Heather Hohenberger, BSN RN CIC CNOR Quality Improvement
Consultant Indiana University Health, Academic Health Centers
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Conflicts of Interest The presenter has no conflicts of
interest to disclose
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Objectives After attending this course, participants will be
able to: List several recent studies addressing the role that
surfaces play in the transmission of healthcare- associated
infections Identify trends in environmental asepsis in the
procedural environment Describe new technologies that can be used
to routinely evaluate the quality of environmental hygiene
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Additions Recommendations for cleaning and disinfection in the
Pre/Post operative patient care area Operating and Procedure Rooms
Sterile Processing areas Enhanced cleaning recommendations for
multi-drug resistant organisms Quality and process improvement
recommendations for evaluation of thoroughness in all applicable
areas
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Multidisciplinary Approach Strong recommendation for
collaboration between Infection Prevention, Environmental Services,
and organizational leadership regarding Selection of cleaning
chemicals Selection of cleaning materials, tools, and equipment
Establishment of cleaning frequencies When enhanced environmental
cleaning procedures should occur Personnel responsible for cleaning
patient care areas and equipment
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Cleaning Chemicals Environmental protection agency (EPA)
registered hospital-grade disinfectants should be used on
environmental surfaces and equipment Surfaces should be cleaned
with a detergent prior to disinfection Disinfectants should be
applied and reapplied as needed to ensure proper dwell time Spray
and misting methods should not be used to apply cleaning chemicals
in procedural areas
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Regulations Safety data sheets must be available and reviewed
Follow manufacturers instructions for use along with local, state,
and federal regulations for the preparation, handling, storage, and
disposal of all chemicals If the cleaning chemical is removed from
the original container, ensure the secondary container is labeled
with the chemical name, concentration, and expiration date
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Patient Safety Assess the environment frequently for
cleanliness Floors should always be considered contaminated
Protective barrier coverings should be used to cover surfaces if
the surface cannot withstand disinfection or is difficult to clean
Equipment should be cleaned and disinfected before being brought
into the patient care area All patient positioning equipment should
have a moisture-resistant and intact covering
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Patient Safety A clean environment should be reestablished
after the patient is transferred from the patient care area
Procedural areas should be terminally cleaned An established
schedule should be determined for terminal cleaning
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Staff Safety All personnel should take precautionary measures
to limit transmission of microorganisms when performing
environmental cleaning and handling of waste materials Appropriate
personal protective equipment (PPE) use
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Education Requirements All personnel should receive initial and
ongoing education and competency verification on their
understanding of the principles and the performance of the
processes for environmental cleaning Cleaning / disinfection
products available PPE requirements for chemical use Reconstitution
ratios (if applicable) Product expiration parameters Storage,
handling, and disposal requirements Safety data sheet location
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Cleaning Policies Policies and procedures for environmental
cleaning processes and practices should be developed, reviewed
periodically, revised as necessary, and readily available in the
practice setting
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Quality Assurance Personnel should participate in quality
assurance and performance improvement activities consistent with
the facilitys plan to improve understanding of and compliance with
the principles and processes of environmental cleaning Ongoing
feedback can show if problems are improving, stabilizing, or
worsening Obtaining data from quality assurance or performance
improvement tools can tell if benchmark goals are met identify
areas where additional help is needed
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Process Monitoring Process monitoring is a necessary part of
every facilitys environmental cleaning program Process monitoring
must include compliance with regulatory standards review of
products and manufacturers instructions for use cleaning procedures
monitoring cleaning and disinfection practices reporting and
investigation of adverse events outbreaks, product issues,
corrective actions, evaluation
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How should cleanliness be measured? Thoroughness of cleaning is
the focus of performance improvement Measure cleaning practices
visual observation of the cleaning process visual inspection of
cleanliness fluorescent marking ATP monitoring cultures
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AORN Environmental Cleaning toolkit Purpose educate all team
members about the recommended practices on cleaning the
perioperative environment promote patient safety prevent the spread
of infection in the perioperative environment Available at
http://www.aorn.org/Clinical_Practice/ToolKits/Environm
ental_Cleaning_Tool_Kit/Environmental_Cleaning_Tool_K it.aspx
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AORN Environmental Cleaning toolkit Resources Modules Power
Point presentations used for orientation, review, annual
competencies Checklists Specific for each practice setting, the
cleaning checklists can be used for documentation and education
Posters Helpful tools for quick reminders when providing targeted
education for staff
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Toolkit Modules Module 1 - Environmental Cleaning: Basics
Module 2 - Environmental Cleaning: Preoperative and Postoperative
Areas Module 3 - Environmental Cleaning: OR and Procedure Rooms
Module 4 - Environmental Cleaning: Sterile Processing Areas Module
5 - Special Cleaning Procedures Module 6 - Quality and Process
Improvement
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End of Procedure Cleaning in the OR or Procedural Room Adapted
with permission from Perioperative Standards and Recommended
Practices. Copyright 2014, AORN, Inc, 2170 S. Parker Road, Suite
400, Denver, CO 80231. All rights reserved.
