How to get rid of what’s bugging you and your patients

by George Clarke

It’s no surprise to anyone in healthcare that hospitals are sickening to some patients. According to the U.S. Centers for Disease Control and Prevention (CDC), healthcare-associated infections (HAIs) account for an estimated 1.7 million infections and 99,000 associated deaths each year. These infections add an estimated $35 billion to the nation’s annual healthcare bill.

Patients are concerned about HAIs and some are shopping hospitals based on infection rates. Studies have shown that it’s not just grubby hands or dirty equipment that factor into HAIs; it’s also the cleanliness of surfaces in healthcare facilities. Surfaces such as countertops and privacy curtains are capable of harboring and transmitting infectious disease causing organisms, including Methicillin-resistant Staphylococcus aureus (MRSA), which is responsible for 63 percent of hospital-acquired staph infections.¹

One way to reduce HAIs in healthcare facilities is to focus on frequent cleaning of “high-touch” surfaces such as doorknobs, patient tables, call buttons, bed rails, telephones and light switches: all are prime real estate for the spread of bacteria. While healthcare workers are getting more disciplined about washing their hands, they will quickly contaminate them if they touch a surface that isn’t clean.

Take for instance a countertop in a waiting area. Someone with contaminated hands touches it, leaving behind organisms. Another person comes along and touches it too, and then another one. Each individual may wind up leaving behind organisms and may also become contaminated with the organisms from those who previously touched the countertop. Not only does the person who touched the surface become contaminated, but he or she could spread the organisms within the facility by touching other objects. All this “touching” increases the risk of cross-contamination.

Cutting Down on Cross Contamination

In 2008, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) issued guidelines that focus on the role of environmental surfaces in the spread of HAIs, noting: “MRSA contaminates the patient’s environment (e.g., overbed tables, bed rails, furniture, sinks and floors), and exposure to this contaminated environment has been associated with acquisition of MRSA.”

In 2003, the CDC issued Guidelines for Environmental Infection Control in Health-Care Facilities (2003) which emphasized that environmental infection-control strategies can effectively prevent HAIs. These strategies include appropriate use of hospital-grade, EPA-registered cleaners and disinfectants in accordance with manufacturers’ instructions; keeping surfaces such as floors, walls and tabletops visibly clean on a regular basis; and cleaning and disinfecting high-touch surfaces more frequently than minimal-touch surfaces.¹

To reduce the transference of surface bacteria among patients and caregivers, hospitals should take a variety of measures including:

• Top-level focus and support of collaborative efforts to reduce HAIs is a must. This means ensuring excellent leadership in the Environmental Services (ES) department and encouraging multidisciplinary teams to work on initiatives to reduce HAIs.
• ES managers and infection preventionists need to have a good working relationship. A 2008 poll conducted by the American Society of Healthcare Environmental Services and the American Hospital Association found that professionals in Environmental Services and Infection Control would like more collaboration between their fields. More than half of the ES professionals and more than one-third of the IC professionals surveyed placed a high value on the role of both departments in reducing HAIs.
• Identify frequently touched items and surfaces that pose a high risk for cross-contamination by patients and healthcare workers. Too often, frequently touched items or surfaces are not identified or cleaned because it is not clear who has responsibility for doing so.
• Proper cleaning and disinfecting protocols should be in place, designating who is responsible for cleaning and disinfecting, delineating the frequency for performing these tasks and specifying which products to use.
• Identify how chemicals impact patients, staff and the environment. ES directors should choose only the most effective cleaning and disinfection products, giving consideration to the effects on individuals and the environment.
• Follow manufacturers’ instructions—The EPA mandates that manufacturers spell out proper product usage. ES staff should follow these instructions for optimal results. Pay attention to material compatibility, proper storage, shelf-life and safe use.
• Provide ongoing assessment and reinforcement to ES staff on the critical importance of their work. ES staff optimizes patient safety by decreasing the risk of HAIs being transmitted from room to room. Ongoing analysis of cleaning performance can be used to highlight successes and identify ineffective processes. Information obtained from monitoring and assessments can be used to develop focused interventions.
• Inspection and observation will ensure that protocols are followed. Monitoring activities can be performed by infection preventionists, the clinical department and ES staff. Establishing “environmental teams” within departments to take ownership in creating protocols and observing practices is a good way to address cross-contamination.

Rules and Regulations

Hospitals are no strangers to the copious amounts of rules and regulations from many different agencies. ES departments should pay particular to the following guidelines and recommendations from the CDC that can be found on its Web site. These include:

• Prepare disinfecting (or detergent) solutions as needed and replace these with fresh solution frequently according to the facility’s policy.
• Decontaminate mop heads and cleaning cloths regularly to prevent contamination.
• Use a one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes in patient care areas where uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or 2) uncertainty exists about the presence of multi-drug resistant organisms on such surfaces.
• Do not use high-level disinfectants/liquid chemical sterilants for disinfection of non-critical surfaces.
• Disinfect non-critical surfaces with an EPA-registered hospital disinfectant according to the label’s safety precautions and use directions. By law, the user must follow all applicable label instructions on EPA-registered products. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability for any injuries resulting from off-label use and is potentially subject to enforcement action under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA).

