A technician wearing appropriate PPE uses a disposable wipe to disinfect operating room surfaces.

Photo courtesy of ServiceMaster clean

With so much riding on patient care and satisfaction, it is essential that all staff, especially those who are responsible for environmental services (ES), understand the science of cross-contamination and work to prevent it. ES staff are the front line of defense against pathogens. Because they are typically in every room every day, they indirectly interact with every patient and visitor in the facility.

An ES staff member begins the day by thoroughly cleaning the family waiting area. He or she is exposed to every germ that may have been left since the previous day’s cleaning. Later, the same staff member will clean the restrooms, then perhaps 20 patient or exam rooms, the break room and, finally, multiple discharges.

Without the proper training and precautions, the ES staff member potentially could carry a pathogen throughout the facility that could infect patients, visitors, physicians and the clinical staff. The ES staff person also is potentially at risk to the dangers of those pathogens.

Proper employee training and quality-assurance measures are extremely important for ES staff. Such training can help to prevent cross-contamination and the health care-associated infections (HAIs) that may result.

It also is important to note that while physicians and nurses are highly trained to prevent cross-contamination, ES staff depend on managers, administrators or third-party service providers for training. With the responsibility for so many areas of the clinic or hospital, ES staff may face an increased risk of infection. Losing valuable ES staff members to sick days puts additional pressure on the remaining staff to complete important cleaning tasks properly and on time and hasty mistakes may create increased infection risks.

Why and what?

Information and leadership are the cornerstones of infection prevention. Everyone in the health care facility, whether it is a 500-bed hospital or a two-chair dental practice, should be knowledgeable about the basic science of pathogens as well as cleaning and disinfection. Managers should seek to create a culture focused on patient and staff safety. It begins with an understanding of why health care facilities do the things they do and what procedures, products and practices are required for an environmentally safe facility.

Every member of the ES team should be thoroughly trained about pathogens, personal protective equipment (PPE) and approved cleaning procedures. Professional cleaning services typically offer levels of training and certification depending on the type of facility and the levels of care they provide. All ES staff should demonstrate understanding of the difference between cleaning and disinfecting. Cleaning is visual — the removal of dirt, dust and debris. Disinfection is microscopic, the killing of harmful microorganisms. Facilitating the prevention of HAIs requires adherence to proper cleaning procedures and proper use of EPA-registered disinfecting products consistent with the label instructions.

The most effective ES training includes both why and what information — why cleaning and disinfecting are so important and what procedures, products and practices are recommended. Understanding the basic science of infection prevention makes every team member more qualified to help prevent HAIs, create a safer environment and protect themselves from infection.

For instance, germs (e.g., bacteria, fungi and viruses) need a host, a place where they live and replicate. This can be a person, a surface, water or food. People can transport germs and spread them by touching, coughing, sneezing or through their bodily fluids. Hospitals and clinics are opportunities for germs to spread to a new host. The situation is often exacerbated in health care settings because of wounds, compromised immune systems, the number of people in close proximity and many other factors.

In a clinical setting, physicians and nurses often can identify dangerous pathogens and isolate patients accordingly. ES staff should have clear lines of communication with all departments about contamination risk. The ES team also should be taught to pay careful attention to hospital signage that warns of contamination risk. Isolation signage ensures staff safety, determines the appropriate PPE, and recommends cleaning techniques — including what disinfection products should be used.

Knowing what cleaning products and procedures to use is critical in the fight against HAIs. Every approved health care cleaning product comes with a Safety Data Sheet (SDS) that lists its uses, application information and efficacy. Different products offer varying levels of disinfection and require varying levels of dwell time — the time necessary for the cleaning solution to achieve kill-claim efficacy. Using products in the proper manner not only helps to kill germs and prevent cross-contamination, it also helps to protect the ES staff from any potential product hazards and the pathogens they are attempting to kill.