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Terminal Cleaning in the Preoperative and Postoperative Care
Area Adapted with permission from Perioperative Standards and
Recommended Practices. Copyright 2014, AORN, Inc, 2170 S. Parker
Road, Suite 400, Denver, CO 80231. All rights reserved.
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What should be cleaned first? Clean from top to bottom clean to
dirty areas Clockwise or counter-clockwise cleaning may be
performed when used along with clean-to-dirty and top-to-bottom
cleaning methods
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Cleaning
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Sample Cleaning Checklist Pre/Post Procedural Areas Pre- and
Postoperative Areas Cleaning ChecklistPatient Discharge Completed
1.Patient monitors 1.Patient beds 1.Over-bed tables 1.Television
remote 1.Call lights 1.Mobile and fixed equipment a.Suction
equipment a.Medical gas regulators a.Imaging monitors a.Radiology
equipment a.Warming equipment 1.Floors and wall if soiled or
potentially soiled (eg, splash, splatter, or spray). 1.Patient
transport vehicles including the straps, handles, side rails, and
attachments should be cleaned and disinfected after each patient
use.
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MicroorganismReservoirPortal of Exit Means of Transmission
Portal of Entry Susceptible Host Chain of Infection
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Hand Hygiene Hand hygiene must always be performed when you
remove PPE as soon as possible after hands are soiled
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Hot Topics One-step vs. Two-step cleaning / disinfecting ATP
testing / Fluorescent marking Ultraviolet / Solar disinfection
Copper / Silver containing disinfectants
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Cleaning / Disinfection Clean The absence of visible dust,
soil, debris, blood, or other potentially infectious material The
first step Disinfection A process that kills most forms of
microorganisms on inanimate surfaces The second step
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One-step verses Two-step One-step product combines detergent
and disinfectant, typically packaged as single-use wipes Two-step
products separate detergent and disinfectant, requires user to
perform cleaning and disinfection in two separate steps *Products
shown are for demonstration only
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One-step Wipes Various terminology used by wipe manufacturers
make it difficult to choose which wipe will best fit the
organizations needs Sanitizing Disinfectant Germicidal Sporicidal
Virucidal Antibacterial *Products shown are for demonstration
only
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Disinfectant Wipes While wipes have gained tremendous
popularity, there is poor evidence to support efficacy at the point
of care Effectiveness of the wipe depends on Detergency ability to
remove dirt on a visibly soiled surface Wetness ability to leave a
layer of disinfectant on the surface of objects / equipment
Disinfectant efficacy once the surface is dry disinfection stops,
if residue is left behind there is no further antimicrobial
effect
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Wipe it Out Royal College of Nursing produced The Selection and
Use of Disinfectant Wipes Ultimate resource for thorough
understanding of benefits and limitations of one-step wipe products
Available at http://www.rcn.org.uk/__data/assets/pdf_file/0011/38
2538/003873.pdf
http://www.rcn.org.uk/__data/assets/pdf_file/0011/38
2538/003873.pdf
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Infection Control Resources Proper Use of Healthcare
Disinfectants: The Implications Associated with Off-Label Use of
