More to Surface Disinfection Than Meets the Eye

Surface disinfection is key to containing viral outbreaks and has never been more important than it is right now. Fundamentally, the concept and importance of surface disinfection hasn't changed. However, the impact of the COVID-19 pandemic on today’s world makes it imperative to change how the health care community conducts proper surface cleaning and disinfection. It starts with mindset – because health care and lives depend on it.

Recent studies have shown that only 32% of the 110,000 objects in inpatient and outpatient health care facilities are thoroughly cleaned.¹

Sharon Ward-Fore, MS, MT(ASCP), CIC

At iClean 2020, an evidence-based cleaning health care leadership conference, Didier Pittet, MD, MS, CBE, called for "urgent reform in our approach to cleaning and disinfection in hospitals and aged-care homes."²

How cleaning is actually done today is based on time, the volume of room equipment, Environmental Services (EVS) staffing levels, experience and training, and the types of cleaning supplies available.

To mitigate the spread of potential pathogens that cause health care-associated infections (HAIs), infection prevention practices must evolve. Everyone practicing should know the following:

1. Proper cleaning and disinfecting are a top priority, and there is a definite distinction between the two
2. Disinfectants and their uses are unique
3. EVS plays a vital role in infection prevention
4. Everyone is responsible for infection prevention
5. Supplies can run short
6. Training about supplies must happen regularly and change based on the readily available supplies

Ruth Carrico, Ph.D., DNP, APRN stated at iClean 2020, "Reforming hospital and aged-care disinfection systems can not only help to continue to manage COVID-19 but also reduce the incidence of other hospital and aged-care facility-acquired infections."²

So, what does success look like today, and how is it achieved? Here are 5 tips for getting cleaning and disinfecting right.

Tip 1: Know who is responsible

Between the trifecta of departments responsible for infection prevention—EVS, nursing and infection prevention—it’s every individual’s responsibility to ensure surface cleaning and disinfecting are done quickly and effectively to prevent potential pathogen transmission successfully. It all comes down to good teamwork and relationships with other IP experts, communication, accountability and unwavering protocol. Everyone must be on the same page.

Tip 2: Know the guidelines and practices

Cleaning is a science. That means every element of the process matters, every single time—from quality cleaning with mechanical scrubbing to contact time to following CDC recommendations.

Protocols for individual patient care areas, including frequency, method and process, should be based on the risk of pathogen transmission. The probability of contamination is based on the patient’s care area, the vulnerability of the patient to infection (immunocompromised versus general patient), and the potential for pathogen exposure, ranging from high-touch to low-touch surfaces. For example, patient toilet areas should be cleaned last in the process because of their patient exposure, frequent contamination and higher risk of pathogen transmission.

The CDC recommends the following core practices for environmental cleaning and disinfection³:

• Require routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling. Clean and disinfect surfaces close to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule than other surfaces. Promptly clean and decontaminate spills of blood or other potentially infectious materials.
• Select Environmental Protection Agency (EPA)-registered disinfectants with microbiocidal activity against the pathogens most likely to contaminate the patient care environment.
• Follow manufacturers’ instructions for proper use of cleaning and disinfecting products. Consider the manufacturer’s dilution guidelines, contact time⁴, material compatibility, storage, shelf-life, safe use and disposal. The shorter the contact time and the more convenient disinfectants are to use, the more often they get used!

Tip 3: Pay attention to detail, provide coaching along the way and articulate success

Share these tips with your team so they can measure and evaluate cleaning quality⁵:

1. Visual inspection: EVS personnel and their supervisors should inspect their completed work to ensure that visible evidence verifies that basic cleaning is complete.
2. Visual proof: Expert infection preventionists suggest that the evidence of the efficacy of the team’s cleaning is literally “on the wipe’ and easy to spot.
3. Adenosine triphosphate (ATP) bioluminescence test: Place environmental surface swabs in the ATP reagent and a luminometer reads the amount of light. The results indicate whether the level is acceptable or unacceptable based on the number of relative light units (RLUs).
4. Fluorescent markers: Apply an invisible fluorescent mark onto the soiled surface. If the fluorescent mark is visible under a UV light after the surface is cleaned, the surface requires recleaning.
5. Cultures: Quantitative environmental cultures such as swabs and Replicate Organism Detection and Counting (RODAC) plates can be used as markers of thorough cleaning; less than 2.5 CFU/cm2 is considered acceptable.

