Green Cleaning and Infection Control: An Expert Roundtable Discusses the Issues

Green cleaning has garnered a lot of attention over the last several years, but how appropriate is it for the healthcare environment, and is it compatible with infection prevention and control guidelines? ICT asked a number of industry experts to share their perspectives on this topic. Our roundtable participants are:

• Steve Ashkin, president, The Ashkin Group, LLC

• Jolynn Kennedy, marketing manager, Tornado

• Tom Morrison, vice president of marketing, Kaivac Inc.

• Mike Nelson, vice president of Marketing, Pro-Link

• Mike Sawchuk, vice president and general manager, Enviro-Solutions

• Peter Sheldon, vice president of operations, Coverall Cleaning Concepts

• Christopher Tricozzi, vice president of sales and marketing, Crown Mats and Matting

Special thanks to Robert Kravitz of AlturaSolutions Communications for his assistance with this roundtable.

ICT:There is concern on the part of environmental service professionals (ESPs) and infection control practitioners (ICPs) that green cleaning products do not have the microbial kill rates that are necessary to fight pathogenic bacteria and viruses in the healthcare environment. How do you address this concern?

Ashkin: Green disinfectants must be effective against whatever organisms the infection control department requires, and if the product is registered with the Environmental Protection Agency (EPA) you can have confidence that it is effective. What is important about selecting a “green” disinfectant begins with meeting the efficacy requirement. After that, compared to the product that is currently used, look for alternatives that further reduce health and environmental impacts, which is by definition what makes a product green. Some examples of improvements include using chemicals with a more neutral pH to reduce the potential for eye and skin irritation; alternatives with no or low VOCs and no or low fragrance to reduce the potential for respiratory irritation; and products that are more highly concentrated to further reduce the impacts from packaging. But under no circumstances should you accept any product that fails to meet the efficacy requirements, green or otherwise.

Morrison: We advise cleaning professionals to focus on removing soils and contaminants rather than just killing them. We refer to this as hygienically cleaning a surface. Without proper removal, even disinfectants made to kill microorganisms may fail. Also, we must remember that technically, in the United States, there is no such thing as a “green” disinfectant. Classification of a disinfectant as green, even if it has been certified by a recognized green-certification organization, is not honored, and manufacturers may not place the logo or “mark” of the certification body on their products or in their marketing material. Because of this, my advice to cleaning professionals in the healthcare industry is first, focus on removal of contaminants, and then select EPA-registered disinfectants where needed or required by law. And use the disinfectants only where needed. Also, some systems provide automatic dilution control that ensures that the chemicals are properly diluted while insulating the operator from direct exposure. These are powerful cleaning chemicals that can be harmful to the user and environment, especially if used improperly. Limiting their use to only where they are necessary is healthier, safer, and more environmentally responsible.

Nelson: The primary objective of cleaning (green cleaning or otherwise) should be to protect the health of building occupants. In a healthcare environment, this is even more important, given many already have health problems, depressed immune systems, etc. ESPs and ICPs should use the products and procedures that are most effective at controlling pathogenic bacteria and viruses. Because the EPA currently does not allow manufacturers to put any type of environmental claim or seal of approval (such as Green Seal) on disinfectants, healthcare facilities don’t have much of a choice but to use “traditional” disinfectant products. Even so, there are a couple of things that can be done to incorporate green cleaning:

1. Use disinfectant only where needed (such as in patient rooms and exam rooms) and not in areas where it is not necessary (file rooms, administrative areas). This allows housekeepers to use the most powerful chemicals only where they are needed.

2. Use a disinfectant product that has the “greenest” profile and still has the necessary kill claims. For example, older phenolic cleaners tend to have more hazardous ingredients compared to quat-based products.

