The process of physical cleaning of environmental surfaces using detergent (soap), water, and friction is the critical step required prior to surface disinfection. The combination of the cleaning and disinfection processes is designed to remove and kill vegetative microorganisms on surfaces. Disinfection will not be effective in the presence of dirt, blood, or other bio burden. The  goal of the cleaning step is to remove bio burden and with it, the majority of pathogens. Disinfection is designed to be a synergistic and somewhat redundant step to ensure comprehensive removal/kill of pathogens on surfaces.

The CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, states that, “noncritical surfaces (e.g., dialysis bed or chair, countertops, external surfaces of dialysis machines) should be disinfected with an EPA-registered disinfectant unless the item is visibly contaminated with blood. In that case, an EPA registered tuberculocidal agent with specific label claims for HBV and HIV should be used.”1 the commonly used disinfectant for blood contaminated environmental surfaces is a 1:100 dilution of bleach (500–600 parts per million [ppm] free chlorine).

The environmental surfaces in HD settings at highest risk of transmitting germs are described using different terms. From the perspective of the patient, the term “patient zone” is used to refer to the surfaces which the patient can touch, or can touch the patient, including the chair, armrests, bedside table top/counter, and drawer/cupboard handles. From the HCW or dialysis staff perspective, the term “high touch surfaces” is used to describe surfaces which are frequently touched by HCWs. These include the same surfaces in the patient zone in addition to others such as the exterior surfaces of the HD machine, computer screens, and keyboards. Cleaning and disinfection of these surfaces (patient zone/high touch surfaces) should be performed between all patient treatments, no matter what the patient diagnosis is, in order to prevent spread of environmentally transmitted pathogens including MDROs (e.g., MRSA, VRE, C. difficile) and bloodborne pathogens (e.g., HBV, HCV). Of note, microorganisms can live for varying periods of time in the environment. MRSA has been documented as viable at 38 weeks on external sterile packaging and VRE at 6 months on a wheelchair. HBV can survive for 7 days in dried blood.

There are certain products and principles which are recommended in order to optimize environmental cleaning in healthcare settings, including HD facilities. These include the following tasks which are typically performed by the dialysis nurse or technician.

• Store cleaner/disinfectant separately from skin antiseptics/patient supplies (separate shelves and below patient supplies to avoid potential contamination).

• Perform hand hygiene before and after cleaning the patient station.

• Don gloves when using cleaner/disinfectants.

• Use one set of cleaning cloths or disposable germicidal wipes for each patient station.

• Use microfiber cloths and mops if possible (more effective cleaning products than regular cotton cleaning cloths).

• Clean all frequently touched or “high touch” surfaces in the “patient zone” between patient treatments (chair, armrests, counters, drawer/cupboard handles, exterior surface of the HD machine)—please note that some of these high touch surfaces may be right outside the patient zone (e.g., computer stations), and must also be cleaned between patient treatments.

• Clean the top of an object first and work down to avoid soiling surfaces just cleaned.

• If using cleaning cloths instead of disposable germicidal wipes:

• When using a disinfectant cleaner, wet the surface, use friction to clean, and allow to air dry.

• Fold the cleaning cloth in a series of squares to provide a number of potential cleaning surfaces. A wadded cloth does not clean efficiently.

• Replace cloth as needed. More than one cloth may be required for a patient station.

• Never use the same cleaning cloth for more than one patient unit.

• Never re-dip used cloth into clean disinfectant solution.

Additional cleaning functions, typically performed by housekeeping staff in HD facilities, should include:

• At the end of the day:

• Wet mop the floor

• Clean patient/staff bathrooms and restock paper products/hand hygiene supplies

• Check and refill all hand hygiene product dispensers in nursing stations and at patient stations (soap, paper towels, lotion, alcohol-based hand sanitizer)

• On a routine basis, walls and high dusting should be performed.

Multi Drug Resistant Organisms Cleaning and Disinfection

Many healthcare workers believe the environment of patients with MDROs require special cleaning. Healthcare workers in HD facilities should clean the environment of the MDRO patient as they would for any patient, as many more patients than are known are colonized/infected with an MDRO. Cleaning involves the use of friction on environmental surfaces to physically remove the soil and germs. The wet contact time of the germicide on the surface helps kill or inactivate any remaining microorganisms. The exception is C. difficile, which requires removal by friction and is not inactivated by any surface disinfectant except bleach.

I hope there is some relief in the activity at your institution now that we have made it through another heavy viral season. Not that there really is a slow season in health care anymore, just a less busy one. So, welcome to the less busy season, when there is time to think and plan.

Environmental services departments are pivotal in the “flow” process, but it must be balanced with proper infection control practices. The challenge is timely, thorough communication—getting and giving good information.

Let’s imagine the emergency room waiting area is filled to capacity and census is at 99 percent. The health care institution has a patient throughput initiative and, hopefully, all of you have been involved in this initiative.

Here is the scenario:

The emergency room has just informed Patient A that he will be admitted. Bed management then scurries to see where the patient can be placed. For purposes of this scenario, we will assume Patient A is a cardiac patient and will need to be admitted into the cardiac intensive care unit, which is currently full. This means the patient shuffle will now occur.

This pending admittance is happening after 7 p.m., when staffing is at a lower level. The most stable patient, Patient S in the cardiac intensive care unit, will move to the step-down unit. But Patient O, who is currently in the step-down unit, needs to be relocated since there is now no need for monitoring this patient, but he is still not ready for discharge. We will now have to move multiple patients to get emergency room Patient A into a necessary room, but the only data that will be looked at is the time it takes to get Patient A to his room, although this is not the only process that is occurring.

The race is on to get Patient A into an intensive care unit room within a certain time frame. Patient S, who is in an intensive care unit room, has to move to the step-down unit room occupied by Patient C. Patient C is stable enough to move to Patient H’s room, which was discharged earlier in the day during the shift change.

This means either there was a lack of communication or miscommunication both from human beings and/or from the “fail-safe” electronic system to notify the incoming environmental services shift of the discharge. The room now resides in “neitherland”; hopefully, it will be discovered and cleaning completed within the required amount of time of the patient flow initiative. If not, we just encountered our first “dam” in the flow.

The current status for environmental services is one critical patient in the emergency room, two patients needing relocating, four rooms counting the ER exam room needing to be cleaned, with the emergency room waiting area overflowing and the health care institution on the verge of going into divert. Contact time to properly disinfect surfaces is 10 minutes, and two of the three rooms are in the same cleaning zone of one person. Patient C needs to go into Patient H’s room, which is the empty discharge room that is lost in the communication process. Patient A, who will move when Patient O moves, can go into Patient S’s room. What does all this mean for the hospital’s environmental services department?

Well if you played along with my little word game, the answer is “chaos”! Most hospitals spend from November to April in this type of scenario. Though the patient flow initiative may not have been accomplished, patients are treated in a timely, effective and safe manner with positive outcomes.

Now, when things are calmer, evaluate your turnaround times, your communication methods and your systems and start to develop process improvement initiatives. Use this time to document, evaluate your data and present this information to your administrator with improvement suggestions. This will assist you and your staff to develop, acquire or change initiatives that will lessen the burden next viral season.

On the road to excellence!

Tina L. Cermignano, CHESP
Operations Manager
Children’s Hospital of Philadelphia
Philadelphia

This article first appeared in the June 2008 issue of HFM Magazine.