Tip 4: Empower health care professionals

Armed with the right tools, products and knowledge, everyone involved in health care facility cleaning and disinfection is empowered to play a vital role in the lives of all who set foot inside—which is just as crucial of a role as patient care. Involving every team member in the surface disinfectant conversation helps solidify their buy-in.

Standards can also help empower professionals. The CDC recommends these core components for a successful environmental cleaning and disinfection program⁶:

1. Integrate environmental services into the hospital's safety culture.
2. Educate and train all HCP responsible for cleaning and disinfecting patient care areas.
3. Select appropriate cleaning and disinfection technologies and products.
4. Standardize setting-specific cleaning and disinfection protocols.
5. Monitor effectiveness and adherence to cleaning and disinfection protocols.
6. Provide feedback on success and quality of cleaning and disinfection to staff and stakeholders.

Tip 5: Instill awareness and adherence of turnaround time

In the approximately 40-to-45-minute turnaround time window⁷ for room cleaning, every moment counts. Team members have to work together quickly and effectively within their allotted timeframe without cutting corners to achieve successful pathogen eradication.

For example, in a typical terminal discharge, nurses need time to clean equipment properly before rolling it out of the room and into the hallway, paving the way for EVS to clean and disinfect the room. The equipment moved to the hallway has to be wiped down again and returned to its place in the room. Having to do all of this in a limited timeframe makes it crucial to follow standardized guidelines that everyone can follow and for IPs to monitor.

Tip 6: Know what to value in cleaning and disinfecting products

When it comes to surface disinfection, success is priceless. However, it's no secret that cost is a consideration for a facility’s financial decision-makers. When weighed against product efficacy and contact time, however, the best tools for the job will be those that can be relied on to get infection prevention right the first time.

For example, choosing a disinfectant product with a U.S. Environmental Protection Agency (EPA) Emerging Viral Pathogen claim for all virus types (enveloped, large and small non-enveloped viruses) is a wise investment to help protect patients and health care workers. According to the National Institute of Allergy and Infectious Diseases, emerging viral pathogens like SARS-CoV-2 are those “that have newly appeared in a population or have existed but are rapidly increasing in incidence or geographic range.”⁸

To qualify for the EVP claim, a disinfectant must be an EPA-registered surface disinfectant and kill at least two different types of small non-enveloped viruses—those that are difficult to kill. The EPA created this claim to establish parameters for disinfectant products to carry specific off-label efficacy claims for new and harder-to-kill viruses during a pandemic. When you use disinfectants with an EVP claim, you are using products formulated to meet current and future infection prevention needs, thus anticipating unpredictable public health crises.

Decision-makers should also look for a surface disinfectant on the EPA's List N–a list of products that the EPA recognizes to be able to effectively kill SARS-CoV-2 when used according to label directions.⁹

Recognizing the importance of proper surface disinfection to help eradicate emerging viral pathogens is the first step in making this life-saving change. Taking responsibility, paying attention to detail, empowering staff, adhering to best practices and knowing what to value—which ultimately saves lives—are crucial factors for success.

Sharon Ward-Fore, MS, MT(ASCP), CIC, serves as Metrex’s Infection Prevention Advisor. Sharon is also an independent infection prevention consultant and is a member of the editorial advisory board of Infection Control Today®.

References:

1. Rutala WA. New technology in environmental cleaning and evaluation. Presented at 40th Annual APIC Conference, Fort Lauderdale, FL, June 10, 2013. Available at: http://disinfectionandsterilization.org/slide-presentations/
2. Global healthcare needs infection control reform, say experts http://hospitalhealth.com.au/content/clinical-services/news/global-healthcare-needs-infection-control-reform-say-experts-957448066#ixzz6WWvpZBtJ
3. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee. https://www.cdc.gov/hicpac/pdf/core-practices.pdf
4. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Update: May 2019. https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf
5. Environmental Services. https://text.apic.org/toc/infection-prevention-for-support-services-and-the-care-environment/environmental-services/#book_section_references
6. Healthcare-associated Infections. Reduce Risk from Surfaces. https://www.cdc.gov/hai/prevent/environment/surfaces.html
7. Patient Room Turnover – A Balance of Speed and Quality https://www.eonsolutions.io/blog/patient-room-turnover-a-balance-of-speed-and-quality
8. What is an emerging viral pathogen claim? https://www.epa.gov/coronavirus/what-emerging-viral-pathogen-claim
9. List N: Disinfectants for Use Against SARS-CoV-2. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2