To the naked eye, a healthcare building might look clean. The floors are polished, windows glisten, the trash is emptied and there’s no apparent dust on furniture. Yet there are millions of potentially dangerous germs on surfaces such as push plates, doorknobs, toilet surfaces, bed rails, bedside tables and privacy curtains.

Germs are everywhere, and are especially prevalent in hospitals and clinics. In these critical areas, many patients’ ability to fight disease or infection is dramatically reduced by their weakened immune system from illness or surgery. Building service contractors play a critical role in meeting best practices for disinfecting, and the first steps are to educate cleaning crews on the potential risk of infection and to train in appropriate disinfecting techniques for patient-care areas.

Hospital infections
In today’s healthcare setting, a great concern is the patient’s risk of a nosocomial infection. When a patient is infected in the hospital, it’s called a nosocomial, or “hospital-acquired” infection. In other words, the person contracted the infection while a patient in the hospital, and the infection was not a result of their medical condition when admitted to the hospital. While most nosocomial infections are treatable, some can be deadly.

The Centers for Disease Control and Prevention (CDC) estimate that in the United States, as many as one in 10 patients, or 2 million patients a year, acquire a nosocomial infection; of those patients, about 90,000 die as a result of the infection. Estimates of the resulting annual cost range from $4.5 billion to $11 billion. One third of nosocomial infections are considered preventable, and can be directly related to BSCs’ standard of practice in infection control cleaning techniques.

However, not all exposure to germs and bacteria results in infection. Factors that affect the risk of contracting an infectious disease depends on the type of organism, the virulence or strength of the organism to overcome the body’s natural defenses, the number of live organisms received in an exposure and the host’s resistance to infection.

Infections require three elements in order to spread disease, and can be thought of as a chain, according to the book, “Infection Control for Prehospital Care Providers.” The chain-linked elements are: Source of infection, route of transmission and susceptible host. If any one of the links in that chain is broken, infections cannot be passed.

Infection sources can be found on living things such as people, animals and insects, as well as on inanimate objects such as bed rails, clothing, bed linens, water glasses and toilets.

The route of transmission is through direct contact with an infected person and susceptible host, through contact between an infected inanimate object and a susceptible host, through droplet contact such as sneezing or coughing, via food, air, water, blood and insects.

The last element in the spread of disease is through a susceptible host which is defined as a person or animal that is capable of becoming infected with the disease being transmitted.

Current concerns
Recently, the most feared disease in healthcare facilities is Clostridium difficile, or C-diff. It is a common cause of antibiotic-associated diarrhea (AAD) and is transmitted by the contaminated hands of healthcare and cleaning workers, or on objects such as toilet seats.

From 2001 to 2004, a particularly unusual strain of C-diff caused outbreaks in seven hospitals in Georgia, Illinois, Maine, New Jersey, Oregon and Pennsylvania. While 23 percent of C-diff-infected patients can be treated with an appropriate course of antibiotics such as Metronidazole or Vancomycin, according to the CDC, C-diff can kill patients with severely compromised immune systems.

C-diff is shed in feces and surfaces that come in contact with feces serves as a reservoir. One of the most common harbors for C-diff spores is on portable and in-room toilet surfaces. The disease can be transmitted throughout the hospital simply by a nurse touching an infected surface and visiting the next patient without either changing gloves or washing hands. It’s easy to see how fast an outbreak can occur.

Another source of concern in healthcare environments is Methicillin-resistant Staphylococcus aureus (MRSA). The first reported case of MRSA in the United States occurred in 1968, and recent CDC estimates indicate more than 100,000 are hospitalized annually with MRSA-related infection.

Most MRSA cases have been limited to long-term care facilities such as nursing homes and rehabilitation hospitals, or to patients with a prolonged hospital stays. The CDC identifies the following as associated with the spread of MRSA: Close skin-to-skin contact; openings in the skin; contaminated items and surfaces; crowded living conditions such as hospitals and nursing homes; and poor hygiene such as infrequent hand washing.

Staph is a common bacterium found in the nose, mouth, genitals and anal area of about 25 percent of the population. It becomes a problem when it manages to get inside the body of people with a weak immune system.

Staph is transmitted via person-to-person contact. The highest transmission route is from infected nasal discharge and skin lesions, but 10 percent of infections can be attributed to cross contamination via medical equipment or infected surfaces. MRSA is classified among hard-to-treat “super bugs,” which are resistant to Methicillin, and must be treated with a high concentration of antibiotics such as Vancomycin.

