Wiping Out Germs: Tips for Cleaning and DisinfectingEnvironmental Surfaces

By Mark Fuglsang

Environmental services and other healthcare professionals can look for guidance on environmental surface cleaning and disinfecting in the “Guidelines for Environmental Infection Control in Healthcare Facilities,” which are recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines note that continued compliance with environmental infection control measures (including environmental surface cleaning and disinfecting) will decrease the risk of healthcare- associated infections among patients. A copy of the guidelines can be downloaded at www.cdc.gov/ncidod/hip/enviro/guide.htm for more detailed information on the suggestions contained in this article.

Based on recommendations found in the CDC guidelines and industry best practices, the following are suggested protocols for cleaning and disinfecting environmental surfaces. Keep in mind that cleaning is the necessary first step of any sterilization or disinfection process and is needed to render the environmental surface safe to handle or use by removing organic matter, salts, and visible soils — all of which interfere with microbial inactivation. In fact, the physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces.

The CDC guidelines divide environmental surfaces into two parts: medical equipment surfaces such as knobs or handles on machines, carts and similar equipment, and housekeeping surfaces such as floors, walls and tabletops. Housekeeping surfaces can be further divided into those with minimal hand contact (referred to as “low-touch” surfaces) and those with frequent hand contact (“hightouch” surfaces).

The number and types of microorganisms present on environmental surfaces are influenced by the number of people in the environment, amount of activity, amount of moisture (microorganisms are present in great numbers in moist organic environments, but some can also persist under dry conditions), presence of material capable of supporting microbial growth, rate at which organisms suspended in air are removed, and the type of surface and orientation (i.e., horizontal or vertical).

In the absence of manufacturers’ instructions, non-critical medical equipment such as stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls usually only require cleansing followed by low- to intermediate-level disinfection.

Most, if not all, housekeeping surfaces require regular cleaning with soap and water or a detergent/disinfectant and removal of soil and dust, according to the CDC Guidelines. High-touch housekeeping surfaces in patient-care areas, such as doorknobs, bedrails, light switches, wall areas around the toilet, and the edges of privacy curtains, should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Horizontal surfaces with infrequent hand contact, such as window sills and hard-surface flooring in routine patient-care areas, require cleaning on a regular basis, when soiling or spills occur and when a patient is discharged from the facility.

Typically, the main criteria for selecting a registered cleaning agent are cost, safety, product-surface compatibility and acceptability by housekeepers. Consider forming a cleaning products selection committee made up of representatives from environmental services, chemical and radiation safety, infection control, purchasing and campus safety. Such a committee may find, for example, that high-impact cleaning agents are seen as too dangerous or toxic for general use and should be replaced with a less toxic agent. Talk with chemical suppliers to supply product data sheets or labels for evaluation criteria such as dilution ratios, minimum exposure time to kill and stability of dilution. The Association for Professionals in Infection Control and Epidemiology (APIC)’s “Guidelines for Selection and Use of Disinfectants” is another good resource.

According to the CDC guidelines, environmental surface germicides (intermediate and low-level disinfectants) should specify (via labels, technical data and/or product literature) indications for product use and provide claims for the range of antimicrobial activity, per Environmental Protection Agency (EPA) regulations. Make sure the cleaning product chosen has been registered with the EPA and has a registration number on the label.

Always refer to manufacturers’ instructions for appropriate use sites, dilutions and application methods. Also note that the CDC guidelines recommend against using high-level disinfectants/liquid chemical sterilants for disinfection of any environmental surface as such use is counter to label instructions for these toxic chemicals. In addition, alcohol should not be used to disinfect large environmental surfaces.

Chemical hazard and toxicity ratings can typically be found on the materials safety data sheets (MSDS) for the product. Refer to manufacturers’ instructions and MSDS to determine appropriate precautions and personal protective equipment (PPE) needed during cleaning and housekeeping procedures. Standard precautions should be followed, including wearing gloves, during the cleaning and decontamination of blood, body fluids and other infectious materials. Other PPE in these situations may include the use of respiratory protection.

