There’s a Guide For That!

Author: Clinical Affairs PDI Healthcare

An admission to the hospital is an unnerving experience for both patients and their families. Patients are hopeful that their hospital experience will mitigate the issues surrounding their illness. However, that is often not the outcome. Statistics show that the hospital environment itself may be the cause of additional infections and subsequent illnesses. According to the Centers for Disease Control and Prevention (CDC), an alarming 1 in 25 hospitalized patients acquire at least one healthcare-associated infection (HAI).^(1.)

Countless hours and dollars are spent trying to identify the perfect solution in eliminating HAIs, including new and advanced products and technologies. There are studies that show the resilience of microorganisms and the latest technologies to help combat these infections. There are also specialists and committees set up to identify the appropriate products to help solve these problems. However, it seems the infections keep coming back, stronger and more resilient than ever.

The key is to remain vigilant and not get caught up in looking for that “one perfect solution” while overlooking the basics of cleaning and disinfection. Utilizing the right products and technologies for each situation will cover all the bases, [hopefully] keeping HAIs at bay.

Back to basics: What is Cleaning and Disinfection?

Regulatory agencies and healthcare associations understand the complexities of trying to standardize [cleaning & disinfecting] facility to facility, as well as within each facility. The task seems daunting and almost impossible to achieve.

So to assure we are all speaking the same language, let’s start from the beginning.

• Cleaning is the necessary first step of any disinfection process.
  • Cleaning removes organic matter, salts, and visible soils, all of which interfere with microbial inactivation.
  • The physical action of scrubbing with detergents and surfactants plus rinsing with water removes substantial numbers of microorganisms.
  • If a surface is not cleaned first, the success of the disinfection process can be compromised.
  • Removal of all visible blood plus inorganic and organic matter can be as critical as the germicidal activity of the disinfecting agent.
  • When a surface cannot be cleaned adequately, it should be protected with barriers.
• Disinfection destroys most pathogenic and other microorganisms by physical or chemical means.² Disinfection can be a one-step process if there is no visible soil or debris on the surface. If there is, it becomes a two-step process where cleaning must be done first and then disinfection can follow.

Contaminated hands and surfaces can transmit microorganisms by contact which can lead to infections. The transfer of microorganisms from environmental surfaces to patients is largely via hand contact with the surface. Cleaning and disinfecting environmental surfaces, appropriately, is fundamental in reducing their potential contribution to the incidence of HAIs.

Let’s be safe. Not sorry!

In healthcare settings, each situation is assessed as part of a holistic approach. Patient diagnosis, comorbidities, types of precautions, types of equipment used, geographic obstacles of the facility, and/or temperature and humidity can differ from facility to facility. Additional factors can also affect the efficacy of disinfection and sterilization including the number and location of microorganisms, innate resistance of microorganisms, concentration and potency of disinfectants, physical and chemical factors, organic and Inorganic matter, duration of exposure and biofilms.⁶ For example, in a large metropolitan institution with many affiliated long-term care facilities, the needs assessment might alert for the potential of a high C. diff population, whereas our assessment of an urban location with a large homeless community could include TB precautions. This is a perfect example as to the importance in customizing an environmental cleaning and disinfection plan to the needs of each area / patient population.

There’s a guideline for that!

Following a standardized protocol for surface cleaning and disinfection can greatly reduce the potential for transmission. Checklists and daily assignment sheets should be customized through a collaboration with Nursing, EVS, and Infection Prevention to ensure tasks are properly addressed. These checklists should outline equipment name, standard of cleaning (ie after use or when visibly soiled), method of cleaning, type of disinfectant and who is responsible for cleaning. It’s important to note that the standard of cleaning should be determined by the infection control committee, while the method of cleaning should be determined by the manufacturer’s instructions ³

There are so many variables to consider within the realm of environmental disinfection that organizations have developed toolkits and implementation and elimination guides. Testing, diagnosis, modes of transmission as well as the importance of assessing the environment is noted.

• The CDC guidelines for disinfection and sterilization in healthcare facilities offers guidance on the basics of cleaning and disinfection, from the effects of bloodborne pathogens to mode of action of chemical disinfectants⁷ Although there are no specific recommendations for times, frequencies, or amount of product use; there is a consensus of collaborative assessments from those within the facility to determine what will work best for them.⁸
• AHE’s guidelines address healthcare environmental cleaning and key differences between occupied isolation rooms, terminal cleaning in isolation rooms, burn units, exam treatment rooms, and labor and delivery rooms.⁹ Although not every facility has these areas, the procedure for each facility must be customized for their needs. The common thread again is that there is not just one generalized protocol to deal with every situation in the same way—the amount and type of product and how it is used will vary.
• The number 1 recommendation from the AORN guidelines is that a multidisciplinary team should establish cleaning procedures and frequencies in the perioperative practice setting¹⁰ Reference charts may even identify high-touch areas that require enhanced cleaning but times, frequencies, amounts and types of products are not specified.¹¹ Once again, the need is for each facility to address their specific needs rather than a generalized process.
• AHA’s guidelines focus on using the health care physical environment to prevent and control infection, addressing why cleaning and disinfecting environmental surfaces are a critical component in the prevention of HAIs.
  • The guidelines illustrate various design components that contribute to supporting or inhibiting effective environmental cleaning. For example, hard, nonporous surfaces, such as bed rails, call buttons and over bed tables form part of the environmental reservoir that are highly susceptible to microbial contamination ¹²
  • Although this is a best practice guide to help health care organizations create safe, healing environments, a multidisciplinary team including administration, nursing, environmental services, infection prevention, facility management, materials management and biomedical engineering should be formed for a successful environmental program
  • Adding to the complexity is the fact that specific patients may be at more risk: patients such as neonates; pediatric patients; burn patients; hematology patients, those who are immunocompromised and others. As a result, specific spaces have different considerations requiring a comprehensive understanding of the epidemiology of infections and the potential role of facility design to contribute to solutions¹³

Many specialized procedures performed in highly individualized settings and locations have a significant impact on the outcomes of the patient. Infection preventionists and infectious disease specialists, as well as healthcare personnel and experts, and key opinion leaders, have worked tirelessly to offer guidance in many formats to help us mitigate HAIs. It’s best not to minimize the importance of environmental cleaning and disinfection by trying to turn it into a one size fits all protocol. Consolidating these efforts and ensuing guidance provides recommendations supported by documented evidence. And in the end, it all comes down to multidisciplinary groups within each facility working together to formulate the right process for them.

So What?

Developing and maintaining a successful cleaning and disinfection program should not focus on one element but rather should include a number of key components. A bundled approach to the entire process will round out the appropriate performance measures for specified areas.

Key factors include…

• The necessary steps to assure that the physical aspect of the cleaning and disinfection task is perfected
• Knowledge of specific unit and isolation procedures
• Proper understanding of the area and equipment to be cleaned and disinfected, as well as proper usage of appropriate products for specific areas
• Ongoing assessment, education and evaluation to keep the infection prevention machine running smoothly

The strength of a structure is only as sound as its weakest point. We must remember to focus on the basics along with the newest technologies to reach and sustain a healthcare-associated infection rate of zero.