1. Best Practices for Environmental Cleaning
Module 4 – General Cleaning
Part A - Cleaning Principles
Welcome to Module 4 – General Cleaning. This is the 4th module in the training program developed in support of the Best Practices document on Environmental Cleaning for Prevention and Control of Infections in all health care settings, developed by the Provincial Infectious Diseases Advisory Committee.  Health care settings are encouraged to work towards best practices in an effort to improve quality of care.  
Module 4 is the largest of the 6 modules and is divided into 3 parts. Part A deals with cleaning principles. My name is insert name and position and I will be your presenter for Part A of this module."

2. Learning Objectives
To identify factors that determine frequency of cleaning.
To correctly sequence tasks for cleaning.
To demonstrate proper procedures for different cleaning applications.
To describe other considerations in environmental management (e.g. waste handling, sharps safety, biological spill cleaning)
After completion of this module, you should be able to:
1. Identify . . .
2. Correctly sequence . . .
3. Demonstrate proper . . .
4. Describe other considerations in environmental management such as the handing of waste, the management of sharps and dealing with spills of blood or body fluids. Part A of this module addresses the first objective
You are encouraged to take a few moments after this module to review the accompanying DVD which demonstrates a number of cleaning scenarios.
Your manager or supervisor may also wish to consider the use of live demos

3. These principles apply to all settings
General Cleaning
These principles apply to all settings
where “hospital clean” is required.
The focus of this module is on hospital clean and the principles we describe apply to all areas of the facility where hospital clean is required.

4. Hotel Clean & Hospital Clean
is a measure of cleanliness based on visual appearance that includes dust and dirt removal, waste disposal and cleaning of windows and surfaces.
Hospital Clean is a hotel clean PLUS:
High touch surfaces in patient/resident/client care areas are cleaned and disinfected with hospital grade disinfectant
Non-critical medical equipment is cleaned and disinfected between patients/residents/clients AND
Cleaning practices are periodically monitored and audited with feedback and education
Let’s review the definitions of hotel clean and hospital clean - Read slide

5. Cleaning Frequencies – Factors Influencing Frequency
Surfaces high-touch or low-touch
Door knob vs window sill
Type of activity taking place in the area and risks associated with the activity
Critical care vs office setting
Vulnerability of patients/residents housed in the area
Intensive care vs patient/resident room
Probability of contamination based on the amount of body fluid contamination in the area
Washroom vs lounge
Presence of antibiotic resistant organisms (AROs)
There are several factors that influence the frequency of cleaning. Are the surfaces high touch or low touch? A doorknob will require more frequent cleaning than a window sill. What type of activity is taking place in the specific area and are there risks associated with that activity? For example, a critical care area is more likely to have high risk activities than an office area. How vulnerable are the patients/residents in the area? Patients in the intensive care unit may be more susceptible to infection than a patient or resident on another unit. What’s the likelihood that the area is going to be contaminated with body fluids under normal circumstances. This may vary depending on the setting. Finally, are there antibiotic resistant organisms such as MRSA or VRE present? All of these factors must be taken into consideration when determining the frequency of cleaning. Further along in this module, we will review the risk stratification matrix which will assist in making these decisions.

6. Cleaning Frequencies – Factors Influencing Frequency
High-Touch Surfaces:
Are those that have frequent contact with hands. Examples: doorknobs, elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards, etc.
High-touch surfaces in care areas require more frequent cleaning and disinfection than minimal contact surfaces. Cleaning and disinfection is usually done at least daily and more frequently if the risk of environmental contamination is higher e.g. in intensive care units, during outbreaks.
Read slide

7. Cleaning Frequencies – Factors Influencing Frequency
High-touch surfaces
How many high touch surfaces can you identify in this picture?
Bedrails, the call bell, handles on bedside tables, and bed controls are all high touch surfaces.
High-touch surfaces
Examples of High-touch Items and Surfaces in the Health Care Environment
NOTE: Dots indicate areas of highest contamination and touch
Figure 1

8. Cleaning Frequencies – Factors Influencing Frequency
High-touch surfaces
More examples of high-touch Items and Surfaces in the Health Care Environment.
Note: the dots indicate areas of highest contamination and touch
Doorknobs, door frame and light switches are all high touch surfaces.

9. Cleaning Frequencies – Factors Influencing Frequency
Low-Touch Surfaces:
Are those that have minimal contact with hands. Examples - floors, walls, ceilings, mirrors and window sills.
Require cleaning on a regular (but not necessarily daily) basis, when soiling or spills occur, and when a resident is discharged from the health care setting.
Many low-touch surfaces may be cleaned on a periodic basis rather than a daily basis if they are also cleaned when visibly soiled.
Read slide

10. Cleaning Frequencies – Factors Influencing Frequency
High-Touch vs Low-Touch Surfaces:
The frequency of cleaning and the level of cleaning are dependent upon the risk classification of the area to be cleaned
Read the bullet. Let’s review the risk stratification matrix referred to previously.

11. Factors that Impact Cleaning
Factors that will impact the frequency of environmental cleaning include:
Probability of contamination with pathogens
Vulnerability of clients/patients/residents to infection
Potential for exposure
The first step is to categorize the factors that impact on the need to clean. Factors to consider include Read 3 bullets.
Once you’ve done that you can start to use the charts.

