The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
The Centers for Disease Control and Prevention (CDC) estimate that there are approximately two million healthcare associated infections (HAIs) and 100,000 deaths each year in the U.S. due to HAIs. While many factors contribute to this steadily-escalating problem, it has become increasing evident that improving environmental cleaning and disinfection of the near patient environment can significantly reduce the infection risk. Some of the pathogens which have been found to be readily transmitted from environmental surfaces to healthcare workers' hands, and from there to other patients, include C. difficile (Clostridium difficile), methicillin-resistant S. aureus (MRSA), acinetobacter, norovirus and vancomycin-resistant enterococcus (VRE). While there are only a few well-documented instances of cross-transmission of these and other microorganisms in ambulatory care settings, standards for environmental hygiene were defined in the CDC's Environmental Infection Control Guideline, 2003.
Environmental Services (ES) Profession
Previously, environmentally transmitted diseases have not always been clearly recognized as the serious threat to patient safety that we appreciate today. Emergence of multidrug-resistant organisms and new, more virulent strains of C. difficile, however, have highlighted the critical role ES plays in minimizing environmental reservoirs in both hospitals and other healthcare settings. ES staff therefore needs to be engaged and provided sufficient support to assure full participation in infection prevention and control. Ensuring that ES staff are recognized as key members of the infection prevention and control team at each medical center and clinic represents a critical step in ensuring patient safety. As the profession of Environmental Services becomes more specialized, guidance from national professional organizations such as the American Society for Healthcare Environmental Services (ASHES) and ISSA (The Worldwide Cleaning Industry Association) has become more important. ES managers at each facility should consider not only membership, but certification through one of these professional groups. Both ASHES and ISSA host annual educational conferences.
Patient Zone – High-risk Settings
Studies have shown that the greatest risk of transmission of environmental pathogens occurs in the "patient zone." This refers to all surfaces within reach/touch of the patient such as: bed rails, bedside tables, carts, charts, bedside commodes, doorknobs, light switches, TV control, call button, faucet handles, exam table, B/P (blood pressure) cuff, door knobs and chairs. The term "high risk settings" refers to inpatient or outpatient settings where patients are the most vulnerable to infection, either due to the invasiveness of procedures or the acuity of their illness. These high risk settings include: ambulatory surgery centers, ambulatory chemotherapy administration suites and infusion centers, dialysis centers, ICUs (intensive care units), operating rooms, interventional radiology and admixture pharmacies.
Equipment (in the Patient Zone) as Part of the Environment
Guidelines for cleaning surfaces frequently touched by patients during daily and terminal cleaning are usually addressed in ES policies, though limited literacy and English as a second language can present barriers to understanding and adherence. Additionally, responsibility for cleaning equipment and semi-dedicated objects, such as patient area computer keyboards, are often not well delineated. As a consequence, cleaning of these potentially contaminated objects is often not performed reliably or comprehensively. Clearly defining accountability and implementing methods to ensure the regular thorough cleaning of these objects represents an important means for preventing environmental pathogen transmission.
Regulatory/Legislative Requirements
Recognition of the importance of optimizing environmental hygiene in the patient zone has led to regulatory and legislative requirements for environmental cleaning and disinfection in several states. In California, recently enacted legislation addressing environmental cleaning/disinfection includes:
Senate Bill 158:
- Ensure maintenance of a sanitary environment and patient hygiene to avoid transmission of pathogens that cause HAI.
- Recommend a standardized method to evaluate healthcare personnel for compliance with infection prevention procedures, including, but not limited to, hand hygiene and environmental sanitation procedures.
Senate Bill 1058:
- Regular disinfection of all restrooms, counter tops, furniture, televisions, telephones, bedding, office equipment, and surfaces in patient rooms, nursing stations, and storage units.
- Regular removal of accumulations of body fluid and cleaning and disinfection of all moveable medical equipment, including point–of-care devices such as glucometers and transportable medical devices.
Quality Assessment
As mandated within various legislation including those quoted above, it is critical to routinely evaluate the quality of environmental hygiene. A review of literature reveals four primary methods available to evaluate the quality of environmental cleaning and disinfection:
A. Direct Observation of Cleaning
Advantages – It is the most direct, reproducible method of assessing if an object is cleaned.
Disadvantages – It is difficult to standardize, labor intensive, cannot be used to compare institutions due to variability in analysis, and the Hawthorne effect cannot be avoided.
Assessment – Useful for individual teaching but not applicable for monitoring.
B. Culturing the Environment
Advantages – It has been used to quantify environmental contamination by specific pathogens in healthcare settings.
Disadvantages – It is labor intensive and expensive. Time for bacterial growth is needed to quantify recovered microbes, and there are no standards for acceptable concentration on these surfaces.
Assessment – May be useful for monitoring environmental contamination with specific pathogens during outbreaks.