Removing or Killing Germs: Something to Dwell On

Knowing that surface contaminants contribute to HAIs, the debate moves to whether or not germs should be removed from surfaces or killed on contact by chemical means. Numerous studies show the pros and cons for each method, but recent efforts are focusing on the use of technological advancements in cleaning, rather than chemical use, which may be harmful to individuals and the environment and take longer to be effective.

The only real way to disinfect a surface is to completely remove the source of bacteria. And in the battle against HAIs, one factor stands out among all requirements for surface disinfection: time. There needs to be proper dwell time to disinfect high-touch areas, staff time for proper environmental services programs, and time for training. Depending on how it’s managed, time can be a friend or foe.

Contact or dwell time is the time necessary for the germicide solution to remain wet on the surface to achieve disinfection of the stated kill claims on the manufacturer’s label. Manufacturers are required to list the longest contact times on usage labels. For example, if a germicidal product has a five-minute contact time for killing M. tuberculosis and a two-minute contact time for MRSA, the overall contact time on the product label must state five minutes.

Specified contact times are often too long to be practically followed. The labels of most products registered by the EPA for use against HBV, HIV, or M. tuberculosis specify a contact time of 10 minutes. The EPA approves shorter contact times when manufacturers submit confirmatory efficacy data. By law, users must follow all applicable label instructions for EPA-registered products.

Ideally, ES directors should select products with the shortest contact time. Dwell times are important and are dependent on the cleaning tools and process used. When calculating how much time is required to clean and disinfect an area, dwell times must be calculated into the process. ES directors should work with infection preventionists to create a best practice that is not based solely on how quickly the job can be completed, but rather how effectively and efficiently it can it be done.

Modernizing the Cleaning Closet

With so many rules, regulations and recommendations, antiquated cleaning approaches are no longer adequate for today’s environmental challenges. Tools such as string mops and buckets have been around for decades and often leave more dirt than they pick up. Buckets containing dirty, contaminated water may spread germs from one room to another, whereas newer products such as micro-denier flat mops trap and remove surface contaminants. String mops are also hard to maneuver in corners, crevices and tight spaces.

Cleaning products made with micro-denier technology are gaining more attention in many fields including healthcare. Products made with micro-denier fibers (a more technologically advanced material) trap and remove up to eight times their weight in liquid. Depending on the manufacturer, micro-denier fibers in these materials are in the same size range as most bacteria. And wipes and flat mop pads made from micro-denier fibers in the four to six micron range are capable of removing surface bacteria without chemicals.
Some hospitals now clean patient rooms with micro-denier products. When dry, the positively charged materials attract dust (which has a negative charge) and are much more absorbent than traditional materials. Color-coded systems, (i.e. orange wipe for the bathroom/blue wipe for the patient room) help prevent the possibility of transferring microbes from room to room because a new micro-denier flat mop and wiper is used to clean each room.

Micro-denier products are designed to thoroughly clean hard surfaces with minimal chemical usage. High performance cleaning textiles use “rechargeable” technology to remove germs, which are then killed in a chlorine bleach wash cycle. Ergonomic tools simplify equipment requirements by replacing old hardware such as cotton mops and wringers. Also, micro-denier products can be used wet or dry to clean surfaces, combining multiple steps to make the entire process more efficient, effective and ergonomic. In addition to reducing water and chemical consumption and associated waste, they also lessen physical strain on staff.

Selecting the Right Products

With a goal of reducing HAIs, a reputable vendor who specializes in healthcare can be a tremendous asset to maintaining focus on a strategic cleaning plan. When selecting a vendor, consider the following:

• Look for a knowledgeable company with EPA-approved products. Leading companies don’t just make and sell products, but also know how to apply the products in the most effective ways. They are adept at transferring that knowledge to ES staff. A good company should be aware of the latest scientific data and developments, not just the products and should have a keen understanding of the regulations placed on healthcare facilities.
• When evaluating cleaning materials, look for products that provide stability, durability and are easy-to-use.
• When purchasing wipes and flat mops, look for clinically acceptable, chlorine-stable micro-denier products can be processed in a commercial laundry environment.
• Look for ergonomically designed mop handles and tools.
• Read product labels for directions, application methods, efficacy claims, and warnings. If it’s not on the product label, it doesn’t matter what the sales rep claims. The EPA is the only government agency that approves and registers all commercial and consumer disinfectants so the proof is right on the label.
• Seek products that ensure ease of use, efficacy and utilize a methodology that prevents employees from circumventing the cleaning process. Forward-thinking manufacturers are color-coding products and cleaning kits to ensure that the right products are used at the right time and in the right place.

The Big Picture

It takes a totally integrated system to efficiently clean a hospital, including a good mix of equipment, methods, training and education. To achieve best results, these must work together properly. While innovative new products may cost more upfront, some health systems are “penny-wise and pound-foolish.” Saving a few bucks on equipment and supplies will cost far more in terms of cleaning effectiveness, HAI-related costs and health issues for staff and patients.

Reference

1. Calfee DP, et al. Supplement Article: SHEA/IDSA Practice Recommendation Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S62-S80.

George Clarke is the CEO and founder of UMF Corporation based in Chicago. For the past 11 years, Mr. Clarke has devoted his efforts to developing and proving the concept for a new line of high performance micro-denier textiles under the brand names PerfectClean^® and Micrillon^®. Mr. Clarke, a graduate of the University of Toronto (BSc.), holds more than 30 patents, both issued and pending.