To protect patients and others, the CDC guidelines caution against performing disinfectant fogging in patient-care areas and against large-surface cleaning methods that produce mists or aerosols or disperse dust in patient care areas. In addition to air-quality issues related to aerosolized cleaners, it’s important to remember that everything that becomes airborne will sooner or later settle on patients, surfaces and equipment, where it may create a contamination or slip-and-fall hazard.

According to the CDC guidelines, part of the cleaning strategy should be to minimize contamination of cleaning solution and cleaning tools. Bucket solutions become contaminated almost immediately during cleaning, and continued use of the solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned. Another source of contamination in the cleaning process is the cleaning cloth, especially if left soaking in dirty cleaning solution. Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the degree of bacterial contamination.

Another potential solution to this problem can be found in disposable cleaning wipers. The main advantage of using disposable cleaning wipers is that they are designed to be used, then tossed when dirty, eliminating problems associated with the re-use of dirty rags and with storing dirty rags in contaminated cleaning solution. In addition, disinfectants such as bleach maintain effective concentration longer when used with disposable cleaning wipers designed to be compatible with bleach than with common cotton rags.

Some disposable cleaning wipers are available in an enclosed-bucket system to help eliminate cross-contamination, reduce exposure to chemical vapors and splashes and combine all cleaning steps into one by eliminating the combination of spray bottle plus rag. With these systems, users can add the cleaning or disinfecting chemical (and solution ratio) of their choice to saturate the wipers, thus allowing the user to more closely control chemical usage and related costs.

The CDC guidelines offer special cleaning advice for areas with immuno-compromised patients and in situations where blood and body fluids are found. For example, when dusting in immuno-compromised patient areas, cleaners are cautioned to wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an EPA-registered hospital detergent/disinfectant, as allowed by the labeling.

Managing spills of blood, body fluids or other infectious materials in clinical, public health and research laboratories requires more stringent measures according to the CDC guidelines because of a) the higher potential risk of disease transmission associated with large volumes of blood and body fluids and b) high numbers of microorganisms associated with diagnostic cultures.

In patient-care areas, workers can manage small spills with cleaning and then disinfecting, using an EPA-registered disinfectant according to its labeling. For spills containing large amounts of blood or other body substances, workers should first remove visible organic matter with absorbent material such as paper towels (be sure to discard in properly labeled leak-proof containment) and then clean and decontaminate the area.

According to the CDC guidelines, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunosuppressive virus (HIV) have never been known to be transmitted from an environmental surface such as floors, walls or countertops. However, prompt removal and surface disinfection of an area contaminated by either blood or body substances is a sound infection-control practice and an OSHA requirement, according to the CDC guidelines.

Severe Acute Respiratory Syndrome (SARS) also prompted special consideration by the CDC, which issued infection control guidance in response to SARS in January 2004. (See www.cdc.gov/ncidod/sars/guidance/I/healthcare.htm#3d10 for more information.) However, the guidance suggests following the same environmental cleaning and disinfection principles generally used in healthcare settings, with cleaning and disinfection recommended at least daily for SARS patient rooms, and more often when visible soiling/contamination occurs.

Cleaning and disinfecting environmental surfaces may be a routine task, but it should not be taken lightly. Adhering to the CDC guidelines and careful evaluation of cleaning chemicals and tools will help to achieve a cleaner and safer facility.

Healthcare-Acquired Infections: Breaking the Chain of Infection

By Becki Jenkins, CST, CRCST, FEL, with Dan Borden, RCST and Andrea Webb, RCST. Researched by Lakisha Bragg, RCST, and Pamela Stigger, RCST

Before the number of healthcare-acquired infections (HAIs) can be reduced, it is imperative to understand the chain of infection. The Centers for Disease Control and Prevention (CDC) estimated that more than 2 million patients in the United States develop HAIs each year, and that about 90,000 patients die as a result of these infections. These estimates are based on information reported from more than 300 hospitals participating in the National Nosocomial Infection Surveillance (NNIS) System. Patient deaths resulting from HAIs are believed to be seriously under-reported.1 In addition, there is no data available on HAIs that develop after the patient leaves the hospital.