Sawchuk: It is important to stress the importance of following manufacturers’ directions as to dilutions, pre-cleaning, dwell time, etc. Having said that, cleaning and disinfecting or sanitizing is a two-step process: clean first and then apply the disinfectant or sanitizer for the stated dwell time (which is leaving the surface wet a specified amount of time). Therefore, a green-certified cleaner can be used to pre-clean. Green-certified cleaners have been proved, albeit some better than others, to work as well as or better than traditional cleaners. Then for the second step, all disinfectants or sanitizers used must have an EPA registration number, which verifies which viruses, bacteria, fungi, etc. that particular product will kill. Those who select the products must ensure that the chosen disinfectant or sanitizer has the stated claims for any virus, bacteria, fungi, etc. that is of particular concern to the facility. That is, all disinfectants or sanitizers do not kill the same viruses, bacteria, or fungi, even two disinfectants approved for hospital use. The most critical selection is the cleaner. The next important factor is proper procedures. Failing on product selection or implementing improper procedures will affect the result.

Sheldon: Healthcare professionals are justified in their concerns. As an ES outsourcing contractor, we follow recommendations from the Centers for Disease Control and Prevention (CDC) utilizing EPA-registered disinfectants in all of our healthcare cleaning compounds and chemicals. We disregard unproven claims that the prudent use of proper disinfectants has a negative impact on our environment.

ICT:“Green” and “natural” claims are not based in science, which is what ESPs and ICPs are looking for when they evaluate and purchase cleaning/disinfection products; until the medical literature catches up with the merits of green cleaning, how can green be justified from a microbiological sense -- can green cleaning both uphold infection prevention goals and reduce toxins, etc.?

Ashkin: Green cannot be justified from a microbiological perspective; after all, if both disinfectants kill the target organism in the same time, we can’t kill them deader than dead. The products have to work, and being “green” is not an excuse for a poor-performing or expensive product. Rather, the question is can the choice of products meet the infection control requirements but do so with alternatives that further reduce potential negative impacts on product users (environmental services and nursing staff), patients and visitors, as well as the environment. Many healthcare facilities truly follow the concept to “do no harm” and today are recognizing that they can provide the appropriate levels of disinfection but with products that further reduce health and environmental impacts in many other ways from packaging and use to disposal and more.

Morrison: I will agree that the term “natural” means essentially nothing when it comes to green cleaning. As to green certification of, for instance, chemicals, they must meet specific standards and guidelines that are essentially the same at the two leading certification bodies. So, if a product has been certified, ESPs and ICPs can rest assured that it meets these guidelines. However, cleaning professionals must also realize that for any chemical, green or not, to be effective, it must be used with the proper cleaning tools, equipment, and systems. Studies introduced at the recent Cleaning Industry Research Institute Symposium at the University of Maryland clearly pointed out that some conventional cleaning methods, such as rags and flat mops, performed poorly when compared to high-flow fluid-extraction systems. What’s more, some of these conventional cleaning methods actually spread soils and microorganisms to other surfaces instead of removing them. This certainly does not help prevent the spread of infection, no matter what chemicals, green or not, are used.

Nelson: Some green claims are based on science, such as claims about products that are Green Seal certified and Design for the Environment (DfE) products. However, this doesn’t apply to disinfectants, as discussed previously.

Sawchuk: Green certification has science, and typically more science than traditional cleaners. Both Green Seal and Eco Logo require the cleaner to pass ASTM standards and criteria. Traditional, nongreen-certified products require no proof of efficacy. Therefore, on the basis of this platform, Green-certified cleaners should always be used over unproven traditional products. Regarding the microbial efficacy claims, as stated in the previous answer, EPA registration ensures the claims of disinfectants or sanitizers.

Sheldon: When green ceases being a marketing campaign and a political agenda and seeks to improve the health and welfare of our population as its first and foremost obligation and then allows itself to be guided by science and research, only then will it be justified in the healthcare community.

ICT:Are there misperceptions about green cleaning in healthcare that you would like to address?

Ashkin: The one misconception that is necessary to address is that green cleaning is just about selecting and using disinfectants. It is about more than that. If the infection control department does not want to change disinfectants for whatever reason, there are numerous other opportunities to “green” environmental services. For example, changes can be made to further reduce the potential negative health and environmental impacts associated with floor and carpet care, especially in low-risk areas. Other chemicals can be “greened,” including glass cleaners, restroom cleaners, furniture polishes, spot cleaners, and exterior maintenance products. Janitorial paper products can be “greened” to address the use of recycled content and reduce the amount of product actually consumed. Equipment can be “greened” to use less water and energy and to capture more of the particulates that can harm patient and occupant health. Then there is new equipment that can clean without the use of additional cleaning chemicals. Plus, there are all the other products, tools, supplies, liners, etc. that can be considered for “greening.” And finally, there are opportunities to improve training and procedures to further reduce the potential negative health and environmental impacts associated with the cleaning processes themselves. Green cleaning in healthcare is not just about disinfectants.