C. ATP Bioluminescence Testing
Advantages – It has been used as a surrogate for environmental culturing. It provides an estimate of cleanliness and is easy to perform.
Disadvantages – Sensitivity and specificity limitations as well as logistical issues (such as the need to evaluate a surface within 15 minutes of it being cleaned) as well as the Hawthorne effect are the primary disadvantages.
Assessment – Useful for individual teaching but not as readily applicable for process monitoring.
D. Fluorescent Marking System
Advantages – It is used as a surrogate for culturing. Monitoring does not depend on an object being contaminated prior to evaluation. Evaluation of thoroughness of cleaning is rapid with a black light.
Disadvantages – It does not monitor for the presence of specific pathogens and requires trained resource for placement and reading.
Assessment – Demonstrated usefulness for both teaching and process monitoring.
Greener Technologies/Processes
Microfiber: Microfiber mops and cloths are comprised of fiber with a diameter of less than 10 micrometers. Microfiber products providing the best pathogen removal are a blend of nylon and polyester called "split microfiber" which absorbs up to eight times its weight in liquids. In studies, microfiber was both laboratory and clinically tested and proven to remove up to 98 percent of bacteria and 93 percent of viruses from a surface using only water (no chemicals). In comparison, traditional cotton fibers have been shown to only remove 30 percent of the bacteria and 23 percent of the viruses from a contaminated environmental surface. Both mops and cleaning cloths are available in microfiber. The microfiber mops are also ergonomically preferred to traditional mops as they are approximately one-quarter the weight. They also permit use of one mop pad per patient room practice to reduce the risk of cross-contamination.
From disinfectants to detergents for floor cleaning: There is a divergence of opinion on whether disinfectants are necessary for routine hospital cleaning – especially floors. No scientific evidence has ever linked floor contamination and infection risk. Daschner et al. reported no difference in hospital-acquired infection rates in an ICU when floors were cleaned for six months with disinfectants compared with six months with detergents. Dharan et al. found that the use of a detergent alone was associated with a significant increase in bacterial counts compared with the methods using disinfectants.
However, they observed no change in the incidence of hospital-acquired infections during the four-month trial compared to the preceding 12 months.
Current Practice and Guidance:
1. Environmental Cleaning and Disinfection Guidelines CDC http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf starts on page 147.
2. ASHES (American Society for Healthcare Environmental Services) Practice Guidelines.
References
Allerberger F et al. "Routine surface disinfection in healthcare facilities: should we do it? Am J Infect Control. (August 2002) Volume 30, Issue 5, Pages 318-319.
Anonymous Global consensus conference: final recommendations, Am J Infect Control. (1999), pp. 503–513.
Carling P, Parry M, Rupp E, Po J, Dick B, VonBheren S, for the Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infec Control Hosp Epidemiol. 2008;29(11):1035-1041.
CDC Guidelines for Environmental Infection Control in Healthcare Facilities. MMWR. June 6, 2003/52,9.
Dettenkofer M, Spencer RC. "Importance of environmental decontamination – a critical view". Journal of Hospital Infection. Volume 65, Supplement 2, June 2007, Pages 55-57.
Dumigan, D. "Who is really caring for your environment of care? developing standardized cleaning procedures and effective monitoring techniques" Am J Infect Control, June 2008 (Vol. 36, Issue 5, Pages E63-E64).
Hoyle M, Slezak B. "Understanding Microfiber's Role in Infection Prevention" Infection Control Today. Nov 7, 2008.
Kahn M. Antibacterial wipes can spread superbugs. June 3, 2008. Accessed at: http://www.reuters.com/article/newsOne/idUSL0383329520080603,
McLeod-Douse MH. "Impact of Environmental Cleaning Procedures on the Incidence of Clostridium Difficile Infections". Am J Infect Control. Volume 35, Issue 5, June 2007, Pages E125-E126.
Ruden H, Daschner F. "Should we routinely disinfect floors?" Journal of Hospital Infection. Volume 51, Issue 4, August 2002, Page 309.
Rutala WA et al. "Microbiologic evaluation of microfiber mops for surface disinfection". AJIC: American Journal of Infection Control. November 2007 (Vol. 35, Issue 9, Pages 569-573.
Rutala W, ed. Disinfection, Sterilization and Antisepsis. June 2006.
Rutala WA, Weber DJ. "Should we routinely disinfect floors – Reply to Professor F. Daschner". J Hosp Infect. (2002), pp. 309–310.
Tanner BD. "Reduction in infection risk through treatment of microbially contaminated surfaces with a novel, portable, saturated steam vapor disinfection system". Am J Infect Control. 2009;37:20-7.
United States Environmental Protection Agency. Environmental Best Practices for Health Care Facilities: Using Microfiber Mops in Hospitals. November 2002.
