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By Mark Fuglsang
According to the Centers for Disease Control and Prevention (CDC), cleaning and disinfecting environmental surfaces in healthcare facilities is fundamental in reducing the potential contribution of those surfaces to the incidence of healthcare-associated infections. In addition to proper hand hygiene, such cleaning and disinfecting can help to minimize the transfer of microorganisms that can occur via hand contact between contaminated surfaces and patients.
Environmental services and other healthcare professionals can look for guidance on environmental surface cleaning and disinfecting in the Guidelines for Environmental Infection Control in Healthcare Facilities, which are recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines note that continued compliance with environmental infection control measures (including environmental surface cleaning and disinfecting) will decrease the risk of healthcare-associated infections among patients. A copy of the guidelines can be downloaded at www.cdc.gov/ncidod/hip/enviro/guide.htm for more detailed information on the suggestions contained in this article.
Based on recommendations found in the CDC guidelines and industry best practices, the following are suggested protocols for cleaning and disinfecting environmental surfaces. Keep in mind that cleaning is the necessary first step of any sterilization or disinfection process and is needed to render the environmental surface safe to handle or use by removing organic matter, salts, and visible soils all of which interfere with microbial inactivation. In fact, the physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces.
The CDC guidelines divide environmental surfaces into two parts: medical equipment surfaces such as knobs or handles on machines, carts and similar equipment, and housekeeping surfaces such as floors, walls and tabletops. Housekeeping surfaces can be further divided into those with minimal hand contact (referred to as low-touch surfaces) and those with frequent hand contact (high-touch surfaces).
The number and types of microorganisms present on environmental surfaces are influenced by the number of people in the environment, amount of activity, amount of moisture (microorganisms are present in great numbers in moist organic environments, but some can also persist under dry conditions), presence of material capable of supporting microbial growth, rate at which organisms suspended in air are removed, and the type of surface and orientation (i.e., horizontal or vertical).
In the absence of manufacturers instructions, non-critical medical equipment such as stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls usually only require cleaning followed by low- to intermediate-level disinfection.
Most, if not all, housekeeping surfaces require regular cleaning with soap and water or a detergent/disinfectant and removal of soil and dust, according to the CDC Guidelines. High-touch housekeeping surfaces in patient-care areas, such as doorknobs, bedrails, light switches, wall areas around the toilet, and the edges of privacy curtains, should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Horizontal surfaces with infrequent hand contact, such as window sills and hard-surface flooring in routine patient-care areas require cleaning on a regular basis, when soiling or spills occur and when a patient is discharged from the facility.
Typically, the main criteria for selecting a registered cleaning agent are cost, safety, product-surface compatibility and acceptability by housekeepers. Consider forming a cleaning products selection committee made up of representatives from environmental services, chemical and radiation safety, infection control, purchasing and campus safety. Such a committee may fi nd, for example, that high-impact cleaning agents are seen as too dangerous or toxic for general use and should be replaced with a less toxic agent. Talk with chemical suppliers to supply product data sheets or labels for evaluation criteria such as dilution ratios, minimum exposure time to kill and stability of dilution. The Association for Professionals in Infection Control and Epidemiology (APIC)s Guidelines for Selection and Use of Disinfectants is another good resource.
According to the CDC guidelines, environmental surface germicides (intermediate- and low-level disinfectants) should specify (via labels, technical data and/or product literature) indications for product use and provide claims for the range of antimicrobial activity, per Environmental Protection Agency (EPA) regulations. Make sure the cleaning product chosen has been registered with the EPA and has a registration number on the label.
Always refer to manufacturers instructions for appropriate use sites, dilutions and application methods. Also note that the CDC guidelines recommend against using high-level disinfectants/liquid chemical sterilants for disinfection of any environmental surface as such use is counter to label instructions for these toxic chemicals. In addition, alcohol should not be used to disinfect large environmental surfaces.
Chemical hazard and toxicity ratings can typically be found on the materials safety data sheets (MSDS) for the product. Refer to manufacturers instructions and MSDS to determine appropriate precautions and personal protective equipment (PPE) needed during cleaning and housekeeping procedures. Standard precautions should be followed, including wearing gloves, during the cleaning and decontamination of blood, body fl uids and other infectious materials. Other PPE in these situations may include the use of respiratory protection.
To protect patients and others, the CDC guidelines caution against performing disinfectant fogging in patient-care areas and against large-surface cleaning methods that produce mists or aerosols or disperse dust in patient care areas. In addition to air-quality issues related to aerosolized cleaners, its important to remember that everything that becomes airborne will sooner or later settle on patients, surfaces and equipment, where it may create a contamination or slip-and-fall hazard.
According to the CDC guidelines, part of the cleaning strategy should be to minimize contamination of cleaning solution and cleaning tools. Bucket solutions become contaminated almost immediately during cleaning, and continued use of the solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned. Another source of contamination in the cleaning process is the cleaning cloth, especially if left soaking in dirty cleaning solution. Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the degree of bacterial contamination.
Another potential solution to this problem can be found in disposable cleaning wipers. The main advantage of using disposable cleaning wipers is that they are designed to be used, then tossed when dirty, eliminating problems associated with the re-use of dirty rags and with storing dirty rags in contaminated cleaning solution. In addition, disinfectants such as bleach maintain effective concentration longer when used with disposable cleaning wipers designed to be compatible with bleach than with common cotton rags.
Some disposable cleaning wipers are available in an enclosed-bucket system to help eliminate cross-contamination, reduce exposure to chemical vapors and splashes and combine all cleaning steps into one by eliminating the combination of spray bottle plus rag. With these systems, users can add the cleaning or disinfecting chemical (and solution ratio) of their choice to saturate the wipers, thus allowing the user to more closely control chemical usage and related costs.
The CDC guidelines offer special cleaning advice for areas with immuno-compromised patients and in situations where blood and body fluids are found. For example, when dusting in immuno-compromised patient areas, cleaners are cautioned to wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an EPA-registered hospital detergent/disinfectant, as allowed by the labeling.
Managing spills of blood, body fluids or other infectious materials in clinical, public health and research laboratories requires more stringent measures according to the CDC guidelines because of a) the higher potential risk of disease transmission associated with large volumes of blood and body fluids and b) high numbers of microorganisms associated with diagnostic cultures.
In patient-care areas, workers can manage small spills with cleaning and then disinfecting, using an EPA-registered disinfectant according to its labeling. For spills containing large amounts of blood or other body substances, workers should first remove visible organic matter with absorbent material such as paper towels (be sure to discard in properly labeled leak-proof containment) and then clean and decontaminate the area.
According to the CDC guidelines, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunosuppressive virus (HIV) have never been known to be transmitted from an environmental surface such as fl oors, walls or countertops. However, prompt removal and surface disinfection of an area contaminated by either blood or body substances is a sound infection-control practice and an OSHA requirement, according to the CDC guidelines.
Severe Acute Respiratory Syndrome (SARS) also prompted special consideration by the CDC, which issued infection control guidance in response to SARS in January 2004. (See www.cdc.gov/ncidod/sars/guidance/I/healthcare.htm#3d10 for more information.) However, the guidance suggests following the same environmental cleaning and disinfection principles generally used in healthcare settings, with cleaning and disinfection recommended at least daily for SARS patient rooms, and more often when visible soiling/contamination occurs.
Cleaning and disinfecting environmental surfaces may be a routine task, but it should not be taken lightly. Adhering to the CDC guidelines and careful evaluation of cleaning chemicals and tools will help to achieve a cleaner and safer facility.
Mark Fuglsang is healthcare market manager for Kimberly-Clark Professional.