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by Karen R. Vallejo, RN, BSN, CIC
Recent changes in health-associated expenditures and health policy have significantlyimpacted healthcare delivery in the US. As a result, a large number of patients receivingemergency care have limited access to preventive healthcare. This significantly increasestheir risk for infection and presents an increased infection risk for healthcare workers(HCWs) in emergency center (EC) settings. Furthermore, trauma patients and acutely illpatients often require immediate lifesaving interventions making infection prevention andcontrol measures a lower priority. HCWs must be familiar with and follow standardprecautions during all patient care encounters. In addition, the appropriate cleaning ofenvironmental surfaces (housekeeping surfaces and medical equipment surfaces) is criticalfor maintaining a safe and healthy environment for patients, staff, and visitors. Thisarticle focuses on cleaning and disinfection of environmental surfaces in the EC.
Environmental surfaces, including floors, walls, and other surfaces can harbordisease-causing microorganisms. However, these environmental surfaces rarely areassociated with transmission of infections to patients or personnel. Therefore,extraordinary attempts to disinfect or sterilize these environmental surfaces are rarelyindicated. Cleaning schedules and methods will vary according to the area of the hospital,type of surface to be cleaned, and the amount and type of soil present. In the EC,hard-surfaced flooring should be cleaned on a regular basis, when soiling or spills occur,and when a patient is discharged. At St. Luke's Episcopal Hospital (Houston, Tex), dustmopping is done prior to scrubbing or mopping the floors to remove a large portion ofdirt, debris, and dust. Generally, low-level hospital grade disinfectants are appropriateproducts for floor care disinfection in the EC. The single-bucket procedure for wetmopping is the most common and practical method. When a single-bucket is used, thedisinfectant solution must be changed when visibly soiled because of increased bioload orchanged every three to four rooms. However, it is imperative that the disinfectantsolution be changed immediately after clean up of blood spills such as those associatedwith trauma, deliveries, or accidental spills. Daily laundering of mop heads in a hotwater cycle followed by thorough drying is recommended.
Other horizontal surfaces such as counters and stretcher mattresses and equipmentshould be cleaned and disinfected with an EPA-registered disinfectant and used inaccordance with manufacturer recommendations. The Occupational Safety and HealthAdministration (OSHA) compliance directive specifies that the disinfectant used for thispurpose should be tuberculocidal. This limits choices to a phenolic disinfectant orchlorine solution (i.e. 1:10 dilution of sodium hypochlorite). However, studieshave demonstrated that other germicides such as quaternary ammonium compounds caninactivate bloodborne pathogens effectively.1 At St. Luke's Episcopal Hospitala thorough, enhanced environmental "bucket method" is used to clean horizontalsurfaces as opposed to the conventional spray bottle method. With the "bucketmethod," a cleaning rag is dipped into a bucket containing an EPA-registereddisinfectant and then used to drench all environmental surfaces. The environmentalsurfaces are left wet for ten minutes before being wiped dry with a clean towel. The"bucket method" allows for direct and longer contact between the surface and thedisinfecting agent. This is particularly important as studies suggest that conventionaldisinfection (spray bottle method) may be associated with a higher frequency of persistentcontamination of environmental surfaces with organisms such as vancomycin-resistant Enterococcus.2Clean cloths should be used for cleaning each room. Routine changing of the soileddisinfectant solution in the bucket is done every three to four rooms or if the solutionbecomes visibly soiled. The solution should be changed immediately after clean up of bloodspills. If curtains are used in the EC and they become visibly soiled, they should beimmediately removed and machine-washed. Finally, walls are spot cleaned of spills andsplashes and completely cleaned when they are soiled.
The rationale for cleaning, disinfecting, or sterilizing patient-care equipment can bebetter understood if medical devices, equipment, and surgical materials are divided intothree categories. Critical items are instruments or objects that are introduced intonormally sterile areas of the body (e.g., surgical instruments, cardiac catheters).Semicritical items generally do not penetrate body surfaces but are in contact with mucousmembranes. Such items include respiratory therapy equipment (e.g., laryngoscopes)and gastroscopy equipment. Noncritical items are those that do not touch the patient ortouch only the intact skin. Such items include stethoscopes, blood pressure cuffs,crutches, and other medical accessories. All these items are used routinely in the EC, anda clear understanding of these categories is essential.
