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by Joe Saunders and Lynda Mathiesen
The primary function of the housekeeping department in a healthcare facility is tocreate a clean, safe, and healthy environment for patients or residents, staff, andvisitors. Included in this function is the disinfection of all environmental surfaces,which comprises floors, walls, counters, furniture, etc.
Establishing and adhering to a sound program is the key to effective cleaning anddisinfecting of environmental surfaces throughout a healthcare facility. This articlefocuses on floor disinfection and provides guidelines for a good floor care disinfectionprogram.
Many environmental surfaces, including floors in a medical facility, can harbordisease-causing germs. Although not directly involved in disease transmission,environmental surfaces may indirectly contribute to secondary cross-contamination by thehands of healthcare workers or by contact with medical instruments that will subsequentlycome into contact with patients/residents. Martin Favero and Walter Bond expanded Dr. E.H.Spaulding's original classification of medically related surfaces to define more clearlythe relative risks of disease transmission. This expansion included dividing theclassification of environmental surfaces into two sub-groups: medical equipment surfacesand housekeeping surfaces. Housekeeping surfaces, of course, include floors, walls,counters, and furniture and are considered non-critical items that require low-leveldisinfection. Cleanliness and infection control of these surfaces can be ensured byremoval of soil on a routine basis. This can be accomplished using water and a detergentor a low-level, EPA-registered, nontuberculocidal, hospital-grade disinfectant designedfor general housekeeping procedures.
A good floor care disinfection program comprises three key elements: use of effectivedisinfectants--detergents, tools, and procedures. All three elements must be present to besuccessful in physically and chemically removing soil and microorganisms. Extraordinaryattempts to disinfect floors are usually unnecessary. The actual physical removal of soiland microorganisms is probably at least as important as the germicidal activity of thedisinfectant used.
Low-level, hospital-grade disinfectants are the recommended products for floor caredisinfection in healthcare settings. The Environmental Protection Agency (EPA) regulatesand registers all low-level disinfectants. To be considered a hospital grade disinfectant,manufacturers must test their germicidal products against three microorganisms: Staphylococcusaureus, Salmonella choleraesuis, and Pseudomonas aeruginosa. Usuallyproducts are tested against a variety of other microorganisms, especially in today's ageof antibiotic resistance (MRSA and VRE) and concern with bloodborne viruses. To obtain aone-step cleaner disinfectant claim, testing of these products is usually done in thepresence of organic serum (at least five percent) and hard water (at least 400 ppm). Thistesting is always done at the manufacturer's recommended dilution rate; therefore, it isimportant for the user to mix a disinfectant according to the manufacturer's label.
The "cleaner" part of the product acts as a penetrating agent through soilloads and allows the disinfectant part of the product to penetrate the cell wall of themicroorganism so that the killing action can take place. A one-step claim is veryimportant in today's cost-conscious healthcare environment because it reduces labor andproduct costs. In laboratory testing, microorganisms must come into contact with thedisinfectant for 10 minutes; however, actual kill time might be less than 10 minutes. Inreal world applications, floors usually do not stay wet from damp mopping procedures for10 minutes. A few minutes can be expected, which should give most disinfectants adequatetime to kill. Physical removal with a mop or autoscrubber in itself will remove asignificant share of microorganisms present. If a mop is used, it will be immersed in asolution of disinfectant upon completion of the mopping procedure. If an autoscrubber isused, any solution applied to the floor will be picked up by the machine and will be heldin a recovery tank until emptied. A related corollary to contact time is residualactivity. Disinfectants in a dry state do not have a residual activity. Disinfectantaction can only take place when moisture is present.
When selecting a disinfectant, first review technical research bulletins provided byvendors. These bulletins will identify the different microorganisms that the disinfectanthas been tested against. Then match the tested microorganisms against those most prevalentin your particular environment. In addition to the microorganisms most prevalent, adisinfectant should have a broad range of kill; it should be capable of killing Grampositive and Gram negative bacteria, fungi, and viruses. Second, compute the parts permillion (PPM) of active disinfectant. This computation simply translates the percentage ofactive ingredients into parts per million. This computation is:
% of active ingredients X 10,000
The resulting number can be used to determine how effective a disinfectant will be asyou introduce soil load. As the employee mops a floor and immerses the mop into the bucketof disinfectant solution, the solution will degrade. At a certain point, approximately 300to 350 ppm, a disinfectant will be rendered ineffective. Therefore, it is recommended tochange the soiled disinfectant solution on a routine basis, usually every three to fourrooms. Exceptions to this rule would include isolation cases, discharges, cleaning insurgery or delivery, and cleaning of blood spills.
