Research continues, but there’s clear indication that the health care environment plays a contributing role in disease transmission. Caregivers not only can transmit pathogens from direct patient contact but also by contacting surfaces that infected patients touch and potentially passing bacteria on to others.
William A. Rutala, Ph.D., director of the hospital epidemiology and occupational health and safety program at the University of North Carolina hospitals, stresses the vital role that surface cleaning and disinfection can play in minimizing the risks of these forms of disease transmission or health care-associated infections (HAIs).
“There is increasing evidence to support the contribution of the environment to disease transmission, and that we pick up pathogens at the same level by touching the environment as we do by touching the patient,” Rutala said in his lecture at the 2012 Association for Professionals in Infection Control and Epidemiology (APIC) conference. “Unless we inactivate or remove these microbes, they are going to be present in a patient room for a long time. Just entering a room previously occupied by a MRSA, VRE or Clostridium difficile patient significantly increases the risk of contacting that pathogen.”
Environmental services (ES) teams and infection control professionals are paying greater attention to cleaning and disinfecting practices, the products and equipment specified for use, training staff and monitoring cleaning thoroughness. Still, results of these efforts oftentimes are inconsistent.
Why aren’t we seeing steadier and more sustained progress in reducing HAIs? Many factors are in play but at least part of the reason may lie in the variability and incomplete monitoring of cleaning and disinfection practices in hospitals across the country.
A study published in 2008 by researcher Philip Carling and co-workers assessed the thoroughness of cleaning high-touch surfaces using an ultravioletsensitive solution in 36 acute care hospitals. After terminal cleaning, only about half were cleaned.
A recent study by John Boyce, M.D., chief of the infectious disease section at the Hospital of Saint Raphael, New Haven, Conn., and co-workers using ATP bioluminescence assays and aerobic cultures demonstrated that medical equipment frequently had not been cleaned as per protocol, Rutala notes. Many experts believe what’s needed to get more consistent results in reducing HAIs is the same kind of dedication to quality management, process improvement and standardization that physicians and nurses have used in recent years to sharply reduce central line-associated bloodstream infections nationally.
In short, ES teams can benefit from defining and following best practices, using checklists for critical tasks and continuously training, measuring performance, evaluating practice and providing feedback to associates.
“You want to have standardization where you can. Standardize your approach for specific situations. This enables you to train to that standard,” says Ruth Carrico, R.N., Ph.D., CIC, associate professor in the division of infectious diseases, University of Louisville (Ky.) School of Medicine.
For example, Carrico says, develop specific policies and clear terminology for how to clean and disinfect rooms upon patient discharge. How much time should be allotted for the specified cleaning purpose? Which cleaners and disinfectants should be used and under what circumstances? What is the contact time truly necessary for adequate disinfection? How will you ensure that products are used according to their EPA-registered specifications?
“Your terminology has to be clear and consistent. We see a lot of issues when there is ambiguity in terminology. A good example is: What’s the difference between discharge cleaning and terminal cleaning, MRSA cleaning, C. difficile cleaning, etc.? If associates don’t know what to do, they can’t be consistent,” Carrico says.
Employing premeasured cleaning and disinfectant agents or so-called “closedbucket” systems is an important step in reducing variability, Carrico explains. The reason is simple: Closed-bucket systems make it difficult for staff to do the wrong thing.
“A closed-bucket system prevents people from going back into the cleaning or disinfectant solution with a mop or cloth and contaminating it. That enables you to perform best practice,” Carrico says.
Karen Martin, R.N., director of infection prevention and environmental services at Advocate Christ Medical Center and Hope Children’s Hospital, Oak Lawn, Ill., agrees.
“Even though you have dispensers that allow you to mix the disinfectant with water to get to the right concentration, nothing is foolproof. You constantly have to monitor this. You’re going to have a group of people who think more is better. If a dispenser is plugged or not working, they’re going to pour it,” Martin says.
She adds that dispensers should be checked regularly for accuracy and to ensure dispensers aren’t plugged. Managers also need to pay close attention to educating and monitoring how well staff adhere to surface wetting times for the cleaning agents and disinfectants in use.
In his APIC speech, Rutala advised health care workers to follow EPA-registered contact times. However, he noted that some products have achievable contact times for bacteria/viruses of 30 seconds to two minutes while others have much longer, nonachievable contact times.
For these latter products, Rutala recommends a contact time of a minute or longer based on Centers for Disease Control and Prevention guidelines and scientific literature. He also notes that wipes should have sufficient wetness to achievethe disinfectant contact time. Discontinue using a disposable wipe if it doesn’t leave the surface visibly wet for more than a minute.
Similarly, Carrico stresses the importance of using the proper wiping materials to clean and disinfect surfaces.
“We’re clearly seeing more and more data that show the substrate of the material used in the wipe is very important,” Carrico says. “We know that many microfiber cloths work very well. They enable the germicides to be delivered to the surface and allow the mechanical friction to physically remove soil and surface matter.”
Conversely, cotton cloths have fibers that are too large to trap and effectively remove dirt. Carrico points out that cotton fibers may not release quaternary ammonia as readily as non-cotton fibers do.
Giving the right cleaning tools to the right personnel is another critical issue, since cleaning and caring for the pa tient environment typically extend far beyond ES associates.
“If you want nurses, for example, to be involved in the cleaning of electronic equipment then you must provide them with not only the ideal wipe product but make sure they know how to use it correctly,” Carrico says. “You need to educate them and reinforce those points and evaluate practice to see how well they’re doing and where they need to improve. These are all simple points, but they’re points that I think we overlook because we’re all looking for that magic bullet [to reduce HAIs].”
Finally, pay close attention to educational and training materials and overall staff competencies. Kent L. Miller, MHL, CHESP, president of the Association for the Healthcare Environment, in a column last month in Health Facilities Management, urged ES directors to go beyond the annual competency measure often in place. He advises establishing an ES competency for each staff member, which can be demonstrated through written or practical assessments.
Beyond surface concerns
Microbial factors that facilitate environmental-mediated transmission for selected pathogens*
- Pathogen able to survive for prolonged periods of time on environmental surfaces (All)
- Ability to remain virulent after environmental exposure (All)
- Contamination of the hospital environment frequent (All)
- Able to colonize patients (Acinetobacter, C. difficile, MRSA, VRE)
- Able to transiently colonize the hands of health care workers (All)
- Transmission via the contaminated hands of health care workers (All)
- Small inoculating dose (C. difficile, Norovirus)
- Relative resistance to disinfectants used on environmental surfaces (C. difficile, Norovirus)
*Clostridium difficile; methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococcus
SOURCE: William Rutala, Ph.D., Director of the Hospital Epidemiology and Occupational Health and Safety Program at The University of North Carolina Hospitals
- Health care surface risk-assessment worksheet
- Centers for Disease Control and Prevention, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
- Training DVDs from the Association for the Healthcare Environment
- Association for Professionals in Infection Control and Epidemiology: Clean Spaces, Healthy Patients