Surface Safety

Knocking out Norovirus

Best practices in surface and medical device disinfection
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This initiative is funded by an unrestricted educational grant from Clorox Healthcare™.

Hospital environmental services (ES) teams don’t focus on one pathogen at a time when cleaning and disinfecting surfaces. But if they did, Norovirus would get more attention in the drive to reduce health care-associated infections (HAIs).

That’s because Norovirus, a pathogen that causes food poisoning and gastroenteritis, is the leading cause of infection outbreaks in U.S. hospitals. The pathogen was responsible for 18.2 percent of all infection outbreaks and 65 percent of ward closures in U.S. hospitals during a two-year period, according to a study in the February 2012 issue of the American Journal of Infection Control.

The Centers for Disease Control and Prevention (CDC) note that each year Norovirus contributes to about 71,000 hospitalizations and 800 deaths, mostly among young children and the elderly. Norovirus also poses a direct threat to hospital caregivers and outbreaks can lead to a rise in illness among staff. Complicating matters, new strains of Norovirus have emerged every three to five years — bringing with them spikes in outbreaks in longterm care facilities and hospitals.

Most Norovirus outbreaks occur when infected patients spread the virus to others, but the pathogen also can be spread through contact with surfaces that harbor the virus, the CDC notes. With this in mind, ES teams and infection control and prevention leaders must collaborate closely on effective cleaning and disinfection protocols to minimize the risks of a Norovirus outbreak.

Brian Currie, M.D., MPH, vice president and medical director for research at Montefiore Medical Center in New York City, says ES teams in particular need to be on heightened alert any time there is heavy environmental contamination with vomitus or diarrhea.

“Cleaning and disinfection should focus on environmental surfaces, especially all bathroom surfaces and surfaces frequently touched by hands, such as door knobs, faucet handles, light switches, bed rails, remote controls, call bells, chair arms and seats, computer keyboards, etc.,” Currie says. He also strongly urges ES teams to consider increasing the frequency of cleaning and disinfection protocols when heavy environmental contamination occurs.

How to respond

“Rooms should be terminally cleaned between patients, with meticulous attention to the disinfection of all room surfaces,” Currie says.

Given that Norovirus has been found to be relatively resistant to some environmental disinfectants, disinfection of surfaces and fomites is accomplished best with bleach (sodium hypochlorite) or another Environmental Protection Agency-registered disinfectant with a label claim to kill Norovirus, Currie notes.

The CDC advises ES teams to clean and disinfect surfaces beginning with areas that have a lower likelihood of Norovirus contamination, such as tray tables and countertops, ending with such highly contaminated surfaces as toilets, bathroom fixtures, etc. Mop heads should be changed when new solutions are prepared, or after spills of emesis or fecal material. CDC Standard Precautions should be used for handling soiled patient-service items or linens, which includes the appropriate use of personal protective equipment (PPE).

Following proper hand-hygiene protocols, always a point of emphasis, is essential for those cleaning rooms of patients with confirmed or suspected cases of Norovirus.

“There must be strict adherence to hand hygiene and contact isolation protocols, including the use of glove and gown PPE for all staff entering the patient room,” Currie says.

Norovirus challenges

It’s also important for ES associates to understand that when it comes to HAIs, spores are not created equally. Norovirus and Clostridium difficile spores are among the most difficult to kill. What makes Norovirus particularly difficult to eradicate in hospital spaces is that it only takes as few as 18 viral particles of the pathogen to infect a patient, the CDC reports. In addition, Norovirus and C. difficile spores can survive on surfaces for up to five months. Thus, ensuring that surfaces are thoroughly cleaned and disinfected becomes paramount to minimize potential threats to patients.

This means that ES associates must focus on more than so-called “high-touch” objects. William Rutala, Ph.D., director of the hospital epidemiology and occupational health and safety program at the University of North Carolina hospitals, urged attendees of the Association for the Healthcare Environment conference last fall to embrace a broader focus. “We need to clean all objects that are touched,” he stressed.

Verifying cleaning thoroughness can be improved by using adenosine triphosphate bio-luminescence tools or fluorescent markers, various studies have shown. A growing number of hospitals have begun to deploy these tools, yet many still do not include them in their cleaning regimens.

These methods provide important teaching and training opportunities about the best way to remove microbes from surfaces, says John Scherberger, CHESP, R.E.H., president of Healthcare Risk Mitigation Inc., a South Carolina-based consulting firm that helps hospitals reduce health care and communityassociated infections. He adds that it’s important that ES directors share cumulative data on verifying room cleanliness with hospital executives so they can more fully appreciate the time and resources needed to reduce HAIs and improve patient safety.

“What we have been doing in environmental services is a clinical process. It’s no different from removing microbes from an injection site or a sur gical preparation site. We’re just doing it on a larger scale,” Scherberger says.

CDC offers guidance on environmental hygiene

In a presentation titled “Norovirus Gastroenteritis: Management of Outbreaks in Healthcare Settings,” the Centers for Disease Control and Prevention offer the following guidance for environmental cleaning and disinfection.

  • The use of chemical cleaning and disinfecting agents is key in interrupting Norovirus spread from contaminated environmental surfaces.
  • Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces, e.g., increase ward/unit-level cleaning to twice daily, with frequently touched surfaces cleaned and disinfected three times daily.
  • Use commercial cleaning and disinfection products registered with the U.S. Environmental Protection Agency, e.g., sodium hypochlorite (bleach) solution, hydrogen peroxide products, etc.
  • It is critical to follow manufacturer instructions for methods of application, amount, dilution and contact time.

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