Since it is neither necessary nor possible to sterilize all patient-care items,hospital policies can identify whether cleaning, disinfecting, or sterilizing an item isindicated to decrease the risk of infection. For example, critical medical devices orpatient-care equipment should always be sterilized as any microorganisms, includingbacterial spores, that come in contact with normally sterile tissue can cause infection.Semicritical medical devices or patient-care equipment should be introduced to adisinfection process that kills all microorganisms (e.g., viruses and tuberclebacilli) but resistant bacterial spores. This disinfection should always be done betweenuses to reduce the risk of transmission of microorganisms to other patients. It isimportant that reusable items be cleaned thoroughly before processing because organicmaterial (e.g., blood and proteins) may inactivate chemical germicides and protectmicroorganisms from the disinfection or sterilization process. Nondisposable, noninvasiveitems (i.e., antishock trousers, blood pressure cuffs) contaminated with blood orother body fluids should be cleaned and disinfected thoroughly with an EPA-registereddisinfectant agent after each use. Patient care equipment intended for single use shouldnot be reprocessed and used. These disposable items usually cannot be cleaned andsterilized adequately or are made of materials that may be damaged by chemical or heatdisinfection or sterilization. HCWs performing these procedures should demonstrateknowledge of and proficiency in proper technique. In addition, appropriate attire (e.g.,gloves, goggles, and gowns) must be worn during cleaning procedures. HCWs shouldunderstand the limitations of gowns, how to remove a gown that becomes grosslycontaminated, and how to dispose of such gowns.
Disposable items that can cause injury such as scalpel blades and syringes with needlesshould be placed in puncture-resistant containers. Used needles should not be recapped,bent, broken, or cut before disposal. The container should be available for sharpsdisposal at point of use. If possible, the person performing the procedure should placeall items with the potential for puncture wounds in the sharps container. Proper disposalof filled sharps containers (three quarters full) are essential. They should be identifiedwith the proper OSHA required labeling.3
Linens on stretchers in the EC should always be changed between patients. If the linenbecomes soiled with blood or other potentially infectious materials (e.g. vaginalsecretions, semen, spinal fluid), it should be placed in a linen bag at the location whereit was removed to prevent leakage. Although soiled linen may be contaminated withpathogenic microorganisms, the risk of disease transmission is negligible if it ishandled, transported, and laundered in a manner that avoids transfer of microorganisms topatients, personnel, and environments. Hygienic and common sense storage and processing ofclean and soiled linen are recommended by the Centers for Disease Control and Prevention(CDC). The methods of handling, transporting, and laundering of soiled linen aredetermined by hospital policy and any applicable regulations.
Adherence to basic infection control practices must be in the minds of all personnelworking in the EC. Although the risk of infection cannot be eliminated completely, theappropriate cleaning and disinfection of environmental surfaces can minimize this risk.Each member plays a vital role in maintaining a clean, attractive, and safe environmentfor patients, staff, and visitors. In addition, a review of current infection controlpolicies and practices should be an ongoing process in the EC.
Karen R. Vallejo, RN, BSN, CIC, is an Infection Control Practitioner at St. Luke'sEpiscopal Hospital (Houston, Tex).
1 Bond WW, Favero MS, Petersen NJ, et al. Inactivation of hepatitis B virus by intermediate to-high-level disinfectant chemicals. J Clin Microbiol. 1983;18:535-538.
2 Byers K, Durbin L, Simionton B, Anglim A, Ada K, Farr B. Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium. Infect Control Hosp Epidemiol. 1998;19:261-264.
3 Occupation Safety and Health Administration: Occupational exposure to bloodborne pathogens: final rule, 29 CFR part 1910.1030, Washington DC, Dec. 6, 1991 U.S. Department of Labor.
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