Morrison: Typically, when cleaning professionals and facility managers think of green cleaning they think of chemicals only. But green cleaning products include a variety of tools and equipment, from extractors and vacuum cleaners to floor machines and even no-touch cleaning machines. For instance, all of our no-touch cleaning systems have received the Seal of Approval certification from the Carpet and Rug Institute. This means they meet a number of criteria and guidelines helping to protect indoor air quality.

Nelson: Just because there is no such thing as a green-certified disinfectant cleaner, that doesn’t mean healthcare facilities can’t clean green. There are numerous other things they can do:

• Use microfiber mopping systems.

• Use green chemicals in nonpatient areas.

• Use Green Seal-certified paper products.

• Use proper entranceway matting.

• Use the right size trash can liner for the container to reduce plastic waste, or use liners with high recycled content.

• Use Green Seal-certified soaps (where antibacterial soaps are not required).

• Install low-flush toilets to save water.

• Install touchless restroom fixtures and soap/paper towel dispensers to reduce cross-contamination.

Sawchuk: There are three issues. First, there have been a lot of studies and reports showing the poor cleaning practices in many healthcare facilities. Given that, there needs to be a better focus on proper (proven and science-based) work loading and scheduling based on the desired level of clean. Second, there is a need for greater training and exposure to more modern custodial hardware, equipment, and chemicals. Last, facilities need to look at going Green as a journey, not a destination. Begin with one product in one area, and make a change to a product that is safer and cleans as well or better. If it works, expand to other areas, and look for a second product to change. Don’t start with the disinfectants and sanitizers if the infection control department has any concerns or needs time to investigate safer alternatives to what is currently being used. Some of the most harsh to people (cleaning staff, patients, and all occupants and visitors to the facilities) and the environment are the floorcare products (strippers, sealers, finishes), bowl and urinal cleaners, and disinfectants. The second area of concern could be the odor-control products.

Sheldon: There is a tremendous amount of misinformation that flies around the world regarding the use of disinfectants and whether or not they contribute to the formation of resistant pathogenic organisms. To date we are not aware of any published scientific evidence that conclusively proves the use of surface disinfectants present any such risk.

Tricozzi: One misconception I would like to address is the belief that green cleaning involves just cleaning chemicals. Healthcare administrators should view green cleaning as the spokes on an old carriage wheel. As long as all the spokes are strong and sturdy, the wheel works fine. But when one is missing or is not performing correctly, the integrity of the entire wheel may be in jeopardy. And one of the spokes often overlooked is high-performance matting systems. More than 80 percent of the soil entering a facility essentially walks in on shoe bottoms. An effective matting system captures, traps, and stores these soils so that they do not contaminate the facility. “Storing” means that the high-performance matting system keeps the soil in place, allowing it to be removed later by vacuuming or cleaning with minimum impact on the building. This is often accomplished because the matting is bi-level. Soils and contaminants fall beneath the surface of the mat so that they cannot be tracked into the facility. And the less soil entering, the less chemical and related cleaning products are needed, minimizing cleaning’s impact on the environment. Additionally, this can help reduce airborne contaminants and volatile organic contaminants (VOCs), often found in cleaning chemicals, which can mar the facility’s indoor air quality. In fact, so important is matting’s role that the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) program awards one point (of the necessary 32) to those facilities that have an effective, high-performing matting system in place.

ICT:What is the No. 1 advantage of green cleaning and can you make a cost-benefit argument for this method to hospital administrators?