Disinfectants Available at
http://www.infectioncontroltoday.com/webinars/2012/09/pro
per-use-of-healthcare-disinfectants.aspx
http://www.infectioncontroltoday.com/webinars/2012/09/pro
per-use-of-healthcare-disinfectants.aspx Infection Control Facts:
How to Select an Ideal Disinfectant Available at
http://view.officeapps.live.com/op/view.aspx?src=http%3A%2
F%2Fwww.csao.net%2Ffiles%2Fppt%2FHow%2520to%2520S
elect%2520an%2520Ideal%2520Disinfectant.ppt
http://view.officeapps.live.com/op/view.aspx?src=http%3A%2
F%2Fwww.csao.net%2Ffiles%2Fppt%2FHow%2520to%2520S
elect%2520an%2520Ideal%2520Disinfectant.ppt
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ATP testing vs. Fluorescent marking CDC recommends all
facilities develop programs to evaluate the thoroughness of
high-touch object cleaning Emerging technologies take evaluation of
cleaning and disinfecting beyond direct observation and checklists
Subjective evidence verses objective evidence
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Objective Methods for Evaluation Direct practice observation
Swab cultures or agar slide cultures ATP bioluminescence
Fluorescent markers
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ATP Testing Measurement of adenosine triphosphate (ATP) on
surfaces using a luciferase assay and luminometer Method Before
room cleaning / disinfection occurs, a specialized swab obtains a
sample from the surface area or object The swab is placed in the
portable hand-held luminometer which identifies the amount of ATP
in the sample After cleaning / disinfection has occurred, the items
are swabbed and analyzed again
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ATP Testing Advantages Easy to use Immediate teaching and
feedback Disadvantages Results vary between systems A threshold
value has not been determined in the healthcare setting for
determining clean / contaminated Significant amount of ATP in the
environment is non- microbiological Bleach based disinfectants
alter the bioluminescence reaction Viruses and bacterial spores do
not contain ATP
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Fluorescent Marking Fluorescent powder, gel, or lotion can be
used to mark objects prior to cleaning Method Objects are marked
before cleaning occurs Evaluation occurs by shining a UV (black)
light over the object to see if the product has been removed
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Fluorescent Marking Advantages Ease of use Immediate teaching
and feedback Disadvantages Some markers can be seen after the mark
is applied, alerting the individual to clean the tagged object more
thoroughly Some marking products can be difficult to remove from
surfaces and equipment, leaving permanent stains
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Comparison MethodEase of UseIdentifies Pathogens Useful for
Teaching Directly Evaluates Cleaning Direct Observation LowNoYes
Swab culturesHighYesUnknownNot determined Agar
culturesGoodLimitedUnknownNot determined ATPHighNoYesNot determined
Fluorescent marking HighNoYes
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Comparing ATP Monitoring Units Article on ISSA Web site Using
an ATP Monitoring System in Healthcare Settings Representatives
from each major industry provider of ATP monitoring systems in
healthcare contributed their perspective of ATP integration into
practice Available at
http://www.fmlink.com/article.cgi?type=Magazine&ti
tle=Using+an+ATP+Monitoring+System+in+Health+C
are+Settings&pub=ISSA+Today&id=41190&mode=sour ce
http://www.fmlink.com/article.cgi?type=Magazine&ti
tle=Using+an+ATP+Monitoring+System+in+Health+C
are+Settings&pub=ISSA+Today&id=41190&mode=sour ce
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Current Research - ATP Sciortino, C.V., & Giles, R.A.
