Here is the two step cleaning training video I participated in as a technical consultant. We filmed this video at the new beautiful Mercy Medical Center in Merced California. The purpose of this video is to help Environmental Services staff save lives. We believe it is not enough to simply clean with a disinfectant anymore. Microfiber, two step cleaning, and a move away from “quat” based cleaners is long overdue.

Don’t start itching, and then check underneath your bed! You see it seems that bedbugs, also known as Cimex Lectularius are showing up in many places.

The bloodsucking bugs were virtually eradicated in the United States in the 1950s. But they are now showing up practically everywhere, nursing homes, jails, apartment buildings, dormitories, even hospitals. There has been a 500% increase in the last few years!

Experts blame the resurgence on increased international travel, immigration, changes in pest-control practices, and the bugs’ growing resistance to insecticides.

Bedbugs can live for a year without a blood meal, but once they start biting their victims may be plagued with multiple bites each night.

The EPA has made some information available to the general population that should be of interest to healthcare professionals.

http://cfpub.epa.gov/oppref/bedbug/

http://www.epa.gov/bedbugs/

Here is a link to the CDC as well:

http://www.cdc.gov/nceh/ehs/Publications/Bed_Bugs_CDC-EPA_Statement.htm

I hope this is of benefit to all of you with problems or concerns.  Please pass this information along to your staff, your Infection Preventionist, Facilities department, and anyone that can be of assistance in addressing the infestations.

I am currently investigating a disposable curtain that does not require a ladder to change. We need a easy way to change curtains much more often then when they look soiled, or every six months. Studies have shown that bacteria can live without the source of a host for months at a time, depending on the bacteria.

What good is it to terminally clean a room including wiping down all of the People Contact Points/Touch Points to rid them of potential microbes that cause HAIs and yet leave curtains that have been touched countless times by contaminated hands?

Curtains should be changed at each and every terminal cleaning – period.  Is it done? No.  Is there documentation that curtains act as vectors for microbes? Yes. You can download the report below.

Infection Control and Hospital Epidemiology November 2008, Vol. 29, No 11; 1074-1076

In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients.

Download the Environmental-Cleaning-Checklist-10-6-2010 from this link or go directly to the CDC site.

In the great work presented in Options for Evaluating Environmental Cleaning, December 2010 by Alice Guh, MD, MPH and Philip Carling, MD, objective monitoring of environmental surfaces was studied and presented as a necessary component of training. In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients. A two level approach to this is presented and quite well discussed.

For now please draw your attention to the 8 locations above. The importance of targeted cleaning to these surfaces must be taught to your staff and reinforced on a regular basis. While many of our staff have an excellent understanding of the basic policies and procedures involved in terminal room cleaning, most will benefit from focused educational interventions related to our evolving understanding of the role of the environment in healthcare-associated pathogen (HAP) transmission. Specific targeted cleaning will not only reduce HAI’s it will greatly increase the awareness level of your staff.

As part of the proposed changes to healthcare, reimbursement for hospital care and post-acute care will be bundled; patient readmission’s will be at a lower rate in some cases; hospital reimbursement and performance will be directly linked; and physician self-referral will be more closely regulated. Out of those four important items, environmental services has a direct impact on two—readmission rates and performance-based reimbursements. A sufficiently staffed environmental services department plays a major role in minimizing patient readmission’s. The proliferation of microorganisms affecting our communities and the patient population demands a properly cleaned and disinfected care environment. It is my belief that investing in the environmental services department and assuring proper funding, staffing, training, and consistent cleaning procedures and protocols will have a positive impact on lowering the infection rates, lowering the rate of “never” events like patient falls and improving patient satisfaction rates. Each of these examples provides a direct link between our departments and performance-based reimbursements.

So what does this all mean to the environmental services department? This is an opportunity to position the department as the front-line quality assurance and infection control team able to facilitate cost containment for the health care facility and ensure a proper setting for care delivery throughout the continuum of care. Speak up and make sure your senior leaders know the value you and the departmental staff bring to the health care facility. Make the business case for what you do and the big-picture impact on finances, patient readmission and performance-based reimbursement.

What is Clostridium difficile?

Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). It accounts for 15-25% of all episodes of AAD.

Clostridium difficile is a bacterium that may develop due to the prolonged use of antibiotics during healthcare treatment. Clostridium difficile infections cause diarrhea and more serious intestinal conditions such as colitis. The CDC provides guidelines and tools to the healthcare community to help end clostridium difficile infections and resources to help the public understand these infections and take measures to safeguard their own health when possible.

C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulating when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients’ bathrooms (e.g., light switches) have been implicated as sources of infection.

How is Clostridium difficile transmitted?

Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.

Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize enteric contamination of patients, health-care–workers’ hands, patient-care items, and environmental surfaces have been published. Hand washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another.

What can I use to clean and disinfect surfaces and devices to help control Clostridium difficile?

Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC’s "Guidelines for Environmental Infection Control in Health-Care Facilities." [PDF 1.4 MB] Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of Clostridium difficile. It is important to distinguish the need for a disinfectant with a sporicidal claim. Currently only specific bleach containing products have this registration. Bleach harms surfaces and is hazardous to the user. Normally, HAI’s can often be controlled with good cleaning practices and a non bleach disinfectant.