A disinfectant should be noncorrosive, nonirritating, effective in hard water, able todilute in hot or cold water (preferably cold water), and as close to neutral pH aspossible so as not to affect floor finishes. Neutralization of the product due to soilload should not occur. Finally, a disinfectant should be economical to use. To determinehow economical it is, focus on the end use cost not the price per gallon. To calculate anduse cost, simply divide the cost per gallon by the dilution rate per gallon.
As important as the disinfectant-detergent is in the floor care disinfection program,the tools and procedures used are as equally as important. Appropriate selection, use, andcare of dust mops, wet/dry vacuums, and wet mops are critical to the success of theprogram.
Proper dust removal is critical. Bertha and Warren Litsky demonstrated in 1968 thateffective dust removal before wet mopping or scrubbing of floors proved to be an importantpart of the cleaning and disinfecting process. Dust removal prior to scrubbing or moppingwill collect a large portion of debris, dirt, and dust that, if uncollected will affectthe disinfecting capability of the disinfectant-detergent. Litsky recommends the followingorder for dust removal effectiveness:
Sweeping floors with a broom is not recommended because particles become airborne andcan be transferred throughout the facility. Since microorganisms are attracted to dust anddirt for a food source, any chance of creating an airborne situation is not advised. Toeliminate this concern in areas like the operating or delivery room and where a wet/dryvacuum is not available, a broom dipped into disinfectant can be used. Dipping the broominto the disinfectant will eliminate any dust particles from becoming airborne, thusnegating a potentially hazardous situation.
Proper care of all dust removal tools should be taken to maintain the life of theequipment as well as to eliminate cross contamination. Wet/dry vacuums should be cleanedinternally and externally daily with a disinfectant and after each use when contaminatedwith blood or body fluids that visibly contain blood. Disposable dust mops should bediscarded when thoroughly soiled. Laundered dust mops should be laundered daily.
With proper dust removal, the wet mopping or scrubbing process is much more effective.Litsky recommends the use of sterile wet mops or freshly machine laundered wet mops forthe wet mopping process. Mops should be replaced after each isolation room cleaning,discharge cleaning, clean up of blood spills, and cleaning in surgery and delivery suites.A routine of changing mops after a certain number of rooms should also be adopted. It isnot unusual for wet mops to become contaminated even after dust removal, so it isimportant to adopt a routine of changing disinfectant solutions and mops frequently. Dirtymops immersed in a bucket of disinfectant, can become a medium for growth of livemicroorganisms. Solutions should be changed after every 3-4 rooms if using a single bucketmethod or 6-8 rooms if using a two-bucket (both buckets contain disinfectant solution),two mop system.
In large open areas like hallways or lobbies, wet mopping of floors is not necessarilythe most productive and cost effective process. In these instances, use of an automaticscrubber is appropriate. An automatic scrubber applies the disinfectant-detergent to thefloor, scrubs the floor with pads or brushes, and then vacuums the floor dry. It is a veryproductive tool for large areas and very effective in the soil removal process. When usingan automatic scrubber to clean and disinfect a floor, double scrubbing is recommended.Double scrubbing is the process of applying the disinfectant-detergent on the floor andscrubbing twice prior to vacuuming the solution. Double scrubbing will allow thedisinfectant more contact time with a microorganism, thus creating a better killingsituation. Automatic scrubbers should be cleaned daily by running a solution ofdisinfectant through the machine. Pads or brushes should also be cleaned in disinfectantfor 10 minutes and allowed to air dry.
Three major problems can occur when cleaning and disinfecting floors:
Problem 1: Film on floor from use of germicides.
Solution 1: Dust mop with untreated dust mop prior to damp mopping withdisinfectant.
Solution 2: Change disinfectant at recommended times--approximately everythree to four rooms.
Problem 2: Tacky floors caused by change from a "quat" to aphenolic.
Solution 1: Scrub floor with a neutral cleaner before using a germicidewith a different active ingredient. If floor is still tacky, mop floor with alcohol.
Solution 2: Check dilution of the disinfectant. Use chemical dispensingsystems for best accuracy.
Problem 3: Discolored floor tile caused by too strong a solution.
Solution 1: Rinse the floor periodically with clean, clear water.
Solution 2: Use disinfectant at proper dilution as a stripping solutionto strip the discolored area.
Despite the fact that floors do not play a major role in the transmission of disease,it is appropriate to clean and disinfect floors in a healthcare facility on a regularlyscheduled basis. This is especially true in all patient care areas. Use of disinfectantsin this process control the spread of bacteria from room to room as long as properprocedures are followed and proper tools are used. Use of disinfectants is also as costeffective as neutral or general-purpose cleaners when comparing end-use costs.
Joe Saunders is Health Care Market Manager and Lynda Mathiesen is Health CareSpecialist for Pioneer/Eclipse Corporation (Sparta, NC). John Hilgren, a principaltechnical affairs specialist for the professional products division of Ecolab Inc. (St.Paul, MN), edited this article.
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