Hospital-acquired infections are a complex problem and contracted facility maintenance personnel often find themselves right in the middle of it. As with any consequential, complicated issue, plenty of blame goes around. Unfortunately, for the problem of healthcare acquired infections, there appears to be a paucity of practical solutions. This article breaks the problem of hospital infections into its two main components—one of which is a problem that must be solved by doctors and nurses—then provides outsourced environmental services personnel with clear, simple steps to do their part.
Every infection acquired in a hospital has a clear and distinct cause. However, a great assortment of people and germs call the hospital environment home, so there can be thousands of infection scenarios in just one hospital. Further complicating the matter, it could take months of work and thousands of dollars to trace even one of them!
We will probably never know the proximate cause of most hospital infections, but I venture that every hospital infection can be broken down into two main parts, the “opportunity” and the “invader.” The opportunity is exactly that thing that makes healthcare environments special—immune deficiencies, wounds, stressed bodies, indwelling, and disruptive medical devices. The invader is the disease-causing microorganism lurking on the patients’ bodies or in the patients’ rooms.
The “opportunity” part of the healthcare infection problem must be addressed by doctors, nurses, and people who design medical devices. In addition, healthcare personnel are responsible for killing invaders that lurk on the patients themselves.
Facility staff is the only group who will kill microbial invaders on the inanimate surfaces of the healthcare environment. Careful disinfection of inanimate surfaces is crucial to any attempt to reduce infection rates. Today’s microbial invaders have many pathways to get into people and cause infection. What’s more, germs of concern in today’s hospital survive extraordinarily well on environmental surfaces and pack a terrible, difficult-to-treat punch.
The purpose of this article is to help interested professionals to reinvent and optimize their surface disinfection strategy and techniques. Environmental services professionals can’t reduce the rich assortment of infection targets in a hospital, but they can reduce the likelihood that a pathogen that has infected one patient will make its way to another via a contaminated surface.
Step 1: Learn the Risk Balance—Consider the Toxicity of Disinfectants to Susceptible Patients
The wise environmental services professional will recognize that a balance must be struck in a healthcare setting between an antimicrobial product’s toxicity to pathogenic microorganisms and its toxicity to patients. Some liquid chemical disinfectants can irritate the skin and respiratory pathways of susceptible patients (asthmatics, burn victims, prematurely born babies, etc.), making for a situation where the benefits of disinfection could be outweighed by potential risks.
Different disinfectant technologies offer different toxicological profiles. Most liquid chemical disinfectants—in diluted form— are considered to be EPA category three (“slightly toxic, slightly irritating”). In concentrated form, many are EPA category two (“moderately toxic, moderately irritating”). An increasing number of disinfectants have been labeled EPA category four (“practically non-toxic, not irritating”) toxicity rating.
One example of a new technology that fits well within the risk balance concept is a steam vapor system, which offers a unique alternative to chemical disinfectants for surface disinfection when toxicity is a concern. Steam vapor systems deliver steam directly to environmental surfaces to disinfect them, and at least one model has been extensively studied for surface disinfection1, 2. Without chemicals, there is no potential for chemical irritation. This means that the technology can be used frequently without any risk of increased chemical irritation to sensitive populations.
The last piece of the risk balance to be considered is that cleaning staff will generally get the most exposure to any chemical used, so it’s a good idea to work with the least irritating/toxic chemical that will still do the job.
Step 2: Understand the Risks of Cleaning Without a Disinfectant Technology
One of the most common—and troubling— misunderstandings found among the environmental services community is the notion that simple cleaning in the healthcare environment will produce roughly the same results as cleaning coupled with disinfection.
For example, some suggest that simple cleaning with microfiber-type cloths and mops will decontaminate surfaces. On a limited basis that is true. Microfiber cloths and mops do, in fact, remove a higher percentage of microbes from surfaces than traditional cloths and mops, and certainly there is a benefit to physically removing contaminants. However, many fail to consider the impact that simple cleaning alone can have on adjacent surfaces (crosscontamination).
In a modern hospital, a single cleaning tool is often used across multiple rooms. Thus, there is a very real risk that it may pick up a great number of pathogens from a highly contaminated small area (a “point source”) and then spread them through the cleaning process, at lower levels, to adjacent areas of the facility.