12. Probability of contamination
Heavy – surfaces/equipment routinely exposed to copious amounts of fresh blood or other body fluids (e.g. birthing suite, ER, bathrooms if visible soil)
Moderate – surfaces/equipment does not routinely (but may) become contaminated with blood or body fluids (all bathrooms)
Light – surfaces not exposed to blood or other body fluids or items that have contact with these (e.g. lounges, libraries, offices)
The probability of contamination is categorized as heavy, moderate and light. An area with a heavy probability of contamination would be routinely exposed to large amounts of blood and other body fluids. Two good examples of this are the emergency room and labour and delivery room suites
All bathrooms would be classified as moderate risk since under normal use, they may become contaminated with blood or body fluids but not routinely. And of course, areas such as offices and lounges are less likely to become contaminated with body fluids (we hope)

13. Vulnerability to infection
Vulnerability of client/patient/resident
More susceptible – those who are susceptible to infection due to medical condition or lack of immunity e.g. elderly individuals who have underlying illnesses
Less susceptible – all other individuals and areas
Potential for exposure
High-touch surfaces – those that have frequent contact with hands
Low-touch surfaces – those that have minimal contact with hands
The next 2 factors to consider in the risk stratification are the vulnerability of the client/patient/resident population from more to less susceptible and the potential of surfaces to come into contact with hands. As described earlier in the module, high touch surfaces are those that have frequent contact with hands while low touch surfaces have minimal contact

14. Risk Stratification Determine the risk Probability of
Contamination with pathogens
High-touch surfaces
(score = 3)
Low-touch surfaces
(score = 1)
More susceptible
Score=1
Less susceptible
Score=0
score=1
Heavy
Score=3 7 6 5 4
Moderate
Score=2 3
Light 2
Based on the probability of contamination and the susceptibility of your clients/patients/residents you can then use this chart to come up with a total score that can help determine the frequency of cleaning by using the chart on the next slide.

15. Risk Stratification Matrix
Determine the cleaning frequency based on risk stratification matrix
Total Risk Score
Risk Type
Minimum Cleaning Frequency 7
High Risk
Clean after each case/event/procedure and at least twice per day
Clean additionally as required
4-6
Moderate Risk
Clean at least once daily
Clean additionally as required (e.g. gross soiling)
2-3
Low Risk
Clean according to a fixed schedule
This chart will then provide guidance on the frequency of cleaning. Read slide i.e. A risk score of 7 is considered high risk and at a minimum, cleaning should occur after each case, event or procedure and at least twice per day. A score between 4 and 6 is a moderate risk and these areas should be cleaned at least once daily. A score of 2 to 3 is considered low risk and these areas should be cleaned according to a fixed schedule. For example, an office area may be on schedule for a once weekly cleaning. In all cases, the frequency described is a minimum and additional cleaning may be required such as when there is gross soiling.

16. An Intensive Care Unit: Probability of contamination is heavy = 3
Example - Hospital
An Intensive Care Unit:
Probability of contamination is heavy = 3
Potential for exposure is high (high touch) = 3
Vulnerability of patients in ICU - more susceptible = 1
Total score = 7 – Clean at least twice per day and additionally as required e.g. if gross soiling
Here is an example of how the matrix can be used in a hospital setting. In an intensive care unit, the probability of contamination is heavy, for a score of 3. The potential for exposure is high for another 3 points and the patients in the ICU are more susceptible to infection, so add another point for a total of 7. In this area, clean at least twice per day and more frequently if gross soiling occurs

17. A Resident Activity Room: Probability of contamination is moderate = 2
Example - LTC
A Resident Activity Room:
Probability of contamination is moderate = 2
Potential for exposure is high (high touch) = 3
Vulnerability of residents – Those participating in activities may be considered less susceptible = 0
Total score = 5 – Clean at least once daily and additionally as required e.g. if gross soiling
In the example of a resident activity room in a LTC home, (read slide)

18. Learning Checkpoint
Here is a learning checkpoint. Ask the group the question on the next slide.

19. Learning Checkpoint
Identify whether the following items are ‘high-touch’ or ‘low-touch’ surfaces.
Toilet handle
Soap dispenser
Baseboard
Wall
Bathroom mirror
Faucet handles
Window coverings
Ceiling lights
Look at the following list of items and identify whether an item is high touch or low touch

20. Learning Checkpoint Answers
The correct answers are:
Toilet handle - high
Soap dispenser - high
Baseboard - low
Wall – low
Bathroom mirror – low
Faucet handles - high
Window coverings – high/low depending on setting – use risk stratification matrix
Ceiling lights - low
The correct answers are Read list. In some settings these surfaces may be either high or low touch depending on where and how they are used. It is important that the risk stratification matrix be used to identify the frequency of cleaning required.

21. References
Fig 1-2:
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings [cited March 27, 2013]:28-29 Available from:

22. Thank You!
This concludes Part a of Module 4 on Cleaning Principles. Thank you

23. Image Sources – Module 4A
Microsoft Clipart used in Slide 18
Images in slides 7, 8 & 10 are © PHO 2013