The 2004 National Patient Safety Goals issued by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) addressed infections requirements as follows:

“7.) Reduce the risk of healthcare-acquired infections
a. Comply with current CDC hand hygiene guidelines.
b. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.”

While no one would argue the importance of hand hygiene in reducing healthcare-acquired infections, it certainly is not the only solution. There are other modes of transmission or pathways that present a greater challenge to reducing HAIs.

The wide variety of opportunities for acquisition of pathogens requires general healthcare standards to be strictly followed to protect all patients. At the same time, each risk group or procedure may require specific controls in removing certain sources of infection. Some general procedures include items such as:

• Supply of adequately sterilized instruments and dressings
• Operating theater design, discipline and procedures
• General application of aseptic technique
• Good environment cleaning, safe food, effective laundry procedures and waste disposal

The infectious disease process can best be illustrated by the “chain of infection.” Each of these links must be intact for the spread of an infectious disease. Remove or break one link in the chain of infection and the spread of infectious disease cannot occur.2 Understanding the six links in the chain of infection is the first step toward reducing HAIs.

The first link in the chain is infectious agents. These include bacteria, viruses, fungi, parasites and prions. The more common causes of infection include but are not limited to:

• Methicillin-resistant Staphylococcus aureus (MRSA)
• Vancomycin-resistant enterococcus (VRE)
• Human Immunodeficiency virus (HIV)
• Hepatitis B virus (HBV)
• Pseudomonas aeruginosa
• CJD prion

Preventing the spread of infectious agents requires the early identification of the infectious agent, prompt isolation of the patient, and initiation of appropriate treatment. Routine use of standard precautions for patients suspected of being infectious will reduce the risk of transmission even before a definitive diagnosis can be made.

The second link in the chain is the reservoir. These reservoirs might be a patient, healthcare worker, healthcare equipment, instruments, beds, linens, or anywhere an infectious agent can survive. The use of appropriate housecleaning measures, cleaning, disinfection and sterilization of hospital equipment along with good personal hygiene can eliminate reservoirs and break the chain.

The third link is the portal of exit. The disease-causing microbe must have a means to leave the reservoir. Humans are the most common reservoir and have many portals of exit. Secretions, excretions or droplets can carry microbes that find their way through these portals of exit. Control of these secretions, excretions or droplets, use of protective attire and equipment, and proper trash and waste removal are other ways to break the chain.

The fourth link in the chain is mode of transmission. Once the microbe leaves the reservoir, it needs a pathway to the portal of entry. Transmission may be by direct contact, indirect contact or through airborne transmission.

The most common mode of transmission is direct contact. This is a person-to-person transmission through touching. This also is the reason the CDC issued a revised guideline on hand hygiene. Direct contact can also be the result of coming into contact with droplets from sneezing and coughing.

Indirect contact includes both vehicle-borne and vector-borne contact. A vehicle is an inanimate object that serves as a means to transmit infection. Common vehicles that transmit infection are surgical instruments, patient equipment, soiled laundry, beds, linens, and surfaces such as door knobs or handles. Other vehicles may include food, blood and water. There has been much emphasis on following the correct procedures/guidelines for disinfection and sterilization of surgical instruments; however, other vehicles indirectly transmitting infection have received little attention until recently.² Appropriate housekeeping and sanitation practices as well as waste management and laundry management are essential in reducing the spread of infection.

Vectorborne contact is the transmission by an animal, insect or parasite. Transmission takes place when the vector injects saliva fluid by biting the host, or deposits feces or eggs in a break in the skin. Vectorborne infection rarely occurs in the hospital setting in the United States.

Airborne transmission occurs when “droplet nuclei” or dust remain suspended in the air long enough to be transmitted to the respiratory tract of a susceptible host. These droplets may be carried throughout a building by the ventilation system. Proper airflow control and filtration would control much of the airborne transmission as long as the airflow system is properly maintained. Smallpox and mycobacterium tuberculosis are examples of bacteria spread by airborne transmission.

