IDEA in Action: A Strategic Approach to Contamination Control

Cleaning the hospital to prevent health care-associated infections.

(Image credit: Dinesh Wadhwani)

Most activities of our environmental services team involve some form of contamination control, targeting microbiological issues. Of these, most situations in which contamination control is of concern involve some form of environmentally mediated infection prevention measure. Interestingly, these contamination situations have a pattern of frequent and repetitive occurrences. When we are alerted to them, we are trained to intervene expeditiously. We often respond with some type of terminal disinfection rather than identify the many risk factors that initially created the contamination conditions. This is a more efficient and practical approach to preventive efforts.

Developing straightforward strategies to prevent any form of microbial contamination is not easy. Throughout our collective experiences, we never found any situation that had a single causative factor. Instead, each required a multifaceted response involving “People, Places, and Things.” This means that simply using a broad stroke of a disinfectant brush does not work. Comprehensive contamination control requires programmed responses that follow a hierarchy of strategies. To achieve this, there are 2 distinct approaches to environmental contamination control: One of intervention and the other of prevention. They overlap. Here is a rational approach to managing risk that works. It is called IDEA: Identify, define, explain, and apply.

Identifying contamination begins with inspecting, auditing, sampling, and process monitoring. As well as gathering information through an epidemiological investigation of microbiological contamination resulting in disease, such as institutionally acquired infections.

All too often, identification yields valuable historical components whereby similar situations were identified and dealt with in the past. These past experiences can help us avoid making the same mistakes twice through corrective approaches that are costly, ineffective, and, in some cases, deleterious to the staff and environment. A word of caution: Do not rush to judgment. Accuracy in identifying the contaminant and condition of contamination is key to an effective amelioration and prevention program.

The next step in this process is to define the contamination situation, including its origin, movement, transfer, time, and place. We want to make a distinct, clear, and detailed description of the contamination problem. To do this in the best and most expedient way possible, use “First Principles Thinking.”First-principle thinking helps reverse-engineer complicated situations and unleash creative possibilities. It separates underlying ideas or facts from assumptions based on them through simple, basic logic. It exposes a problem to its essentials by basing decisions on the explanation with the fewest moving parts.

In short, this is a form of reasoning where the problem or situation is identified and understood instead of relying on conventional wisdom. There are no frivolous observations; everything should be considered. It encourages us to start with what we know to be true through sound science and reason up from there. We can devise new insights and solutions by dissecting problems into their basic components. We know this colloquially as “Occum’s Razor.”

Once the contamination situation is well-defined into its parts, we can begin sensible remediation and develop a rational prevention strategy, which brings us to the third step: Explain. Here, our approach to remediation and prevention requires “Second-Order Thinking,” where we need to consider our actions and their immediate consequences as well as the subsequent effects of those actions. We often rely on a new, more powerful disinfectant without considering that its use can destroy the biome of the sewage disposal plant, expose the housekeeping and nursing staff to respiratory and contact irritants, or corrode and damage furnishings and finishes. We may think a reasonable solution may, and often can, create another and, oftentimes, more severe problem.

The last principle is to apply. This is where we need to correct or alter the identified and defined situation and initiate a preventive strategy to avoid a future problem with a similar contaminant. To do this, we need to apply a logical approach to contamination control strategies that follow a general hierarchy of efficacy.

It starts with a simple concept: Keep the contaminants out. This is also the easiest and most effective thing to do. Delimiting materiel movement, changing airflow patterns, using physical barriers, and even a thorough review of existing policies and procedures with sensible enforcement will go a long way in excluding unwanted contaminants. This strategy uses simplicity and apparent actions. Ideally, if we can accomplish this, our job is done. However, the world does not work this way; there is no such thing as keeping everything out. Somehow, a contaminant will always find its way through necessity or oversight.

