Cleaning and disinfection of environmental surfaces

Environmental cleaning and disinfecting of surfaces is a critical component in the prevention of health care-associated infections. Surfaces form part of the environmental reservoir that are highly susceptible to contamination from many different dangerous pathogens.

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Three approaches exist for routine disinfection of hard, nonporous surfaces in patient rooms: 1) chemical disinfection with manual cleaning; 2) using “self-disinfecting” surfaces that are impregnated or coated with metals such as copper, silver and germicides; and 3) no-touch technology such as ultraviolet light (UV-C) or fogging with hydrogen peroxide vapor or mist.

By using the best practices and recommendations outlined in Using the Health Care Physical Environment to Prevent and Control Infection — A Best Practice Guide to Help Health Care Organizations Create Safe, Healing Environments, health care leaders can identify environmental process deficiencies, develop an action plan for correcting these deficiencies, implement the action plan and monitor the plan for positive outcomes.

Multiple stages

The cleanliness and disinfection of the health care environment is important for infection prevention and the patient’s well-being. This effort starts with hospital leaders forming a multidisciplinary team that should include the people with the knowledge and experience to make decisions aimed at improving the cleaning and disinfection of the environment throughout the entire organization.

The team should include administration, infection prevention and control, nursing, environmental services (EVS) professionals and facility management. The team’s focus should be on developing and sustaining a successful cleaning and disinfection program.

Multiple stages need to be followed to develop a successful program, and sustaining the program will require the ongoing commitment of everyone in the organization.

Stage 1. Stage one of the program is determining what chemicals will be used to clean and disinfect the various surfaces in the health care environment. Disinfectants that are to be used in the health care setting must be registered with the Environmental Protection Agency for that use. The EVS team generally performs intermediate-level disinfection and low-level disinfection functions in a health care facility.

The most commonly used chemical disinfectants are quaternary ammonium compounds (referred to as quats) for routine cleaning and disinfection. They are bactericidal, virucidal against enveloped viruses and fungicidal, but not sporicidal and generally not mycobactericidal or effective against nonenveloped viruses. Sodium hypochlorite (commonly known as bleach) is bactericidal, fungicidal, virucidal, mycobactericidal and sporicidal and is generally recommended for surfaces or objects contaminated with C. difficile spores. Accelerated hydrogen peroxide has been recently introduced for surface disinfection with generally short contact times; it is bactericidal, virucidal, fungicidal, sporicidal and mycobactericidal.

When selecting products for cleaning and disinfection, many factors must be considered. First, consider the disinfectant’s spectrum of activity (kill claim). Look for products that have short contact times, a one-step cleaner and disinfectant that is compatible with surfaces, noncorrosive and that has long shelf life. Follow the product manufacturer’s recommendations for use on certain surfaces and use the correct dilution ratio.

Once the chemical selection is completed and guidelines are set on when to use what chemical for a specific pathogen, a determination will need to be made on how the disinfectant will be applied to the surfaces. The disinfectants can be applied with cotton cloths, microfiber cloths or disposable wipes. The disinfectant may be wiped with a moistened cloth, sprayed or applied with a saturated cloth soaked in a disinfectant-filled bucket.

The most important factor is that the disinfectant be applied liberally enough to achieve the appropriate wetness to ensure that the disinfectant contact time is achieved per the label’s instructions. A method for achieving the correct chemical dilution will need to be decided; most chemical vendors offer automated dispensing and mixing systems to ensure accurate dilution ratios each time. Other methods include ready-to-use bottles and ready-to-use wipes, although there is a substantial additional cost associated with these methods.

Stage 2. Stage two of the program is defining policies and procedures, and every discipline that has any role in the cleaning process needs to be represented at this stage so that policies and procedures can be effectively defined. The policies need to clearly define the cleaning task, the responsible department to perform the task, the cleaning frequency and the products to be used.

Using the Spaulding classification, which categorizes levels of disinfection based on the object’s intended use and the risk for infection with the use of that item, noncritical items in the health care setting are those that only touch intact skin, and these require low-level disinfection and an intermediate-level disinfection for C. diff. Equipment should be disinfected between patients if shared or at least daily and at terminal cleaning.