The fifth link in the chain is portals of entry. Infectious agents enter a susceptible host through various portals of entry, such as the respiratory tract, genitourinary tract and gastrointestinal tract and mucous membranes The skin usually serves as a barrier to infection, unless there is a break in the skin, accidentally or intentionally as with a surgical incision or use of an invasive device. Following aseptic technique, proper wound care, catheter care and hand hygiene are some of the ways to break the chain.

The sixth and final link in the chain of infection is the susceptible host. This is someone who lacks the ability to resist an infectious agent, an immune-compromised person. Several characteristics affect the susceptibility of a host and the severity of the disease. These include:²

• Age: the very young or elderly
• Sex: certain reproductive diseases are sex specific
• Ethnicity: for example, sickle cell disease in African-Americans and Tay-Sachs disease among Jewish persons of European descent
• Disease history/underlying disease: for example, cancer, diabetes, and heart disease
• Nutritional status: inadequate nutrition
• Compromised immune status: this includes patients undergoing chemotherapy or radiation therapy, those taking steroids and patients with other infectious diseases such as HIV
• Trauma: injury itself and the measures used to treat the injury increase the risk of infection and surgical procedures where invasive incisions or therapeutic devices are applied.

Recognizing high-risk patients and taking measures to alter the host’s susceptibility including treatment for the primary disease, administering vaccines or antibiotics at the time of the surgery are ways to break the chain.

As a result of the sentinel events arising from infection, healthcare organizations implemented various risk reduction strategies.

These include:³

• Revising orientation and training processes and competency assessments including requiring certification of all central service personnel
• Revising equipment cleaning processes
• Revising handwashing procedure
• Switching to the use of single-use IV flush vials
• Adding a waterless hand scrub
• Defining supervisory expectations
• Revising critical care privileging and ICU admission criteria
• Conducting in-service and team training
• Instituting tracking systems

These are sound strategies to reduce the risk of infection, but in order to be effective, healthcare organizations must provide adequate training and methods to ensure their effectiveness.

It is estimated that approximately one-third of HAIs could be prevented using current universally accepted recommendations.⁴ If one-third of these infections could be prevented by following current universally accepted recommendations, why are they not part of hospital procedures? And, if they are part of the procedures, why are they not being followed?

Recently, the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC released a draft document, “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting 2004: Recommendations of the Healthcare Infection Control Practices Advisory Committee.” The document is intended for use by infection control staff and personnel responsible for implementing and evaluating infection control programs for healthcare. On the topic of education, the document’s authors write, “Education of the principles and practices for preventing transmission of infectious agents during healthcare begins ideally during the training in the health professions and is provided to anyone who has an opportunity for contact with patients or medical equipment.” They add, “Periodic assessment of healthcare workers’ knowledge and adherence to recommended practices with feedback is another important component of all educational programs. Patient and family members can be partners in preventing transmission of infections in healthcare setting.” For more information on this guideline, go to: http://www.cdc.gov/ncidod/hip/ISOLAT/2004DraftIsoGuideline.pdf  

There have been many recommendations for reducing HAIs. One common recommendation is education. Since most healthcare organizations work with reduced budgets, training is often the first thing that gets put on the back burner. Healthcare administrators must look for alternative resources for training dollars. Some states have state funded training programs to help offset training costs. In-house training might also be an option. What about insurance companies? Wouldn’t it be in their best interest to help support the healthcare industry by funding some of this training? After all, if infection can be reduced through proper training, wouldn’t this reduce the hospitals stays for patients and in turn save the insurance companies millions, perhaps billion of dollars in claims?

1. Sentinel Event Alert. Issue 28, Jan. 22, 2003.

2. Central Service Technician Manual, Sixth Edition.

3. Jenkins B. Bioburden: Eradicating the Hidden Vectors. Infection Control Today.

4. Central Service Technician Manual, Sixth Edition.

5. Sentinel Event Alert. Issue 28, Jan. 22, 2003.

6. Harbath S, Sax H, Gastemeier P. The preventable portion of nosocomial infections: an overview of published reports. J Hosp Infect. 54:258-256, August 2003.