Protecting the patient

by J. Hudson Garrett Jr., PhD

Now more than ever, disinfection of the patient’s environment is a key component of the infection prevention and control process. One of the most critical interventions that can be routinely performed to decrease the risk for cross transmission and development of healthcare-associated infection (HAI) is routine cleaning and disinfection of the healthcare environment. This includes both medical equipment and environmental surfaces.

Environmental Surfaces

Environmental surface disinfection is an important factor in the prevention of healthcare-associated infections. The many environmental surfaces that are in healthcare settings are considered “non-critical” surfaces and therefore require a low-level disinfectant. Cross-contamination can occur in a variety of ways, but most often the environmental surface becomes contaminated and then serves as a reservoir for microbial growth. The hands of either the healthcare provider or the patient come in contact with this contaminated surface, and then contact is made with another device or surface, thereby contaminating it as well. Thus, the chain of infection transmission begins.

The ability of microorganisms to successfully survive and reproduce on environmental surfaces has never been greater. Organisms such as Methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli., <I>Clostridium Difficile (C-Diff), and Mycobacterium tuberculosis can survive on surfaces for several months. Because of the resilience of these microorganisms, it is important to routinely disinfect potentially contaminated surfaces to reduce the risk of transmission.

Before effective disinfection can occur, it is important to thoroughly clean visibly soiled environmental surfaces to allow for the full efficacy of the chosen disinfectant product. Cleaning as defined by the latest Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities released in 2008 is “the removal of foreign material (e.g. soil, and organic matter) from objects, and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.” Cleaning removes bioburden from the affected surface by reducing the number of microorganisms that must be inactivated.¹ Removing bioburden from the surface prior to application of the disinfectant solution will result in increased disinfectant efficacy. It is also important to also apply friction to the area being cleaning and disinfected in order to remove more resistant forms of microorganisms such as spores (i.e. Clostridium difficile) from the surfaces that may not be readily inactivated by the disinfectant. This will decrease the risk for development of multi-drug resistant organisms (MDROs).

The use of a product that is approved by the U.S. Environmental Protection Agency (EPA) with proven efficacy claims is also crucial to selection of the appropriate product. In addition, the infection preventionist should refer to the facility’s risk assessment, and ensure that the disinfectant selected has efficacy claims for microorganisms that are routinely found within the facility. Efficacy claims are readily available through the product’s manufacturer, and should be carefully reviewed prior to introduction of the product into the facility.

The disinfection of high-touch surfaces such as blood pressure cuffs, stethoscopes, and glucometers require frequent disinfection to prevent cross-transmission between patients. The physical number of microorganisms present on any given surface is influenced by a number of factors including: 1) the amount of moisture present on the surface, 2) the amount of activity taking place in the immediate environment, 3) the number of people having contact with the environment, and 4) the type of environmental surfaces present and their ability to support the growth of microorganism.

Standardized Approach

The primary focus of a thorough environmental disinfection program should be on those items that are used with multiple patients and/or procedures. Dr. E. H. Spaulding created a standardized approach to Disinfection in the Healthcare environment that consists of three categories: critical, semi-critical, and non-critical.

Critical items are those that will enter sterile tissue or the vascular system or areas in which blood flows would be sterile. The objective with disinfection of these items is complete sterility, which can be achieved through a variety of techniques such as EtO sterilization, gas hydrogen, chemical, or steam sterilization. Examples of critical items include IV catheters, implant devices, needles, urinary catheters, cardiac monitoring catheters, and surgical instruments.

Semi-critical items are those that will come in contact with mucous membranes and/or intact skin. The objective for disinfection with these items is to eliminate all vegetative microorganisms including viruses, bacteria, fungi and mycobacteria. These items require high-level disinfection, which can be accomplished by chemical disinfectants.

Non-critical items such as wheelchairs and bedside tables are those that have contact with intact skin, but not sterile body tissues or mucous membranes. These items require the use of a low-level disinfectant. With the recent migration within most acute care facilities to the electronic medical record (EMR), disinfection of non-critical items such as computer keyboards is of high importance to reduce transmission of microorganisms throughout the entire environment. Hand hygiene in these circumstances is still the most critical intervention to break the chain of infection, but routine disinfection of these potential reservoirs for microbial growth is a key component as well.

It is critical to have a complete set of policies and procedures identifying each individual’s and department’s responsibility in the cleaning and disinfection process. Careful collaboration with the environmental services team is necessary to in order to ensure that all surfaces are routinely disinfected by the appropriate personnel. Educational programs are available through organizations such as the Association for Professionals in Infection Control and Epidemiology (APIC) or the American Society for Healthcare Environmental Services (ASHES).

Staff Education

Education of the healthcare staff is key to minimizing risks associated with using any disinfectant product. Staff members should be educated on the appropriate indications for use for the product, the instructions for use including total overall contact time required to effectively inactivate the microorganisms on the product’s efficacy label, the Material Safety Data Sheet (MSDS), and also the appropriate use of personal protective equipment (PPE) as required by the OSHA Bloodborne Pathogens Standard. By educating the appropriate staff members on the appropriate use of the chosen product, this will ensure the manufacturer’s documented product efficacy will be achieved as well as protect the end users of the product from adverse reactions.

A thorough cleaning and disinfection program combined with careful selection of the most appropriate hospital-grade disinfectant will dramatically improve the healthcare professional’s daily fight against healthcare-associated infections. Appropriate product usage combined with education of the users will give healthcare facilities the greatest opportunity to reduce environmental contamination within the facility. With the continual development of new surface disinfection technologies each year, it is also crucial for healthcare providers to evaluate these new technologies carefully and review the supporting efficacy data thoroughly prior to changing processes already in place. Hand hygiene combined with disinfection of the patient’s environment will significantly reduce the risk for cross-transmission within the healthcare environment.

For more information on disinfection and sterilization, visit the ASHES’s Web site at www.ashes.org or the Association for Professionals in Infection Control and Epidemiology at www.apic.org.

Reference

1. Rutala, W A; Weber, D J; CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, Centers for Disease Control and Prevention, 2008.

J. Hudson Garrett Jr., PhD, is director of Clinical Affairs at PDI Healthcare. For more information, contact the author at hgarrett@pdipdi.com.