Protocols for cleaning these noncritical items are to be consistent, such as cleaning and disinfecting of all high-touch surfaces (e.g., bed rails, overbed table and nurse call buttons). These high-touch surfaces that frequently come in contact with the hands of patients or health care personnel should be cleaned and disinfected daily (or more frequently) and at terminal cleaning. Identify which areas might call for less frequent cleaning because they are not likely sources of contamination (e.g., walls, ceilings and window sills); these noncritical surfaces need cleaning only periodically or when visibly soiled. Outline the steps employed for cleaning occupied patient rooms and terminal cleaning of patient or procedure rooms.

When defining cleaning and disinfection protocols, follow predetermined guidelines for the cleaning path (top to bottom, clockwise/counterclockwise, clean to dirty). This will ensure that no areas are skipped and help prevent pathogens from being transferred from a dirty area to a clean area. The restroom in the patient room should always be cleaned last to reduce the likelihood of spreading contaminants and to increase efficiency and safety.

When it comes to assigning responsibility for cleaning equipment, EVS, nursing and infection control should collaborate to decide who is going to clean and disinfect specific noncritical equipment. Once all parties agree on who will be responsible for cleaning each type of equipment, compile a list. The list should have the following outlined on it: the equipment name, the standard of cleaning (for example, after use or when visibly soiled), method of cleaning and type of disinfectant, the group responsible for cleaning and any additional comments.

The standard of cleaning should be determined by the infection control committee, while the method of cleaning should be determined by the manufacturer’s instructions and, at a minimum, noncritical equipment should be disinfected when visibly soiled, prior to use on a patient and on a regular basis. Incorporate this list of responsibilities into new-hire orientation and training for EVS technicians and staff to prevent confusion about who is responsible for cleaning specific equipment.

Checklists and daily assignment sheets should be developed that will help EVS technicians properly complete the tasks they are performing. The cleaning checklist should include low- or intermediate-level disinfectants specific to the type of isolation the technician may encounter.

The daily assignment sheet should have all areas listed for that assignment and have the amount of time the technician has to complete the cleaning in each area. The time for completing each area should be sufficient to allow a thorough cleaning, accounting for adequate contact time for cleaning agents. Checklists and daily assignment sheets can be easily implemented.

When performing cleaning for an isolation room, follow the same procedures as used for a regular room cleaning. In addition, a few more detailed steps will be included. Don appropriate personal protective equipment for the particular isolation precaution following the isolation sign instructions and check for proper fit before entering the room. Use the specified disinfectant for the type of isolation.

These special procedures should be included in the cleaning and disinfection protocols as they relate to isolation cleaning: use low- or intermediate-level disinfectants that are specific to the type of isolation, consider potential contamination of items that need to be cleaned, only leave the room when cleaning is completed, adhere to proper removal protocols of personal protective equipment as it is critical to avoid contamination and exposure to the pathogens, avoid touching the outside of items where infectious organisms may have settled, immediately perform hand hygiene and disinfect cleaning equipment before returning it to the cart.

Stage 3. The next stage of the program is environmental cleaning education for the environmental staff and any other health care personnel designated to clean certain equipment. Ensuring competence of EVS staff and those assigned to clean equipment is critical, and a hospital should have a competency-based training program in place.

The Centers for Disease Control and Prevention (CDC) recommends “structured education,” where the training includes the technician’s role in improving patient safety. The program should reinforce the importance of cleaning and disinfecting and be specific about the expectations and the necessary skills. The environmental team and those assigned to clean equipment must understand the “why” behind their everyday actions and the key role EVS technicians and those who clean equipment play in preventing the spread of infection.

EVS technicians must be given an abundance of information to perform their daily tasks effectively. They must be educated on the types of pathogens and understand how infection is spread and how they can prevent that spread. They need education on the proper cleaning and disinfecting practices of the required items they are to clean, the frequency of cleaning those specific items, the guidelines about the order in which to clean those items, the right cleaning/disinfection chemical to be used for the organism, the proper dilution ratio of the products they are using and the correct dwell time to achieve disinfection of the surface they are cleaning.

New-hire training should include classroom training that covers department policies and procedures and should include a knowledge assessment, like a written quiz. Training should define how the quality and consistency of their work will be monitored and audited on both a daily and yearly basis.

