stack of surface samples
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Preventing health care-associated infections (HAIs) is a top concern of all health care organizations. On the front lines of these efforts, environmental services (ES) professionals are availing themselves of the latest science-based training, technology and supplies as they fight multidrug-resistant organisms.

Beyond their traditional role in cleaning and disinfection, however, ES professionals are playing an ever-larger role in determining which surfaces are selected for health care interiors. This not only ensures that these finishes won’t degrade under rigorous cleaning regimens, but they also will be easier to disinfect in the first place.

Foundational issue

Most people think of surfaces as part of the design and construction process rather than part of an infection prevention and control program. When selecting materials, a lot of focus tends to be given to colors and textures. Although these aspects of a surface material are certainly important, there are many other surface properties that are critically important, yet are not thought about or given proper evaluation. After all, the most soothing color and texture is of little value to a surface that cannot be cleaned or disinfected properly.

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People interact with surfaces throughout the day without a second thought. If hands are washed regularly, someone with a healthy immune system has a good chance of reducing his or her risk of infection. This is not necessarily true for someone with a compromised immune system.

Ironically, surfaces often are cleaned and disinfected based on visual inspection, even though it is commonly understood that microbes cannot be seen. Research has shown that at the microscopic level, microbe counts can rebound quickly — oftentimes to levels seen prior to cleaning and disinfection. This leaves patients, health care workers and the general public at constant risk of acquiring and spreading infection. In fact, studies have shown that patients are at a 35 to 50 percent risk of contracting an infection such as methicillin-resistant Staphylococcus aureus or Clostridium difficile from the patient who previously occupied the same room, depending on the infection and despite routine and terminal cleaning and disinfection.

The science of surfaces as a fomite (object or material that is capable of carrying infectious organisms and serve in their transmission) is just maturing. Research has shown that microbes can live on “clean and disinfected” surfaces for days, weeks and even months. How is this possible when surfaces are being regularly cleaned and disinfected? Below are seven aspects of surface selection that will help ES professionals to gain an understanding of why facilities must set surface criteria to minimize risk and prevent harm to patients, health care workers and the general public.

Selection of surfaces

Currently, the surface evaluation and selection process is predominantly based on specific design criteria established before any construction or renovation project. The look, feel and location of the surface is based on creating a homelike healing environment. While this is important, the selection of surfaces is complicated and the evaluation process must go far beyond the way it looks and feels. Ultimately, it is important that surfaces can be cleaned and disinfected effectively, leaving little room for human error. Unfortunately, the majority of surfaces being used in health care today are difficult, if not impossible, to clean effectively.


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There is a science around the spread of infection via surfaces. It is not enough to learn every physical characteristic of a surface or to become an expert in the latest disinfection agents and protocols. These data must be combined with an understanding of microbiology, the physical environment and insight into human behavior. Taking all seven of the following aspects into consideration and setting surface selection criteria within health care facilities will begin to address the critical surfaces issue.  


1. Materials and textiles. Health care facilities are full of many different surface materials, textiles and products. Necessary products such as chairs, beds, sheets, privacy curtains and bedside tables are selected by looking at sample books or swatches of material in addition to special features any of these products may offer. While these properties are important, they are only the tip of the iceberg, providing only a glimpse into what is truly needed in any health care setting.

ES professionals should be aware of textured surface materials such as brushed stainless steel, pebble-textured acrylic wall surfaces, fabrics with tight or open weaves, and vinyl and plastic materials that may create additional challenges during the cleaning and disinfection process. This is true with any surface material.

There are many critical questions to be answered regarding each surface material being considered. A few important ones are: What will it take to clean this surface? Can it be cleaned with the products the facility is currently using? Has it been tested to verify that hospital-grade disinfectants can be used without causing damage? How often will it need to be cleaned and disinfected to reduce bioburden and prevent cross-contamination?

2. Surface assemblies. Selecting a surface based on sample swatches doesn’t provide enough insight into what the potential challenges might be. It is critical that during the evaluation process, the assembly of surfaces is understood. Different materials and textiles often are combined into a single product, making the final product difficult or impossible to clean and disinfect. It is true that some of this is unavoidable. However, it is possible to reduce the number of products in a room that present difficult or impossible disinfection challenges.

Cross-contamination can occur easily if levels of bioburden are not continually reduced to safe degrees by cleaning and disinfection. An evaluation of assembled surfaces surrounding the patient will provide insight into the challenges faced when trying to clean and disinfect the many combinations of materials, textures and textiles. Seams, batten strips and connects between surface materials create additional microbial reservoirs that often can be avoided completely when this problem is understood.

3. Microbiology. A person typically sheds some 37 million bacteria every hour into the surrounding air and onto environmental surfaces that are continually being touched. Patients are a major source of contamination, and bioburden is heaviest within three feet of the patient. If the patient is mobile, research has shown that the patient bathroom is also an area where bioburden is high. With the knowledge that pathogens survive for days, weeks and months, these areas absolutely need to be able to be effectively cleaned.

