Abstract:
Main Article:
In our world today, but especially in healthcare, there are few if any, tenets as impervious to overstatement as the importance of cleanliness. A facility might appear to be ‘clean’ and not be safe and disinfected. However, IF the facility is safe and disinfected, it is clean, too.
Improving sanitation (safe, clean and disinfected) and infection prevention can seem to be an expensive proposition, but for hospitals there’s nothing as unaffordable as ‘bad medicine.’ We’re not talking about dollars only. The cost of pain, suffering and death from healthcare acquired conditions has to be considered along with a damaged reputation in the community.
Gus Iverson writes, “Our ancestors in Mesopotamia were washing wounds with alcohol 4,000 years ago, but the real gravity of sanitation didn’t start to resonate until about 150 years ago, when the work of Louis Pasteur led surgeons towards new concepts like wearing gloves and disinfecting their instruments. Today, the mission is clear: to practice medicine in the cleanest environment possible.” Or, as Hippocrates quipped, “FIRST, DO NO HARM.”
Webster defines CLEAN (as an adjective)- free of soil, pollution and other undesirable materials. As a verb- make clean, remove dirt, marks or stains.
In recent years, there has been much discussion and debate surrounding the terms “environmental cleaning” and “environmental disinfection”; to many epidemiologists and microbiologists the terms seem to be interchangeable. “Clean hands” seem to have one definition while “clean environmental surfaces” seem to have different criteria.
Hands can be made clean and safe with potable water, soap, time, proper friction, rinsing with potable water and thorough drying. But, environmental surfaces are rendered “disinfected” by merely wiping the “proper” disinfectant on the hard non-porous surface and allowing the proper contact time (which may take re-wetting the surface six times to attain a 10-minute contact time).
I believe the goal of cleaning hands and environmental surfaces ought to be to break the chain of infection from hosts, to persons or commonly touched surfaces (fomites) and to other humans. Or, as I like to say, returning the commonly touched surface to its “fit for purpose” condition.
In order to make an environmental surface (especially, a frequently touched surface) fit for purpose, I believe the term “processing” should be adopted. Whether addressing the epidemiologist, microbiologist or the front-line Housekeeper, we all understand that environmental surfaces must be processed.
Processing
Definition of “PROCESSING” –includes cleaning and disinfecting an item or area using a clean micro-denier cloth or flat mop, and an appropriate and facility-approved, EPA-registered disinfectant. We don’t clean operating rooms, we process them. We don’t clean a patient’s room, the Housekeeper processes the room.
This isn’t a matter of semantics but a realization that a new, more descriptive term must be adopted, understood and communicated to the person who must deliver a safe, clean and disinfected item or area (i.e., the Housekeeper or Cleaning Professional). The Housekeeper’s role must be a part of a multi-modal approach to infection prevention whether she works in a hospital, ambulatory surgery center, long-term care facility, office building, fitness center or an elementary school.
Cleaning
Cleaning is not the same as disinfecting or sanitizing. Cleaning may and should occur before disinfecting or sanitizing surfaces. Cleaning is the removal of all foreign material from objects by using water and detergents, soaps, enzymes and the mechanical action of washing or scrubbing the object. Disinfection/sterilization cannot be accomplished if soil removal is inadequate. Witness the recent news about “dirty” duodenoscopes causing the death of 100 patients in the U.S. (http://www.usatoday.com/story/news/2015/01/21/bacteria-deadly-endoscope-contamination/22119329/)
If 98% of the micro-soil can be removed from an environmental surface with a clean micro-denier cloth and clean potable water, then it doesn’t matter what disinfectant you choose. If microbial pathogens are collected from a hard, non-porous surface, held in the micro-denier cloth and NOT released until laundered, then we change the conversation.
We need to stop looking at the wiping material, be it cotton or man-made fiber, as a cleaning cloth. Instead, it is merely a delivery system for the disinfectant. If the wiping material is binding the active ingredients in the disinfectant, does it matter whether or not the contact time (or dwell time) is observed? If the soil load on a surface is greater than the 5% mandated by EPA’s disinfectant registering protocols, is the efficacy of the disinfectant diminished?
