Environmental Cleaning

Background According to the Centers for Disease Control and Prevention (CDC), cleaning and disinfecting environmental surfaces in healthcare facilities is essential to reducing the potential contribution of those surfaces to the occurrence of healthcare–associated infections (HAIs). 1 Environmental surfaces can serve as reservoirs for certain microorganisms that cause infections. 2 Some pathogens, such as Clostridium difficile, can remain active on environmental surfaces for extended periods of time, potentially leading to the transmission of disease in the healthcare setting. Every day, facilities face multiple challenges to effectively and efficiently clean and disinfect their environment and medical devices. 1.Fuglsang M.: Tips for Cleaning and Disinfecting Environmental Surfaces. (accessed January 4, 2013). 2.Centers for Disease Control and Prevention: HICPAC guidelines for environmental infection control in health- care facilities, MMWR: Morb Mortal Wkly Rep 52(RR-10), Jun. 6, (accessed Jan.4, 2013).

Effective environmental cleaning and disinfection strategies may include: Educating personnel on proper cleaning and disinfecting techniques frequently due to high staff turnover. Ensuring that education is provided in a language and at a reading level that will be understood by employees Daily cleaning and disinfection of high-touch surfaces Monitoring for compliance with recommended practices and providing feedback to environmental services Optimizing cleaning products and technologies Addressing challenges and barriers as they arise

Something to remember… Transmission of infection may not be a failure of the cleaning and disinfecting agents but rather a failure to completely follow the cleaning and disinfecting process. Approach cleaning in a orderly, regularly scheduled method. Clockwise or counter-clockwise Working from top to bottom Cleanest to the dirtiest

Common terms Clean = remove all visible dust, soil, and any other foreign material Decontaminate = remove disease-producing microbes to make safe for handling Disinfect = kill or destroy nearly all disease- producing organisms (except spores) using a chemical or physical agent Sterilize = destroy microorganisms and spores Adapted from the APIC, 2009 Infection Prevention Manual for Long-Term Care Facilities

Cleaning: the first step Cleaning is the physical removal of all visible soil and other foreign material (such as dirt, dust bunnies, and body fluids) so you can get to the microbes underneath. You can’t kill microbes if you cannot get to them. One can clean without disinfecting, but one can not disinfect without cleaning, therefore, one must clean first to remove the materials. Cleaning agents such as detergents do not have antimicrobial claims. Clean spills of blood and body fluids as soon as they occur.

Disinfectants Substances applied to inanimate objects to destroy microorganisms. Use products registered with the Environmental Protection Agency (EPA) for use in medical facilities. Disinfectant will have claims that it can kill certain types of microorganisms – make sure you know what the product can and cannot kill.

Read the label Cleaners and disinfectants should be reviewed for use, dilution, contact time, and shelf life – Contact time: amount of time needed for the chemical to come in contact with the microorganism so that a significant number of organisms are killed. – Shelf life: how long the chemical can be used. After the shelf life expires, the product is no longer as effective at doing its job. Remember that bleach solutions should be prepared fresh daily

Routine cleaning/disinfection for standard room (no noted C. diff) Use EPA-registered disinfectant - Quaternary ammonia-based disinfectants are widely used in healthcare settings. Consider disinfectant wipes for use by healthcare workers

Cleaning and disinfecting the room of a patient with C. diff Use for C. diff outbreak situations, and possibly throughout units with high C. diff rates or with ongoing C. diff transmission Clean first Units with high C. diff rates should consider using a disinfectant such as hypochlorite bleach solution (1:10 dilution if using 5.25% sodium hypochlorite) or an EPA‐registered disinfectant with a sporicidal claim

Why not always use bleach‐based products? Bleach-based products can cause corrosion/pitting of some equipment and surfaces over time. May cause respiratory irritation. Requires careful dilution (e.g., solution for food surfaces VERY different than general environmental cleaning). Bleach is a corrosive chemical and must be used with caution. After a 10 minute contact time, rinse with water.

Challenges Administrative Technical Physical Educational

Staff turnover: the revolving door

Confusion about who cleans what and when

Confusion about products

Cleaning can be difficult

Technical issues Sufficient contact time to kill pathogens Pre-cleaning to remove organic material Mechanical removal

When and how should portable equipment be cleaned? SHEA/IDSA Guideline for prevention of CDI Use dedicated patient care items and equipment; if items must be shared, clean and disinfect the equipment between patients Develop and implement protocols for disinfection of equipment and the environment

Environmental transmission Frequency of C. difficile acquisition has been linked with the level of environmental contamination Patients admitted to a room previously occupied by a patient with C. difficile have a higher risk for C. difficile acquisition Improved room disinfection has led to decreased rates of C. difficile infection

Germicidal wipes If wipes are used: – The wipe must wet the surface being disinfected – Use the right wipes for the right type of job – The user should: Know the contact time for the germicide used Know the ability of the wipe to maintain contact time for the task for it will be used Be involved in selection of the right type of wipes – Staff must be trained to use the wipes appropriately (for example, wear gloves when using cleaning products)

Monitoring environmental cleaning Consistency with recommended cleaning and disinfection procedures should be routinely monitored. – Include all surfaces and items near the patient Staff performing cleaning should use checklists – Confirm that each critical area has been cleaned and disinfected – Each item must be checked off as it is completed If there is ongoing transmission: – May indicate non-compliance – Thorough cleaning and disinfection of the environment must be done – Increase frequency of monitoring compliance with cleaning and disinfection procedures

Environmental services staff Engage environmental services, especially front line personnel – Make them a part of the team! – Involve in decision-making process (such as product selection) when possible Instruct using basic infection prevention methods Train with activities that relate directly – Hands-on demonstrations – Address any language or cultural barriers – Appropriate educational level Encourage open communication and share appropriate feedback in a non‐punitive manner

Environmental services training Produced by the Illinois Department of Public Health

Conclusion Cleaning well enough to pass the white glove test is not good enough to ensure that an environment is free from microbial contamination. Think before you clean!