever waste isremoved. Cleaning of vertical surfaces such as walls and curtains is neededperiodically or whenever soiling is visible.
Bathrooms must be cleaned daily and special attention should be paid to thesink, faucet handles, commode and door handles. Thorough cleaning is necessarydue to the high concentration of body fluids that may be present on surfaces,says Otero. Soap dispensers should be checked daily for function and replenishedas needed.
Not all surfaces are created equal, Webber says, explaining that some areasof the hospital pose greater challenges to cleaning and disinfecting.
"Areas of concern include handrails that run along hallways, the stringsattached to bedside call bells, the bed-surround curtains that hang close to thefloor and other high-touch areas like door handles, doorframes andbathrooms," Webber adds. "In most cases I would support thoroughcleaning of these surfaces. In my opinion we disinfect way too often and thatthis may someday be our downfall. Shared toilets and sinks, and isolation roomsare appropriate places for cleaning and disinfection."
Webber adds that carpets and other fabrics require ongoing, special attentionfrom environmental services staff.
"For several years there was a trend toward carpeting floors inhospitals," Webber says. "They carpeted hallways and stairs, patientrooms, clinics ... they even carpeted intensive care units and emergency rooms.Generally the floor is not a concern for infection control (except in pediatricunits) but all of the bacteria, viruses and fungi that would normally be sweptup and mopped away have to be vacuumed and extracted. The vacuuming and thesteam cleaning would aerosolize the potentially pathogenic organisms, therebycreating an airborne infection hazard, not to mention a chronically wet floor insome places. How do you disinfect a chair that has vomit or diarrhea on it, evenin minute quantities? For example, if there are Norwalk viruses in the vomit orfeces a quat disinfectant won't do it, and bleach will take the color out of thefabric. Imagine a fabric chair in which hundreds of people sit, and on whichthey rub their hands in nervous anticipation. Hundreds of thousands of Norwalkviruses are on and in that fabric and we know that it takes as few as just oneto make people very sick, but we have no way to get the Norwalk out. ManyCanadian hospitals will use products made with accelerated hydrogen peroxidethat are safe on fabrics and effective at killing viruses and bacteria, but Idon't think that they are available in the United States yet."
The challenge continues in areas containing water sources. "Bathtubswith circulating water jets are troublesome, too," Webber says."Organisms along the walls of the tub can usually be simply wiped off witha 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 asampling of every disgusting bacteria, feces and body soil of every person whohas ever used the tub. Ordinary disinfectants won't clean out that biofilm, eventhose that are marketed specifically for those tubs. An oxidizing solution suchas bleach (at 5,000 ppm) or accelerated hydrogen peroxide must be circulatedthrough the pump and jets to clean out that slimy and potentially very dangerousfilm."
Webber says another troublesome area in the hospital is the flooring."In infection control circles it is a common mantra that floors are not anissue but I think that they might have a larger impact than we give them creditfor," he emphasizes. "When hospital floors are buffed and/orburnished, a little bit of the floor coating is sanded off and then allowed tobecome airborne. Some pieces of equipment have filters to reduce the amount ofdust that is released. I am concerned that whatever microorganisms might beliving happily on the floor will also be vortexed up into our breathing space orat least onto surfaces that will have hand contact. Certainly the filters usedto 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 thisspecific issue. "The studies that are available look only at theparticulate level as an IAQ issue, not at the microbial content of theparticulate."
Given the risk of airborne transmission of bacteria, environmental servicespersonnel must follow standard precautions and don personal protective equipment(PPE), according to the Yale-New Haven Hospital infection control manual. Thetype of barrier protection required is dependent on the procedure performed andthe environmental conditions encountered. Handwashing should be performed in thefollowing circumstances:
Non-sterile, disposable gloves should be worn during all cleaning procedures,and they should be discarded if there is evidence of deterioration or if theyare punctured, cut or torn. The should also be changed between each patient roomor area in the healthcare facility, as well as after contact with grossly orvisibly contaminated items or surfaces.
Fluid-impervious gowns should be worn for any cleaning task that involveslarge amounts of blood or other body fluid that may splash or splatter or bedifficult to contain. Masks must be worn for any cleaning procedures thatinvolve:
Protective eyewear should be worn if environmental services personnel will becleaning large amounts of blood or body fluids that may splash.
Environmental services personnel should be familiar with how to safely andproperly handle and dispose of sharps and infectious medical waste, and makesure that containers for holding such items are emptied and processed accordingto facility protocol and mandates by the state health department and theOccupational Safety and Health Administration (OSHA).
Communication about policies and procedures is essential to ensuringenvironmental services personnel follow aseptic technique. Webber acknowledgesthat as budgets are stretched and HCWs are expected to multi-task, thiscommunication and structured education can sometimes fall through the cracks.
"Housekeepers are becoming multi-skilled workers and are being used todo many other jobs, and this has its good side and its bad side," Webbersays. "On the good side, more relationships are being formed between peoplein different departments who might never get the opportunity to work togetherand who are much more likely to understand the other's challenges and point ofview. On a grander scale, setting the multi-skilled issue aside, the key iseducation and awareness. The housekeeping department is low profile; if there isto 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 publicityfrom administrators. Housekeeping has a critically important role, but istypically the entrance point into employment in other areas of the hospital, orthe exit point to which one is demoted just before being shuffled out thedoor."
Webber continues, "To ensure housekeeping staff members know the purposeof their job, a supervisor can do several things. He or she can invite nursingstaff, medical staff, infection control professionals and administrators tospeak to the workers to let them know how important their contribution is andhow exactly it helps to break the chain of infection."