(2012). Validation and comparison of three adenosine triphosphate
luminometers for monitoring hospital surface sanitization: A
Rosetta Stone for adenosine triphosphate testing. American Journal
of Infection Control, 40(8), pp. e233. Validation occurred for all
three meters tested, but only one could be verified due to
variations in system performance between units Recommends careful
consideration of technologic application in the healthcare
environment
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Current Research Marking Presentation at the International
Conference on Healthcare-Associated Infections (2010) by Rupp,
M.E., Adler, A, Schellen, M., Cassling. K., Lyden, E., Fitzgerald,
T., Sholtz, L., & Carling, P. Hospital-wide Assessment of
Patient Room Environmental Cleanliness With the use of fluorescent
marking, 10 high-touch surfaces were evaluated for cleaning
efficacy 74% of high-touch surfaces were adequately cleaned
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Several studies have shown us two certainties Cleaning
practices are often subpar Improvements made through education and
feedback do not last This leads us to reach out for new
technologies that can be applied to the healthcare environment
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Ultraviolet vs. Hydrogen peroxide Manual cleaning /
disinfection relies on the individual to follow manufacturers
stated contact time and appropriate distribution of the chemical
across surfaces Even with vigorous cleaning, multidrug resistant
organisms (MDROs) can remain in the environment for months Both
methods have published evidence of reduction of contamination in
the healthcare setting
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Ultraviolet Light Acts by breaking down the molecular bonds of
DNA, causing cell destruction Requires appropriate intensity,
exposure time, air movement, and bulb strength Can be used as an
adjunct to manual cleaning / disinfecting practices
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Hydrogen peroxide Acts by releasing the oxygen (oxidizing) from
within the cell membrane of organisms, leading to cell death
Available as a vapor, aerosolized dry mist, and vaporized hydrogen
peroxide Active against bacteria, fungus, viruses, and spores
Numerous systems available in various price ranges Can be used as
an adjunct to manual cleaning / disinfecting practices
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Comparison MethodAdvantagesDisadvantages UV light Effective
against a wide range of organisms Ease of use No need to seal off
air supply Expense Requires furniture movement Must be placed in
middle of the room Use in unoccupied room only Hydrogen peroxide
Effective against a wide range of pathogens More effective than
manual disinfection No toxic by-products Disinfection of complex
equipment Room must be unoccupied Requires sealing room and air
supply Time Logistical issues
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Current Research UV light Rutala, W., Gergen, M., & Weber,
D. (2010). Room decontamination with UV radiation. Infection
Control & Hospital Epidemiology, 31(10), pp. 1025-1028. Boyce,
J., Havill, N., & Moore, B. (2011). Terminal decontamination of
patient rooms using an automated mobile UV light unit. Infection
Control & Hospital Epidemiology, 32(8), pp. 737-742. Both
studies showed significant reduction of organisms despite high
levels of contamination, including C diff spores
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Current Research Hydrogen peroxide Falagas, M., Thomaidis, P.,
& Kotsantis, K. (2012). Airborne hydrogen peroxide for
disinfection of the hospital environment for infection control: A
systematic review. Journal of Hospital Infections, 78(3), pp.
171-177. Study shows vapor or dry mist distribution of hydrogen
peroxide can effectively disinfect the hospital environment
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Copper Acts by altering the structure of proteins, leaving them
unable to perform their natural functions (inactive) Used in
self-disinfecting surfaces Not a cleaning / disinfection strategy,
rather this is a proactive approach to decreasing microbial
load
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Silver Containing Disinfectants Action is not entirely
understood, but believed to have a germicidal effect on some
bacteria, viruses, algae, and fungi Not toxic to humans Testing and
standardization is difficult in the healthcare setting Used in
self-disinfecting surfaces Not a cleaning / disinfection strategy,
rather this is a proactive approach to decreasing microbial
load
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Comparison MethodAdvantagesDisadvantages Copper Not user
dependent Continuous action Corrosion Can irritate skin Expense Few
studies available for result validation Silver Not user dependent
Continuous action No studies in the healthcare environment
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Current Research Copper Karpanen, T., Casey, A., & Lambert,
P. (2012). The antimicrobial efficacy of copper alloy furnishing in
the clinical environment: A crossover study. Infection Control and
Epidemiology, 33(1), pp. 3-9. Study found a reduction in organisms
in the healthcare environment with the use of copper alloy
materials However, the items must contain greater than 58%
copper
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Healthcare Cleaning Bundles Havill, N.L., (2013) Best practices
in disinfection of noncritical surfaces in the health care setting:
Creating a bundle for success American Journal of Infection
Control, 41(5), supplement, pp. S26-S30. Steps include Creating
policies and procedures Selection of cleaning products Determining
method of application Education Monitoring Providing feedback
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References AORN Recommended Practices for Environmental
Cleaning (2013). AORN Environmental Cleaning toolkit (2014).
Association for the Healthcare Environment of the American Hospital
Association. (2012) Practice Guidance for Healthcare Environmental
Cleaning (2 nd Ed.) Royal College of Nursing. (2011) Wipe it out;
One chance to get it right.
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Questions?
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Contact Information Heather Hohenberger, BSN RN CIC CNOR
Quality Improvement Coordinator Indiana University Health, Academic
Health Centers (317) 963-1344 office [email protected]