Patient shedding is not the only contamination threat. Toilet spray, also referred to as “toilet plume,” plays a major role in the transmission of infectious diseases. Ironically, patient toilets typically do not have lids, due at least in part to the difficulty in cleaning them. After discarding objects laden with viruses and bacteria into a toilet, the toilet is flushed. As a result, these microbes are released into the air and land on surfaces at a relatively high concentration within a three-foot radius of the toilet. This area typically includes a variety of ceramic tiles and many grout lines.

Other materials assembled in this area include towels, shower curtains and sinks with faucets. As a result, these surfaces become microbial reservoirs that provide safe harbor where disinfectants cannot reach their intended targets.

4. Location. The location of a surface matters. Different departments within a hospital require different surface selection criteria. In such areas as the emergency department (ED) or surgery, health care professionals are faced with the need to turn over rooms quickly. Often, this means that health care workers with a primary responsibility for patient care also must clean, disinfect and turn over a room.

Some of these professionals do not understand that it is critical to clean and disinfect these areas effectively. The criteria for selecting surfaces must take this into consideration. Health care workers often say grabbing a wipe and wiping off the gurney railings is about all that time allows. With this in mind, using surfaces that can be disposed easily or cleaned effectively is critical.

Recently, a facility was confronted with a community-based outbreak of C. difficile that had started to spread within the facility from patients who entered through the ED. Facilities must set surface criteria based on the location, taking into consideration short turnover times and which staff member holds primary responsibility for room turnover. 

5. Human behavior. Patients, health care workers and visitors interact with surfaces in many ways. Clothing, equipment and hands can become contaminated and move pathogens throughout the patient room and the entire facility.

While being an advocate for a patient during a three-day acute care hospital stay, I took the opportunity to observe human behavior around surfaces. The behavior of health care workers was fairly common. “Pumping in” by using the hand sanitizer was routine and a good start. However, the very next action was nearly always to reach into a pocket in their scrubs to retrieve a pen. Most health care workers interacted with surfaces in similar ways and in the same order — computer, mouse, nurse call button, controls on the IV and IV pole, catheter bag, bed and bedding.

Visitors interacted with many of the same surfaces, but they also touched such things as the windowsill, bed and chair next to the patient bed, which was often covered with a blanket for the patient to sit on. Visitors also used the patient bathroom.

Specific surfaces that should be considered “high-touch” would not be easy to identify, because many people frequently touched virtually every surface within three feet of the patient. In fact, ES staff cleaned some surfaces but ignored other frequently touched surfaces during the daily cleaning process.

6. Cleaning and disinfection. This is an aspect that is obviously critical, but is often misunderstood. Everyone knows that it is important to clean and disinfect everything. However, can each surface be cleaned and disinfected effectively in the time frame set for completing that task? The typical response from a manufacturer would be, “Yes, you can use anything to clean all surfaces.” Clearly, this is not the case. Not all surfaces of a bed, for instance, can be effectively cleaned and disinfected the same way. Further questioning often begins to reveal a lack of understanding of infection prevention protocol as well as cleaning and disinfection products that are being used at different times and in different situations.

Surface manufacturers don’t know what they don’t know, particularly when it comes to infection control strategies, processes and products. Many different cleaning products are used, some of which can cause serious damage to surfaces. Often, this damage is unseen and creates a microbial reservoir that harbors pathogens that can proliferate, untouched by disinfection products.

7. Manufacturer warnings. Finally, it is extremely important to request and understand manufacturer warnings. Surface materials often come with warnings about using cleaning and disinfection products commonly used in health care facilities. Additionally, ES professionals should make sure surface materials are tested as an assembly. Testing specific materials will give one result, but combined materials that are cleaned and disinfected can produce an entirely different result. Equipment may include many different surfaces that cannot be cleaned and disinfected the same way.

It is not unusual to find that a manufacturer has tested specific chemicals on its product, but has not tested disinfection products. Results can vary when an actual disinfectant product is tested, because it may comprise multiple active and inactive chemicals. Even if cleaning products are not called out in manufacturer warnings, ES professionals should confirm that they are safe to use for each product and surface.

A critical role

Environmental surfaces play a critical role in the transmission of HAIs. By being aware of the seven aspects of surface selection, it becomes clear that health care facilities must set surface criteria to minimize risk and prevent harm to patients, health care workers and the general public.

By using the seven aspects to create surface selection criteria, health care facilities will lay a foundation to achieve a sustainable reduction in the number of HAIs.

Linda Lybert is president of Healthcare Surface Consulting LLC and co-founder of the Healthcare Surface Summit. She can be contacted at linda@healthcaresurface
. The Seven Aspects of Surfaces is used by Healthcare Surface Consulting LLC as the core focus of their business. Excerpts of this article were originally published at