Since many pathogens of concern in hospitals have very low infectious doses, the risk to patients could actually be higher after simple cleaning if not done in conjunction with disinfection.
Step 3: Make Sure That Disinfectant Is Working!
In actual use, the power of a chemical disinfectant can be described as a combination of its concentration, purity, and dwell time. For that reason, it is important to make sure that disinfectants are diluted properly, not overused, and given plenty of time to do their job on the surface.
The purity of the disinfectant liquid is a concern because naturally, the process of cleaning can dirty a disinfectant solution. Dirty disinfectants rarely work as well as pure, fresh ones. The best thing environmental services personnel can do is to avoid re-use of such solutions whenever possible. If re-use makes sense (such as in a mop bucket), then it’s a good idea to use test strips to check active ingredient levels or simply change out the liquid on a conservative basis (such as every other room). The concept of purity also applies to the cleaning tool itself. In most commercial and medical settings, the wiper or cloth is used over and over again on multiple surfaces, causing accumulation of organic matter on the wipe that can interfere with the action of the disinfectant, or worse, the spreading of pathogens from surface to surface. To make sure that a disinfectant isn’t wiped out by organic matter on the cloth or wipe, it should be changed out regularly.
All too often in healthcare facilities, the “spray then wipe” approach is used (where surfaces are misted with the disinfectant product and then immediately wiped dry), yet very few liquid chemical disinfectants have recommended dwell or contact times under five minutes. Since laboratory testing of disinfectant products is only done at the contact time specified on the label (usually ten minutes) it is difficult to know whether the product is actually working at such short “real-life” contact periods. To help ensure a disinfectant is working, the best bet is always to adhere to the contact time listed on the label.
Step 4: Increase the Frequency of “High-Touch” Surface Disinfection
Surfaces that tend to harbor pathogens in healthcare settings include the following:
• IV poles
• bed or bedside tables
• sink handles and basin
• toilet flush handles
• visitor chair rails
• television remote controls
Unfortunately, the frequency of disinfection of these surfaces (in many facilities) is no higher than for other surfaces in the room. From a microbiologist’s perspective, these are the surfaces that should get the most attention. They should be disinfected at least once a day if possible.
One surface often neglected is fabrics. Fabrics and other porous surfaces in health care settings can become contaminated with pathogens in much the same way as nonporous surfaces, but are more difficult to disinfect. Laundering of bed linens will deal with the bulk of fabric contamination, but other fabrics can become contaminated, too. A prime example of this is privacy curtains—in part because they are difficult to disinfect and, thus, they are rarely decontaminated.
Increasing the frequency of disinfection naturally amplifies the negative attributes of any chemical disinfection technology (e.g, toxicity, corrosivity, etc). Additionally, increasing the frequency of surface disinfection with traditional means makes the surface unusable during the contact time required for efficacy. Certainly no one would be happy to touch a doorknob covered in soapy quaternary or caustic bleach!
For the reasons mentioned above, steam vapor systems offer a unique alternative to chemical disinfectants for surface disinfection. Without chemicals, there is no potential for chemical irritation. Also, requisite contact times are brief, so the technology can be used more frequently to disinfect a high-touch surface, without the down time that could come about from the use of chemical disinfectants.
Step 5: Take Advantage of New Technologies
As the president of a contract microbiology laboratory specializing in the testing of antimicrobials, I have a first-hand view to the antimicrobial industry as new technologies develop, are validated by testing, and gain a foothold in the marketplace. Steam vapor systems are finding more frequent use in hospital settings, with at least one unit offering contact times for sanitization of a broad array of pathogens within a two second contact time2.
Surfaces with impregnated antimicrobials or inherent antimicrobial activity are becoming more common in healthcare environments. The majority of these surfaces are not registered with EPA for claims related to microorganisms of public health concern, and in general they are much less efficacious than treatment with a disinfectant. One major exception is copper surfaces, for which EPA has recently granted public health claims. Antimicrobial surfaces still require regular disinfection, but may serve to reduce the pathogen burden in healthcare settings. As a general rule, antimicrobial surfaces should be disinfected at the same frequency as other surfaces.