The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. I recommend using microfiber towels and an accelerated hydrogen peroxide based disinfectant. There are now a few products with a C.difficile claim. One I have tried is Dispatch wipes. I found the odor to be acceptable for most of my staff but the film left after using is a significant and required a second cleaning to remove it for an acceptable appearance.

The major difference between cleaning a medical facility and any other building is the focus on the un-seen enemy, bacteria. Environmental Service’s job is to not only provide good visible results, but to reduce the number of surface bacteria to a safe level in order to control cross infection. This is an extremely important responsibility because it keeps harmful bacteria from infecting the person next door or across the hall. Persons whose bodies are recuperating from surgery, injury or a primary infection are in a weakened condition and therefore, cannot put p their normal fight against harmful bacteria. A secondary infection in these cases can cause very serious illness.

Read the rest of this entry

I had a request for basic cleaning principles for a doctor’s office. Here is a list for any healthcare facility, and for your home as well.

• Scrubbing is the best way to physically remove dirt, debris and microorganisms.
• Cleaning is required prior to any disinfection process because dirt and debris will decrease the effectiveness of disinfectants.
• Cleaning products should be selected on the basis of their use, efficacy, safety and cost.
• Cleaning should always progress from the least soiled areas to the most soiled areas and from high to low areas, so the the dirtiest areas and debris that falls will be cleaned up last.
• Dry sweeping, mopping and dusting should be avoided to prevent dust and microorganisms from getting into the air and landing on clean surfaces.
• Mixing and dilution instructions must be followed. Too much or too little will reduce the effectiveness of cleaners and disinfectants.
• Cleaning methods and written cleaning schedules (work routines) should be based on the type of surface, amount and type of soil present and the purpose of the area.
• Routine cleaning is necessary to maintain a standard of cleanliness. Work schedules and procedures should be consistent and posted.

There you go, general principles for cleaning hospitals, clinics and other healthcare facilities summarized.

We are living in a bacterial world. For decades now we have been waging chemical warfare against the bacteria and viruses that are in our environment. We have been lobbing hand grenades at them in the form of disinfectants, antibiotics and antiseptic soaps. The bacteria have been throwing hand grenades back at us in the form of acquired resistance and the ability to make us sicker faster (increased virulence). In the Housekeeping Department we have loved our disinfectants, particularly quaternary ammonium chlorides – quats. Experts believe that the bacteria in our environment have been learning to resist quats because of the residual chemical smear that remains after the cleaning is complete, and in doing so they have gained an increased resistance to antibiotics as well. Also, we’ve known for years that gram-negative bacteria like Pseudomonas and E.coli can actually thrive in a mop pail or spray bottle of diluted quats – they are thriving, not being killed. In our effort to sterilize our environment by cleaning everything with a disinfectant we have succeeded in providing a competition-free zone for the harmful strains of common bacteria to grow wildly and cause worse infectious outbreaks. We are living in a bacterial world!! They were here long before we were, and they will be here long after we’re gone. Bacteria surround us and live in us, and on us. There are more bacterial cells in the human body than there are human cells, and they are absolutely necessary to our survival. Disinfectants are necessary in the operating room, Intensive Care Units, Burn Units, on the surface of dialysis machines, and in other areas specified by AHA and the Centers for Disease Control. For most surface cleaning we use germicidal detergent solutions at the Medical Center and Medical Office buildings for a healthy healthcare environment, clean well and love your bugs.

A critical member of the staff at Scripps Green Hospital in La Jolla California talks about her job and the rewards it offers.

Here Betco Corporation offers a video overview of how and why we clean critical areas. This is a good video for regular review.

Highlighting common scenarios from hand hygiene and glove use to properly cleaning patient rooms, this video will illustrate the type of precautions that housekeeping staff should take to protect themselves and patients from germs and infections that could make them sick.

According to Mitchell Schwaber, MD, from the National Center for Infection Control of the Israel Ministry of Health, bacterial infection threats are not getting the attention they deserve given that the World Health Organization and public health agencies continue to focus on the spread of the H1N1 influenza virus. While methicillin-resistant Staphylococcus aureus (MRSA) has made headlines in recent years, carbapenem-resistant Enterobacteriaceae infections have not. Generally, antibiotic resistant bacteria affect the elderly and unhealthy patients first, usually in hospitals, before migrating into the surrounding community. According to the Journal of the American Medical Association, in the three decades it took to recognize the threat of MRSA, it had killed more than 18,000 people per year. Currently, carbapenem-resistant Enterobacteriaceae has caused more than 100 deaths near New York City, while H1N1 has caused 436 deaths across the United States during the same four month period.

From “Don’t Forget the Bacterial Threat”

Wall Street Journal (08/12/09) Schwaber, Mitchell J.; Carmeli, Yehuda

Factors that influence the choice of disinfection procedure for Environmental Surfaces:

-Nature of item to be disinfected

-Number of organisms present

-Innate resistance of organisms

-Amount of organic soil present

-Type & concentration of germicide contact

-Specific indications & directions for use.

Consider efficacy, spectrum, versatility, ease of use, safety profile and cost.

It is cheaper and more effective to prevent environmental & health damage than to attempt to manage or cure it. Prevention requires examining the entire life cycle of products. It encourages the exploration of safer alternatives and the development of cleaner workplaces.