Once classroom training is complete, new hires should train with a preceptor for five to seven days. Once preceptor training is completed, a direct observation assessment should be conducted by EVS management or the infection control professional at the facility. The assessor should ensure new hires follow environmental cleaning procedures, donning and doffing of personal protective equipment, daily room cleaning, a standard discharge room cleaning and a C. diff discharge isolation cleaning. New hires should perform two discharge cleanings on their own and have an assessment done once completed.

After EVS management conducts the assessment, the new hire can work an assignment on their own or, if necessary, go back for more training based on the assessment outcome. Ongoing monitoring of cleaning should be used for retraining purposes and should not be done as a punitive measure.

In addition to new-hire training, ongoing training should be provided to maintain competency of existing EVS staff and those health care personnel assigned to clean equipment. This training should be held monthly, include written exams and attendance should be tracked by management. The training program should include yearly competencies to measure the technicians’ and health care personnel’s technical skill as it relates to cleaning and disinfecting.

Achieving a professional certification is one way for EVS staff to demonstrate expertise. The Association for the Health Care Environment (AHE) offers the Certificate of Mastery in Infection Prevention for Environmental Services Professionals. 

This robust certificate program provides the requisite knowledge for a “trained” professional in infection prevention and control specific to the clinical environment of care. The AHE offers the only certification for frontline technicians that validates their knowledge and technical skills. The Certified Healthcare Environmental Services Technician designation sets national standards specifically for EVS technicians working in health care.

Stage 4. Next, the multidisciplinary team will need to determine how the environmental cleaning will be audited and monitored. The CDC, Association for Professionals in Infection Control and Epidemiology and other professional associations recommend that health systems monitor their cleaning to ensure the adequacy of their cleaning practices.

Four current methods available to monitor cleaning practices include direct observation, aerobic colony counts (e.g., contact plates and swab/wipe-rinse), fluorescent marker systems and ATP bioluminescence assays. Visual assessment after a room has been cleaned can only assess visible cleanliness such as removal of organic debris and dust, not the microbial contamination. Visual assessment alone is not adequate, and another method for measuring surface cleaning needs to be selected.

The monitoring methods of direct observation, the fluorescent marker system and ATP are relatively easy and cost effective to implement within the health system. The team will need to make careful consideration of the advantages and limitations of the cleaning monitoring approaches prior to deciding which system or combination of systems best meets the needs. In 2010, the CDC put out a checklist with recommended surfaces to monitor after terminal cleaning.

Stage 5. Next in the program is feedback to the EVS team and those assigned to clean other equipment. Providing feedback is extremely important in the success of the environment cleaning program and has been shown to improve cleaning and disinfection practices. The CDC recommends discussing the results of the monitoring programs and interventions as a “standing agenda item for the infection control committee.” Feedback on the results of the monitoring program should be shared with the EVS team, unit level leadership and hospital administration.

Collaboration is paramount

Collaboration between the hospital and health system infection prevention and control practitioner and the EVS professional is paramount to the success of the environmental cleaning and disinfection program.

The multidisciplinary team has many tools and resources at their disposal to be successful, which are referenced in the Using the Health Care Physical Environment to Prevent and Control Infection publication. 

ABOUT THE AUTHORS 

As lead developer for the Using the Health Care Physical Environment to Prevent and Control Infection publication, the American Society for Health Care Engineering recognizes the contributions of the following individuals:

• Project leader Linda Dickey, R.N., MPH, CIC, FAPIC, senior director of quality, patient safety and infection prevention, University of California Irvine Health.
• Ellen Taylor, Ph.D., AIA, MBA, EDAC, vice president of research, The Center for Health Design.
• Laurie Conway, R.N., Ph.D., CIC, infection prevention and control nurse, Kingston, Frontenac, Lennox, & Addington Public Health.
• Frank Myers, MA, CIC, infection preventionist, University of California – San Diego.
• Dan Bennett, CHESP, MT-CHEST, director of environmental services, St. Joseph’s Hospitals, BayCare Health System.
• Amy Nichols, R.N., MBA, CIC, FAPIC, director, hospital epidemiology and infection control, University of California – San Francisco Health.
• Paula Wright, R.N., BSN, CIC, project manager, Massachusetts General Hospital.
• The Association for the Health Care Environment, a professional membership group of the American Hospital Association.