Ashkin: There are several advantages to a green hospital. First, however, is the assumption that the environmental services and infection control departments are currently doing a good job. If not, then I’m confident that the hospital already can calculate the cost of hospital-acquired infections and extended hospital stays. However, assuming that the effort to “green” is not tied to improving performance, there are other reasons to implement green cleaning. These include reducing potential risk to environmental services personnel through the use of more benign chemicals and equipment with better ergonomics; increasing recycling and improving waste management to reduce waste disposal costs especially tied to red-bag waste; and increasing marketing as patients and staff prefer to stay and work in greener facilities. And if the products all cost the same, many hospitals find even these “soft” benefits well worth it, even if we can’t put hard dollar figures to them.

Kennedy: There are several primary advantages of green cleaning to people and the environment. Green cleaning helps reduce exposure of building occupants and maintenance personnel to hazardous chemical or particulate contaminants in the air that negatively affect indoor air quality (IAQ), such as bacteria, mold, and allergens. For example:

- Vacuums utilize true HEPA filtration designed to filter fine particulate and dust through a multistage filtration process, improving indoor air quality and occupant health.

- Low-moisture floor care equipment such as cylindrical brush automatic scrubbers, moisture-controlled carpet extractors, or encapsulation carpet systems can minimize moisture that causes mold, bacteria, and allergens. The U.S. Green Building Council and its LEED-EB (Leadership in Energy and Environmental Design for Existing Buildings) encourages facilities to incorporate strategies that reduce moisture in building construction or operation, which includes cleaning. According to the LEEDS-BE criteria, credits will be awarded to those facilities that take steps to reduce moisture and the adverse impacts it has on indoor air quality.

- The use of eco-friendly, maintenance-free Absorbed Glass Mat (AGM), EV Traction Dry Cell, or gel batteries minimizes the risk to your cleaning staff and to the environment. Not only do traditional, wet acid-cell batteries contain sulfuric acid and require your cleaning crew to maintain proper fluid levels to ensure batteries perform properly, they pose danger to both the cleaning worker and to your facility’s indoor environment.

- Lightweight and ergonomically designed equipment minimizes worker injuries and compensation claims.

The use of less wasteful cleaning processes also benefits worker health and safety while minimizing environmental impact and waste. For example:

- Recycling and the use of recyclable materials such as the use of post-consumer polypropylene equipment helps to minimize waste that may go into a land fill in the future.

- Floor care equipment that is designed to consume less water minimizes environmental impact and has a positive effect on human health and indoor environments.

Nelson: The primary advantage of green cleaning is that it reduces the impact on the environment, the people in the building, and the people doing the cleaning.

Even if green products are a bit more expensive (usually they are comparable in price), the advantages far outweigh any cost premium. Green cleaning:

• Improves productivity and morale of building occupants

• Improves the health of the cleaning staff and building occupants, helping to reduce sick days

• Contributes to recognition in your community for reducing resource usage and pollution

• Reduces liability from worker safety issues

• Earns points toward LEED certification

• Creates satisfaction for yourself, the cleaning staff, and the building’s occupants because you are helping to make your facility and your community a better place.

Sawchuk: The products are proved safer for people — cleaning staff, patients, doctors, nurses, administrative staff, visitors, etc. The cost-benefit advantages have been proved in many studies — that there are green-certified cleaning products that work as well as or better than traditional products and are cost-competitive for the complete bundle. It is also suggested that hospitals and nursing homes consider looking outside of their buying groups for these types of products. Just as with medical specialists (Would you want your open heart surgery done by a specialist or a general practitioner?), when researching and selecting the green cleaning products, procedures, etc. for your facility, search out local green experts.

Sheldon: Being in the business of executing a healthcare-driven ES service we do not promote any “green” program that would preclude the use of proper disinfectant chemistry in any and all health care environments. The lack of proper aseptic cleaning taking place today in all phases of healthcare facilities demands we address this very real issue in our own built environments. Our objective is and should always remain to reduce the risk of infection in our population by utilizing safe and proven science which includes the use of disinfectant chemistry and advanced soil and matter removal systems.

Additional Resources

Hospitals for a Health Environment offers a 10-Step Guide to Green Cleaning Implementation. This guide addresses policy development, careful selection of products, staff training, standardized operations, adequate equipment and supplies, and monitoring of innovative efforts. The guide can be accessed at:

www.h2e-online.org/docs/h2e10stepgreenclean-r5.pdf