There has been a recent surge of vaporphase disinfectants (devices that disinfect rooms by filling them with an antimicrobial vapor). These technologies are generally effective but most require substantial validation and room-sealing prior to use. Another emerging technology is ultraviolet light (UV) room disinfection, using very powerful light arrays. The UV technologies do not clean but in general these are very promising additions to the healthcare antimicrobial arsenal.
Step 6: Establish a Relationship with Hospital Infection Control Personnel
Organizational separation between infection control staff and environmental services personnel is horribly inefficient. Both parties have much to gain from a close working relationship, yet such relationships remain the exception rather than the rule. Infection-control personnel stand to gain by learning the ground-level issues related to surface disinfection. For example, cleaning staff may note that a certain surface is difficult to disinfect or does not get disinfected often; infection control personnel could then decide if an institutional fix (i.e., replace that particular surface with another type) or a procedural fix (i.e., allow more budget/time for disinfecting that particular surface or experiment with other ways to disinfect it) is in order.
Infection control personnel also stand to gain from knowing exactly what level of cleaning and disinfection they can expect from the hospital environmental services budget. All too often, infection control personnel have unrealistic expectations of how much work can be done in a given amount of time. By working closely and collaboratively with environmental services personnel, both parties could tailor the cleaning regimen to suit the facility, the budget, and the particular infection control issues faced by the hospital.
Environmental services personnel can also benefit from the relationship. For example, environmental services personnel may begin to see from the infection data how changes in disinfection practices reduce infection rates. They could then share the credit, which would in turn motivate hospital administration to budget for even better and more careful surface disinfection in the future.
Lastly, close collaboration would allow environmental services personnel to become aware of current infection trends, so that they can take action as needed. For example, if infection control personnel note an uptick in a certain kind of infection, or an increase in infections in a particular area of the facility, environmental services personnel could tweak their disinfection technology or regimen to address the issue before it gets out of hand.
Step 7: Adopt “Maintenance” and “Outbreak” Disinfection Regimens
Surface contamination can be controlled in non-outbreak conditions by simple, regular disinfection and sanitization procedures. During outbreaks however, facilities and patients may benefit from alternative surface disinfection schemes where disinfection frequency is increased along with the potency of the disinfectant technology used. For example, toxicological, odor or surface compatibility issues may make bleach less desirable under normal or “maintenance” circumstances, but it may be a worthy choice for frequent disinfection under outbreak conditions, since it is one of the most powerful and broad-spectrum disinfectants available.
Working with infection control personnel can also help facility caretakers to match the available technologies to the problematic microbe. For routine disinfection, a broad-spectrum disinfectant is always a good choice. However, if a facility is plagued with a certain class or species of infectious agent, then environmental services personnel can aid in the fight by choosing a disinfectant known to demonstrate particular efficacy against that particular microorganism. For example, quaternary ammoniums are very effective against Gram-negative bacteria but have generally poor efficacy against nonenveloped viruses such as norovirus (stomach flu virus).
Conclusion In conclusion, health care environmental services personnel cannot be expected to solve the problem of infections entirely, but can take steps to reduce the reservoir of pathogens on hospital surfaces. Learning what makes a disinfectant “tick,” which surfaces to focus on, and the importance of a relationship with infection control personnel will surely help prevent a great deal of suffering related to illness and even save many lives in the years to come.
1. Reduction in Infection Risks through Treatment of Microbially Contaminated Surfaces with a Novel, Portable Steam Vapor Disinfection System. Benjamin D. Tanner. American Journal of Infection Control. 2009. 37(1): 20-27
2. Advanced Vapor Technologies Device. Information downloaded from (http:// www.advap.com/com_introduction. htm), 17 May 2010.
Benjamin D. Tanner holds a PhD in microbiology and immunology from the University of Arizona, where he studied with Dr. Charles Gerba. He has worked for the Clorox Company researching innovative antimicrobials and disinfectants, and is now the president and owner of Antimicrobial Test Laboratories, a microbiology laboratory specializing in disinfectant research and development.