Time-honored and effective practices of room cleaning and hand hygiene must now pair with modern-day approaches. (PurThread Technologies Inc. photo)

Pairing New Approaches with Conventional Cleaning to Improve Hospital Infection Control

Mixing novel technologies and methods with increased diligence in patient room decontamination is key to improving infection prevention.

According to a 2002 study, hospitals in the United States report more than 1.7 million healthcare-associated infections (HAIs) annually, resulting in approximately 100,000 deaths a year.1 Additionally, the U.S. Centers for Disease Control and Prevention (CDC) estimates that HAIs cost U.S. hospitals at least $28 billion annually.2 Further research has also tied HAI rates to contamination in the patient environment. In an era of growing numbers of immune-suppressed patients seeking inpatient treatment and the continued rise of antibiotic-resistant superbugs, the reduction of bioburden contamination throughout facilities is a top priority for hospitals in the 21st century.

The conventional method for removing pathogens from patient rooms is thorough and regular cleaning. However, with room surfaces harboring high amounts of bacteria and the re-depositing of new bacteria over the course of a few hours from a variety of sources, numerous studies suggest that cleaning and hand hygiene alone may be insufficient to the challenge.

A study3 at the University of Cincinnati College of Medicine that was published in the Journal of Clinical Microbiology found "transmission of a microorganism from a person (patient or health care worker) to the environment and then to another person is the ability of that microbe to survive on that environmental surface." Another study4 from the Hospital of Saint Raphael in New Haven Connecticut, published in the Journal of Hospital Infection, revealed that environmental contamination "may contribute to transmission of healthcare pathogens when healthcare workers contaminate their hands or gloves by touching contaminated surfaces, or when patients come into direct contact with contaminated surfaces. Because routine cleaning of equipment items and other high-touch surfaces does not always remove pathogens from contaminated surfaces, improved methods of disinfecting the hospital environment are needed."

More than Just Janitorial
Environmental services employees fill vital roles at hospitals and medical centers. They are on the front line of infection prevention and an essential part of hospitals' infection control strategies.

A major task of environmental services employees is ensuring that patient safety is upheld through meticulous room cleaning and decontamination. Therefore, it is crucial that all environmental services personnel receive certified education and training on patient room cleaning and disinfecting protocols. Beyond following a hospital's individual cleaning and decontamination protocols, employees should also adhere to guidelines set out in The American Society for Healthcare Environmental Services' (ASHES) publication, "Practice Guidance for Healthcare Environmental Cleaning."5 The book effectively correlates guidelines from the CDC, OSHA, and other government agencies.

Starting with Environmental Protection Agency-approved, hospital-grade cleaning and disinfectant products to clean all room surfaces, the guidelines go into great detail to list elements that must be incorporated into the cleaning procedure. These include a bed's side rails and headboards, nurse-call devices, tabletops, cabinet handles, armchairs, closet handles, and phones. In the bathroom, it's not good enough simply to clean the sink and counter areas. Shower support bars, fixtures, mirrors -- basically all surfaces -- should be disinfected, no matter how likely the patient is to touch them.

The guidelines also state that privacy curtains should be removed and replaced on a regular basis. On the contrary, window curtains need to be changed only when visibly soiled.

Privacy curtains are often the last item freshly washed hands touch before coming in contact with the patient. Unfortunately, in practice, hospitals seem to apply the window curtains rule to privacy curtains, as well, typically changing them twice a year unless they are visibly soiled or damaged. Worse still, a 2012 study6 published in the American Journal of Infection Control found that 92 percent of curtains studied showed contamination within one week, including 21 percent with MRSA (methicillin-resistant Staphylococcus aureus) and 42 percent with VRE (vancomycin-resistant enterococcus).

New Hope for Patient Room Decontamination
To better tackle contamination, the time-honored and effective practice of room cleaning and hand hygiene must now pair with modern-day approaches. New products and pioneering ideas that have come to light within the past few years were developed to be additions to, not replacements for, conventional cleaning. This combination has the potential to help hospitals reduce the spread of infections.

Disinfecting Robots. These R2-D2 looking machines are used to disinfect a patient room after it has been cleaned by personnel. One technology created by Bioquell utilizes hydrogen peroxide vapor to saturate the air in sealed rooms with hydrogen peroxide, disinfecting all surfaces before converting the potent mist into water vapor.

