Infection Control Today - 10/2002: Fast-Paced EDs Require Speedy YetThorough Clean-ups

October 1, 2002

Fast-Paced EDs Require Speedy Yet Thorough Clean-ups

By Kelly M. Pyrek

Emergencydepartments (ED) often are the busiest parts of a hospital, generating enormousamounts of foot traffic and dramatically increasing the odds of transmission ofinfectious pathogens. A National Hospital Ambulatory Medical Care Survey: 2000Emergency Department Summary reveals there were 108 million ED visits in 2000,up 14 percent from 95 million visits in 1997. Because the number of hospitalsproviding emergency care decreased from 4,005 to 3,934 between 1997 and 2000,the number of annual visits per emergency department has increased about 16percent since 1997, from 24,000 to 27,000, according to the Centers for DiseaseControl and Prevention (CDC) report.

EDs also are receiving patients with a more acute degree of illness. Dramaticchanges in healthcare-related policy at the federal, state and local levels haveimpacted the number of individuals able to access preventive care. As a result,many individuals delay seeing a physician until their medical condition worsensand they require emergency care. This kind of behavior significantly increasespatients' risk for infection and presents an increased infection risk forhealthcare workers (HCWs) in the ED. Opportunities for cross contaminationescalate when ED personnel provide life-saving, therapeutic interventions toacutely ill and trauma patients. In the rush of tending to squirting arteries,infection control principles can take a back seat until it's time to clean anddecontaminate the ED.

The thorough cleaning and disinfecting of all surfaces (medical andhousekeeping) is critical in maintaining an aseptic environment. While cleaningschedules and the kinds of products used will vary from one hospital to another,industry guidelines dictate that hard surfaces such as floors and countersshould be cleaned regularly and according to the amount and the kind of soil orbody fluid spills present. Dropped packages, spent dressings and other packagingthat may have been dropped to the floor must be collected, and a light moppingor sweeping to remove initial amounts of dirt and debris can be done prior to amore labor-intensive wet mopping. Generally, low-level, hospital-gradedisinfectants are appropriate products for floor disinfection in the ED, and thesingle-bucket procedure is a common and practical method. The disinfectantsolution must be changed when visibly soiled so that bacteria are nottransferred from bucket to floor and back again. The disinfectant solution mustbe changed immediately after clean-up of blood spills, and daily laundering ofmop heads in a hot water cycle followed by thorough drying is recommended.

Other environmental surfaces in the ED that require thorough cleaning includestretcher mattresses, stretchers, tables, counters and carts. These should becleaned and disinfected regularly with a disinfectant registered by theEnvironmental Protection Agency (EPA) and used according to the manufacturer'sinstructions. Fresh cloths should be used for cleaning each room and if a bucketmethod is used, the visibly soiled disinfectant solution must be changed everythree to four rooms. ED curtains should be laundered if visibly soiled and wallsbehind them should be spot-cleaned if there is evidence of spills and splashes.

Another safe harbor for bacteria are patient-care items used in the ER.According to Karen R. Vallejo, RN, BSN, CIC, an infection control practitionerat St. Luke's Episcopal Hospital in Houston, Texas, medical devices, equipmentand surgical materials are divided into three categories. "Critical itemsare instruments or objects that are introduced into normally sterile areas ofthe body (e.g., surgical instruments, cardiac catheters). Semi-critical itemsgenerally do not penetrate body surfaces but are in contact with mucousmembranes. Such items include respiratory therapy equipment (e.g.,laryngoscopes) and gastroscopy equipment. Non-critical items are those that donot touch the patient or touch only the intact skin. Such items includestethoscopes, blood pressure cuffs, crutches, and other medical accessories. Allthese items are used routinely in the ED, and a clear understanding of thesecategories is essential."

She continues, "Since it is neither necessary nor possible to sterilizeall patient-care items, hospital policies can identify whether cleaning,disinfecting, or sterilizing an item is indicated to decrease the risk ofinfection. For example, critical medical devices or patient-care equipmentshould always be sterilized as any microorganisms, including bacterial spores,that come in contact with normally sterile tissue can cause infection.Semi-critical medical devices or patient-care equipment should be introduced toa disinfection process that kills all microorganisms (e.g., viruses and tuberclebacilli) but resistant bacterial spores. This disinfection should always be donebetween uses to reduce the risk of transmission of microorganisms to otherpatients. It is important that reusable items be cleaned thoroughly beforeprocessing because organic material (e.g., blood and proteins) may inactivatechemical germicides and protect microorganisms from the disinfection orsterilization process. Non-disposable, noninvasive items (i.e., antishocktrousers, blood pressure cuffs) contaminated with blood or other body fluidsshould be cleaned and disinfected thoroughly with an EPA-registered disinfectantagent after each use. Patient-care equipment intended for single use should notbe reprocessed and used. These disposable items usually cannot be cleaned andsterilized adequately or are made of materials that may be damaged by chemicalor heat disinfection or sterilization. HCWs performing these procedures shoulddemonstrate knowledge of and proficiency in proper technique. In addition,appropriate attire (e.g., gloves, goggles, and gowns) must be worn duringcleaning procedures. HCWs should understand the limitations of gowns, how toremove a gown that becomes grossly contaminated, and how to dispose of suchgowns."