Cleaning and Disinfection Update

The fact that hospitals continually see an influx of coughing, sneezing, sick patients ensures that cleaning and disinfection throughout the facility will always be necessary. New concerns regarding methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE) and other problematic pathogens means that the environmental services staff is needed more than ever.

Healthcare-associated infections have become such a focus that other countries are also implementing new barriers to bugs the United Kingdoms department of health reported statistics at the end of July indicating that although MRSA bacteremia rates fell to the lowest winter level since 2001, the figures indicate that more work must be done to fight other pathogens such as Clostridium difficile. In fact, the nations health law has been revised to deal with organizations that consistently fail to follow best practices to reduce healthcare infections. Health Minister Andy Burnham emphasized, Clean, safe care is not an optional extra.

Meeting best practices for general cleaning and disinfection in the hospital is often a challenge, due to turnover of patients and the need to get a room ready for the next admission as quickly as possible. And the rush means that some steps may be forgotten.

One of the biggest challenges weve had is to determine who should be responsible for each item that needs to be disinfected on a routine basis, says Sharon Krystofiak, MS, MT (ASCP), CIC, manager of infection control at Pittsburgh Mercy Health System.

Each group nurses, housekeepers, and nursing assistants/ aides feels that they are overworked (and they often are!) and that cleaning is not part of their job duties. Weve created a document that specifies who is responsible for each cleaning duty, what product is to be used, and how often the task should be performed. Our housekeeping staff often uses spray bottles and other equipment for large-scale tasks and our clinical groups use prepackaged cleaning wipes, which can be kept within the patient room or near the nurse station for quick retrieval. Both product lines utilize quaternary ammonium compounds to achieve the sanitization. Of note, the housekeepers are responsible for all bathroom cleaning, she adds.

Certain products require the removal of surface soil before disinfection, so a wipe-off followed by a disinfection step may be needed, she continues. It can also be a challenge to move the patients belongings or equipment before cleaning, so there is some concern about staff that may sometimes clean around patient items rather than lifting or removing them.

Oftentimes, Krystofiak says, there are no special cleaning requirements based on a specialty location of the hospital, such as a burn unit, the operating room, the intensive care unit (ICU), or isolation wards for patients with contagious diseases such as tuberculosis.

We do not have many special cleaning requirements based on location. We do use disposable plastic curtains in the burn units hydrotherapy room to limit cross transmission of organisms, but have not been able to prove that it makes a tremendous difference, she says. The most important part is to focus on good products, appropriate frequency, and lots of elbow grease.

Research on inanimate surfaces and the transmission of pathogens discusses the presence of antibiotic-resistant bacteria present in the patient environment, and the need for appropriate cleaning procedures. It is very difficult to identify which items might be responsible for transmission of pathogens, but its a general rule that its the staff members hands that carry the bacteria from the environment to the patient, Krystofiak adds. Barrier precautions (gowns and gloves) are being donned by employees entering isolation rooms to keep the employee from becoming a vector for infections.

Equipment and flat surfaces can be a mode of transmission of organisms, if there is not ongoing cleaning, points out Harriett Pitt, RN, BSN, MSN, CIC, director of epidemiology at Long Beach Memorial Medical Center and Miller Childrens Hospital in California. Housekeeping in her two facilities is diligent in their cleaning duties, she adds, noting that they are able to utilize detergent wipes to be used after treatments and to clean flat surfaces.

For routine cleaning of surfaces in the ICU or general ward, any Environmental Protection Agency (EPA)-approved product is adequate, says Edward Septimus, MD, medical director of infectious diseases and patient safety at Deaconess Billings Clinic in Montana. Septimus also serves as consultant and faculty for VHA Inc. clinical programs.

For surgery or areas with blood, a tuberculocidal agent is used (e.g., phenolic but it is not advised in the nursery), a quaternary ammonium with hepatitis/HIV activity is used, or 10 percent sodium hypochlorite. The reason is activity against bloodborne viruses. There are specific pathogens that require special mention: there is good evidence that the environment can play a role with Clostridium difficile, vancomycin- resistant enterococcus (VRE), and Staphylococcus aureus (in burn units). Norovirus, influenza virus, rotavirus, and hepatitis B can survive on surfaces and occasionally are associated with transmission. Most of these agents can be decontaminated with a standard EPA-approved disinfectant except norovirus and Clostridium difficile (spores), for which sodium hypochlorite is preferred, he says.