Another bacteria present in every human body, enterococci bacteria, can sometimes cause infection. A common antibiotic use to fight this infection is Vancomycin; however, some enterococci no longer respond to the antibiotic and are thus termed “Vancomycin-resistant” (VRE). VRE was first reported in U.S. hospitals in 1989, and the CDC has determined that one in every three infections in hospital intensive care units can be attributed to VRE.

VRE shares some common denominators with C-diff, and MRSA. At risk for VRE are patients hospitalized for an extended period of time with a weakened immune system, those who have had a recent surgical procedure and patients who have been on a heavy regimen of antibiotics.

VRE is typically spread by direct contact with feces, blood or urine containing VRE, and through indirect hand contact or surface contact. VRE is not spread airborne through coughing or sneezing, nor is it passed with casual contact such as hugging.

Elimination processes
For healthcare BSCs, the prime focus should be on eliminating the sources of disease by adequate surface cleaning, prevention of transmission by using proper barrier substance protection and reducing susceptibility to infection by continuing good hygiene and health.

The first line of defense against the spread of disease is through frequent hand washing. While waterless hand cleaners and antimicrobial soaps are good, extended and overuse of these cleaners may actually decrease the effectiveness of eliminating bacteria. Using soap and friction for 20 to 30 seconds is the best method to clean hands.

The use of barrier substance protection such as latex gloves, the use of gowns if soiling of clothing is likely, and the changing of gloves between patient rooms are also important in preventing the spread of disease, and diligent training of the cleaning staff in this area is imperative.

Evidence-based practices for cleaning show that by reducing the bioload (number of infecting microorganisms on a surface) on high hand contact surfaces, outbreaks of C-diff, MRSA and VRE can be decreased. The highest concentration of bioload that will be encountered by the cleaning staff is found in the patient’s bathroom, light switches, bed rails, on privacy curtains and table surfaces — and these are the areas that staff should focus their infection control efforts on by using proper disinfecting chemicals.

Managers should team with the hospitals’ infection control officer and chemical manufacturer to determine which EPA-registered hospital disinfectant will be most effective against C-diff. A challenge in eliminating C-diff in particular is that the spores do not effectively react to quaternary disinfectants or phenols. They do, however, respond to the use of hypochlorite-based products. Quaternary disinfectants are usually effective with MRSA and VRE.

Most EPA-registered disinfectants suggest a 10-minute dwell time. Otherwise, the disinfectant may not be as effective.

One concern about current disinfecting practices is the use of spray bottles to disperse the chemical to the contaminated surface. Spraying a surface followed by a quick wipe with a paper towel is not sufficient to reduce bioload. Only germs that come in direct contact with disinfectant will be killed, which typically takes four applications of spray on a surface to properly kill microorganisms.

When partnered with disinfectant, microfiber cloths are effective in achieving proper disinfecting using fewer applications.

“At our Madigan Army Hospital in Tacoma, Wash., we have found that the procedure of submersing the microfiber cloth in the disinfectant is ideal for frequent cleaning and total disinfecting of applied area,” says Hugo Galatoire, vice president of operations at Aztec Facility Management in Houston. “The cloths are replaced after every patient room in order to decrease cost-contamination. This method significantly helps reduce the spread of disease and nosocomial infections which are a high priority in today’s healthcare environment.”

This practice allows a sufficient drop in the bioload by a wider coverage of disinfectant on the surface. Added benefits of microfiber products have shown they use a lesser amount of chemicals, and microfiber towels are reusable after laundering with a mild bleach solution.

Finally, BSCs can benchmark their cleaning programs against standards to ensure they are performing proper infection-control measures. The best standards and protocols in healthcare infection control are set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO was designed to be a risk-reduction, patient safety arena, and an effective control program is a partnership between the hospital’s infection control officer and the EVS service provider, with everyone following JCAHO policy standards.

Improving cleaning practices requires multidisciplinary collaboration between the hospital and its BSC. With well-defined cleaning protocols and a good in-service training program, reduction of microorganisms will promote a healthy environment for patients, visitors, cleaning staff and healthcare workers.

Dannette Young Heeth, CEH, NREMT-B, is the director of medical treatment facilities at Aztec Facility Management, Houston.




POSTED ON: 10/1/2006