Ultraviolet light is another approach. Utilization of this method by Xenex Healthcare Services resulted in an 82 percent reduction in Clostridium difficile (C.diff) infection rates at a hospital in Northampton, Massachusetts.7

While the effectiveness of these devices is documented, their cost could deter some hospitals.

Antimicrobial Surfaces. Antimicrobial surfaces provide a way for patient rooms to maintain low microbial contamination levels after cleaning. These surfaces are continuously active, which means that they work around the clock to combat contamination. For hard surfaces, Antimicrobial Copper8 is gaining some attention on call buttons, bed rails, and door knobs. It's EPA-registered as being able to kill more than 99.9 percent of infection-causing bacteria within two hours of exposure when cleaned regularly.

Meanwhile, antimicrobial textiles offer a similar pathogen resistance for soft surfaces, which are far more difficult to clean.

Cleaning Management Tools. Though not as sci-fi as the disinfecting robots, cleaning evaluation tools can help to improve cleaning procedures by monitoring and evaluating outcomes. Ecolab's EcCompass Environmental Monitoring Program consists of applying its DAZO Fluorescent Marking Gel on high-touch surfaces before room cleaning. After a room is cleaned, the surfaces are inspected using a black light pen to determine whether the marks were removed, indicating whether or not the surfaces were effectively cleaned. Environmental services employees then record those results on an app preloaded on an iPod touch, provided by Ecolab.10

Neogen's AccuPoint ATP Monitoring System11 is a cleaning verification and tracking system that measures adenosine triphosphate (ATP), a substance found in all living cells. After an area is cleaned, a technician uses a self-contained sampler to swab a surface. ATP is collected on a sampler tip and then placed in an AccuPoint instrument to determine the results. Data are stored along with the area, room number, test site, cleaning employee, time and date in Neogen's Data Manager HC software.

These systems are ideal for keeping track of the effectiveness of a hospital's cleaning practices.

Combining Resources
Cash-strapped hospitals unable to purchase new products to fight infection rates are finding that reorganizing staff structures to combine environmental services with infection prevention can be effective. In 2008, Advocate Christ Medical Center12 in Oak Lawn, Ill., restructured some departments to allow the then manager of infection prevention to manage the environmental services team. The Registered Nurse used the opportunity to enlighten the environmental services team on how cleaning a room should not just be about cleaning, but also about preventing the cause of infections. She went so far as to show the team photos of flesh-eating disease, staph infections, and C.diff infections. As a result of her efforts, ACMC accomplished a 55 percent decrease in C.diff rates and a 58 percent improvement in cleaning consistency for high-touch areas, and it drove down room turnaround times from an average of 73 minutes in 2009 to 44 minutes in 2010.

While new to the health care scene, these products and methods have been proven effective in clinical settings. As environmental services teams work tirelessly to disinfect rooms in an effort to prevent patient infections, hospitals should consider implementing products that have the ability to support those efforts. The opportunity is here to decrease the spread of harmful bacteria today, instead of waiting years for someone else to "go first."

1. www.cdc.gov/hai/pdfs/hai/infections_deaths.pdf
2. www.cdc.gov/hai/pdfs/hai/scott-costpaper.pdf
3. http://www.ncbi.nlm.nih.gov/pubmed?term=Survival%20of%20Enterococci%20and%20Staphylococci%20on%20Hospital%20Fabrics%20and%20Plastic
4. http://www.ncbi.nlm.nih.govpubmed?term=Environmental%20contamination%20makes%20an%20important%20contribution%20to%20hospital%20infection
5. http://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_prc_prd_key=529ab0ff-718f-401d-8433-175d01bef546
6. http://www.ncbi.nlm.nih.gov/pubmed/22464039
7. http://www.xenex.com/?page_id=119
8. http://www.antimicrobialcopper.com/us.aspx
9. http://www.jstor.org/discover/10.1086/668022?uid=3739920&uid=2&uid=4&uid=3739256&sid=21102397774007
10. http://www.ecolab.com/industries/healthcare/acute-care
11. http://www.neogen.com/FoodSafety/AP_Index.html
12. http://www.advocatehealth.com/cmc/

This article originally appeared in the August 2013 issue of Occupational Health & Safety.

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