So, the following stratagem is to destroy contaminants we could not exclude from getting in. This includes applying all equipment, chemicals, housekeeping, and patient care techniques. Here, the demands for the best of our knowledge, skill, and ability as professionals come into play. Floors, fomites, equipment, indoor air, and personal hygiene, to mention but a few, are the primary targets for the destruction of contaminants that are introduced into critical areas and onto critical surfaces.

This contamination control strategy focuses on traffic patterns, separation, compartmentalization during critical procedures, frequent hand washing, and, most importantly, effective cleaning and disinfection on a schedule that will significantly impact control. Cleaning and a monitoring program are key to ensuring effective bioburden removal. The goal is to significantly reduce disease risk as far as possible and as early as possible.

Realistically, we also know that we cannot eliminate all contamination risks. Therefore, our next aim is to keep unwanted microbes from growing and any other environmental contaminants from creating harmful conditions. To this end, we need to rely on scientifically sound sanitation practices. This includes emphasizing clean, common-touch surfaces predicated on exposure and timing.

Other strategies include air purification, elimination of condensation and moisture, clean storage of food and supplies, clean internal transportation systems, and assessing traffic patterns. It is all about preventing contamination from direct and indirect human contact, vector, vehicle, and fomite.

Finally, to ensure that we have achieved minimal risk of contamination, we apply our last strategy, which is to minimize the movement of all remaining contaminants within the environment. To do this, many industries and institutions have embraced the “Hygienic Zoning.” This idea comes from biosafety, detailed in a 1969 book titled Microbiological Contamination Control Facilities.¹

Through zoning, we can separate any operation into four basic risk groups. These include nonproduction zones (office, storage, building exterior) to low-risk (raw materials), medium-risk (postmicrobial reduction), and high-risk areas. The highest risk of contamination is assigned to areas where environmental conditions may support the survival and growth of pathogens or where patients, clients, and residents are most vulnerable to contracting illness. The objective of zoning is to prevent traffic and movement of products, people, and things between these areas. And, yes, it can be done in any setting by using passive barriers, with active hurdles in high-risk zones, control of visitors, contractors, and employees, and training everyone within the facility.

While it takes a bit of imagination, through zoning, materials flow in 1 direction. Ideally, people and products should flow from negligible risk to the high-risk area by passing through a microbial reduction step. Waste should be transported from the area where it is generated to a nonproduction area or a low-risk area.

Ideally, all equipment, supplies, materials, and personnel should move in the opposite direction. Also, consider keeping equipment, including maintenance tools, used in a high-risk zone to remain within that zone. All tools and equipment introduced into a high-risk zone should be cleaned and sanitized before use. Ensure adequate space is planned for storage and cleaning. Finally, when inspecting and monitoring any operation, movement should be from high to minimal risk, clean to soiled.

We cannot leave this subject without mentioning the most vital component in mitigating and preventing contamination: training. Train workers involved with the tasks of removing contaminants and the risks associated with the jobs they perform. Ensure they understand the controls in place, protective measures available, and contamination prevention strategies.

Training should include actual environmental services practices, such as cleaning and sanitizing surfaces and minimizing further contamination before performing their duties according to established policies and procedures. This should also include information about recognizing tasks involving exposure and methods to reduce exposure, such as using administrative and engineering controls, specific work practices, and personal protective equipment.

To be most effective, a comprehensive contamination control training program should include as many visual and firsthand performance aids as possible. Learning by seeing and doing significantly decreases the risk of future contamination situations that follow a pattern of frequent and repetitive occurrences.

Effective contamination control is not easy; it is the most challenging thing we do. A sensible, rational, and practical approach to contamination control through amelioration, prevention, and training will significantly reduce the risk of disease and injury and assure us that our efforts are cost-effective.

Reference

Runkle RS, Phillips GB, eds. Microbial Contamination Control Facilities. New York, NY: Van Nostrand Reinhold Co.; 1969. Library of Congress Catalog Number: 70-81349.