The use of molecular epidemiology to better document the role of the environment in transmission is new. Existing studies are difficult to interpret, since studies of possible transmission do not take into account measurements of environmental cleaning or hand washing.

There is debate over specific cleaning methods, too. There is some controversy about whether or not one really needs to use a tuberculocidal agent with blood cases and whether every room of a Clostridium difficile patient requires sodium hypochlorite for its sporicidal activity, Septimus comments.

VHA Inc. is attempting to clear up some of the controversy through its Transformation of the Operating Room program. This plan aims to improve the culture and teamwork inside the OR, improve clinical outcomes and patient safety, and make the OR a positive financial source.

In the OR, turn-around time is extremely important, says Kirsten Thompson, a technical service expert with Ecolabs healthcare division. Ecolab develops and markets cleaning, sanitizing, pest elimination, maintenance and repair products, and services for the hospitality, foodservice, healthcare, and industrial markets.

In addition, the product used should meet the requirements for efficacy against bloodborne pathogens, she adds. Wipes impregnated with chemistry to provide short contact times are valuable in this area. Similarly in the ICU, convenience is important for cleaning with little disruption for the patient. Surface-compatible chemistries are also important for patient equipment. Ready-to-use products in wipe, spray bottle, or squirt bottle form offer the nursing staff a stable use solution of disinfectant that may be used for cleaning. For general patient room cleaning, some of the exciting advances include systems that provide both efficiency and efficacy. Housekeeping carts equipped with presaturated mop heads and cloths, color-coded for each area of the room to be cleaned, make the cleaning process quicker and reduce the chance of cross-contamination within the room and from room to room.

Differences in cleaning these various areas depend not only on the invasiveness of procedures done in the room, but also whether the room is occupied or not, whether the room is an isolation room, and whether there is an organism of concern, Thompson observes. Special products and procedures may be implemented as part of an intervention strategy for outbreaks of antibiotic-resistant organisms or spore-forming pathogens like Clostridium difficile.

While several studies demonstrate the survival of microorganisms in the environment, as well as cross-contamination of materials, there is very little evidence relating environmental contamination to healthcare-associated infection, she notes. Most of the practices today are based on what has been done in the past. The surfaces with the highest risk for pathogen transmission (bed rails, patient equipment, etc.) should certainly be disinfected, while the use of disinfectants on surfaces that pose a low risk, such as floors, may be debated. Disinfectants are routinely used on floors in North America, while hospitals in Europe typically use a general purpose cleaner.

Certainly label contact time is an issue that is debated, Thompson continues. Manufacturers are held to the recommendations of their EPA-approved label, which was generated from laboratory data to meet very stringent criteria. In practice, these contact times are often too long, but also dont correspond to the real-life soil and contamination present on the surface. Disinfection practices surrounding Clostridium difficile are a hot topic. Evidence for contamination of the hospital environment by C. difficile is compelling, and disinfection is effective in reducing the number of C. difficile positive cultures in the environment. The vegetative form of C. difficile, such as might be found on fecally- contaminated surfaces, may be killed by hospital-grade disinfectant products or simply in the presence of air.

There are some EPA-registered disinfectants with Clostridium difficile (vegetative form) claims on their labels. However, it is important to note that disinfectants or disinfectant-detergents intended for use on environmental surfaces are not effective against the spore form of C. difficile under practical use conditions, regardless of the class of disinfectant or the manufacturer of the product. Current expert recommendations include handwashing, barrier precautions, and meticulous environmental cleaning with an EPA-registered disinfectant for routine disinfection of rooms with C. difficile, but a diluted hypochlorite (a 1:10 dilution of household bleach is cited in the literature) should be considered in units with high C. difficile rates, she says.