High-reliability culture

Creating a safer health care environment requires meticulous attention to cleaning and disinfecting, and all departments working together to create a high-reliability culture that is relatively free of harmful pathogens and safer for patients and staff. There are fundamental protocols to which everyone, especially the ES team, should adhere to create an effective first line of defense against cross-contamination.

In general, all clinics and hospitals should clean and disinfect every nonporous surface every day and, as much as possible, eliminate items in family areas that cannot be effectively disinfected (e.g., magazines and cloth toys). Also, staff should focus on high-touch areas like coffee urns, door handles, vending machines, bathroom fixtures and so forth. The goal is cleaning and disinfecting — removing or killing the harmful pathogens that may be present in those areas.

Beyond those basics, other tips for creating a high-reliability culture include:

  • Hand hygiene. ES staff should know and practice the Centers for Disease Control and Prevention’s (CDC’s) hand-washing guidelines. The high points include using antibacterial soap, scrubbing for 20 seconds including the backs of hands, rinsing with clean water and drying with a clean towel or air drying.
  • Donning PPE properly. After performing hand hygiene, ES staff should put on their surgical gowns (if needed) and then their masks or respirators. Eye protection is next, then gloves. When removing PPE, they should take off gloves first, then gowns, then perform hand hygiene. Next, they should remove protective glasses, then masks or respirators and perform hand hygiene again. The level of cleaning required will determine the recommended apparel.
  • Don’t touch unless necessary. When cleaning, ES staff should avoid touching surfaces or tools unless it is necessary to perform the task.
  • Environmental awareness. ES staff should be aware of the risk factors where they are working. They should pay attention to signs that identify infection risk or other dangers (e.g., sharps and wet floors). They should also be aware of areas where patients are in contact isolation or have airborne illnesses.
  • Change pads. When cleaning floors, ES staff should change microfiber pads on the mop every time they change rooms.
  • Dust control. The goal is to capture and not spread dust, dirt and debris. ES staff should only use vacuums with HEPA filters. They should use microfiber cloths for wiping surfaces and change cloths frequently while always using a new disinfectant wipe for each room.
  • Kill claims. All Environmental Protection Agency-approved cleaning products have SDS with instructions on usage, kill claims and dwell times. ES staff should know this information and use products according to protocol.
  • High-touch points. ES staff should have a list of all high-touch points in rooms and pay special attention to these areas to ensure that they are cleaned properly with the appropriate level of disinfection. These areas also may be known as patient hot zones or the patient triangle.
  • Hazardous waste. ES staff should make sure that hazardous wastes are tracked from cradle to grave and discarded into the appropriate bins.
  • Sharps lookout. ES staff should never grab a bundle of linens or towels without first carefully sifting through and looking for sharps. If sharps are found, they should be thrown in the appropriate receptacle.
  • Work top to bottom and clean to dirty. Generally, ES staff should start with the higher surfaces and work downward, making the floor the last surface to clean. The dirtiest surfaces should be cleaned last.
  • Linens. Linens can be among the most contagious items in a health care facility. ES staff should handle linens with extreme care and make sure they are laundered according to state health codes as well as CDC and Occupational Safety and Health Administration requirements. Also, ES staff should make sure that dirty linens never come in contact with clean linens. Both clean and dirty linens should be covered with impermeable covers at all times.
  • Restroom focus. Restrooms are areas that often harbor increased levels of pathogens because of the presence of bodily fluids, many high-touch surfaces and lots of traffic. ES staff should be especially cautious in restrooms and generally clean them last.

The highest priority

Patients expect to be healed by health care providers. The quality of ES operations at health care facilities will determine if the facility’s environment of care controls pathogens that can affect patients and lead to HAIs.

Creating a safer environment will help hospitals and clinics to reinforce their mission of healing patients. It is an ongoing effort that requires diligence every day and ES staff are at the front lines of the battle.

Steve Zimmerman, CSCT, is director of health care services for ServiceMaster Clean. He was formerly director of environmental services for a large children’s hospital, where his department won several awards. He can be contacted at szimmerman@smclean.com.