With expert recommendations, hypochlorite is recommended only in units with high rates of C. difficile or in outbreak situations. The routine use of bleach is discouraged, as it is very corrosive to metals, damaging to environmental surfaces including floor finish, is inactivated by organic matter, provides no more detergency than plain water, and is toxic. Inactivation by organic matter can be significant when fecal contamination is considered, as is detergency. The CDC has stated in several guidelines that the actual physical removal of microorganisms by scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used. The physical removal of the organism by cleaning with a good detergent is paramount.

The combination of a hospital-grade disinfectant and superior detergency make for good product choices for this application as well as general housekeeping procedures. Stringent handwashing practices are absolutely essential for minimizing the transmission of disease via the hands. Hand hygiene is crucial in the interruption of potential disease transmission from person to person.

In the Intensive Care Unit

Although the cleaning techniques may not differ in the ICU, there may just be more of them needed, for the simple reason that there are more devices involved in the patients care, and therefore, more equipment requiring cleaning.

One of the biggest problems in the ICU setting is the increased presence of equipment, such as ventilators, dialysis units, etc., accompanied by all of the healthcare personnel who enter the area on a more frequent basis than in regular patient units, points out Krystofiak.

More people plus more stuff equals an increased chance to contaminate the patients environment, she adds. Unfortunately, housekeeping personnel are frequently not trained to clean this specialty equipment and the tasks fall to nursing staff which of course often means that routine surface disinfection is minimal.

To step up surface cleaning in this area, she says, cleaning products must have rapid contact times for surface disinfection and cover a broad range of organisms. They have to come in convenient packaging and be compatible with the equipment in the area. This will enable nurses or environmental services staff to get the job done more quickly and efficiently.

Surface cleaning should be a priority, but it must be accomplished in simple, easy-to-complete, hard-to-skip steps, adds Katie Calabrese, MSN, NNP, CNS, product manager/market management for Baxa Corporation. The harder or slower the practice seems, the less likely it is that it will be completed properly.

It is crucial to emphasize to the cleaning staff how indispensable their services are. Your environmental services staff needs to be inserviced on the importance of their role in keeping the patient environment clean, says Karen Williams, manager for infection control at Morristown Memorial Hospital, a Level 1 trauma center, located in northern New Jersey.

Educational staff must address their cleaning processes and the products they use, she adds. In addition, you need to have your clinical staff in tune with the same thoughts. They need to be aware that if a pump/pole/whatever is discontinued on one patient and is going to be used on the next patient, it needs to be cleaned.

Ideally all equipment needs to be sent to your sterile processing department for cleaning, but in reality, there may be times that this equipment may go directly to another patient, she continues. In that case, a hospital-approved germicide should be available in that unit so that staff can clean equipment themselves. Staff can also take responsibility for doing tasks such as wiping down patient side rails once per shift.

Surface cleaning is the responsibility of both environmental services staff and the clinical personnel and is required on an on-going process, adds Pitt. The detergent-based wipes [should be] available to all patient care areas for use.

Attention to the frequently touched horizontal surfaces is important, emphasizes Boyd Wilson, system director for infection prevention and control/epidemiology for the HealthEast Care System at St. Josephs Hospital in Saint Paul, Minn.

Generally, routine surface disinfectants approved for healthcare environments are sufficient to effectively provide a clean environment in the ICU, he points out. Housekeeping staffing levels, and the need to turnover beds quickly due to patient flow challenges, has the potential to result in room cleaning that is suboptimal, he cautions. Housekeeping personnel need to understand how important their role is in maintaining a safe environment for infection prevention and control. This education/ communication to housekeeping must be balanced with information that gives them a level of comfort with cleaning effectively, and knowing that they are not at increased risk in the process. It is again important to focus on the frequently touched surfaces and to pay particular attention to this for rooms that were used for patients on isolation precautions.

However, it should be noted that this does not mean corners can be cut in cleaning other rooms. It has been demonstrated in the literature that the environment can become easily contaminated with resistant organisms such as VRE with high-risk patients, and in particular, in an ICU environment. It has also been demonstrated that routine cleaning practices consistently applied to include those frequently touched surfaces is sufficient to provide a safer environment.