Instead, we should be choosing the best, micro-denier wiper available to do a superior job of soil removal. The guiding principle is always to remove germs if possible rather than kill them, and then, when necessary use the least amount of the mildest chemical or disinfectant that will do the job; because stronger often means more toxic to humans.
In closing, simple cleaning of the environmental surfaces may be one of our key defenses in the future battle against infectious disease. With antibiotic-resistant organisms proliferating on surfaces for up to 56 or more days, the study of cleaning and measuring cleanliness is becoming all important.
Ken Nolan
[…] Here at OSHA Review, Inc, we have always advocated the importance of cleaning surfaces as a first step before disinfecting them. A recent article by infection prevention expert Darrel Hicks goes even further to describe cleaning and disinfection as “a process”, explaining that “disinfection/sterilization cannot be accomplished if soil removal is inadequate.” The article provides a good explanation why effective cleaning is the most important step in the process. To read the entire article, please click here. […]
Excellent points raised by Darrel regarding the often, overlooked importance of the “applicator” we’re using to apply our Cleaners and Disinfectants.
However, I pose the following question to you…. Could your reusable cleaning/disinfection cloths be contributing to HAI’s?
Scour the Internet and you’ll find studies to support whichever position favors your opinion! Welcome to the world of healthcare infections!
Even if your in-house or outsourced laundry fully ascribes to all 69 pages of Healthcare Standard ANSI/AAMI ST65:2000 – “Processing of Reusable Surgical Textiles for Use in Healthcare Facilities”, can you, without a doubt, state that the workers on the front line of the laundry operation are 100% compliant with everything in the Standard?
Healthcare facilities notoriously struggle with Hand Washing and Environmental Cleaning & Disinfection protocol compliance everyday. I can assure you the Laundry, whether in-house or outsourced is no different! You can have the best systems & procedures in place, but unless there are stringent monitoring controls in place to ensure compliance to the Standard, chances are, short cuts are being taken. It’s human nature!
The study linked below found that 93% of reusable, reprocessed cloths have been found to be contaminated – http://laundry.infectioncontroltoday.com/news/2014/10/microbial-contamination-of-hospital-reusable-cleaning-towels-and-laundering-practices.aspx
Studies have also revealed that 56% of reusable textiles used in healthcare had significant defects that could seriously compromise their performance, which could cause infection.
The only way to know for sure is to conduct microbial testing on the laundered cloths. The international organization that sets the standards and certifies textile laundering operations, only requires quarterly microbial testing. Four times yearly, two textile items are submitted by plant personnel to an approved laboratory for bacteriological testing. Samples are selected on a rotating basis, with a goal of testing twenty-eight (28) different textile items as least once in the first three-year period. So if reusable cleaning/disinfection cloths are selected during the first quarter of year one, it could conceivably be three years before they’re required to submit samples of the cloths again! A lot of infections can happen in a three-year period!
The laundering of reusable MicroFiber cloths is even more critical because the heat of the drying process, if too high, can effectively melt the microscopic pores of the cloth together and negate the Trap & Removal properties of the cloths. Even though the cloth may appear visually normal, once the pores of the cloth are closed, the cloth is really nothing more than an applicator of liquid over a surface. You are not removing the biofilm, which becomes a food source for new pathogens to adhere and begin to multiply.
“But we’re not using reusable cloths in our facility. We’re using ready-to-use disposable cloths, so we don’t have the risks associated with laundered cloths, right?” True, the risk associated with reusable cloths is eliminated, but there are also risks associated with commercially available ready-to-use wipes.
The wipe/cloth substrate used by manufacturer’s of RTU Disinfecting wipes main purpose is to achieve an EPA registered “Contact” Kill Time and not the “Trap & Removal” of pathogens from the surface? RTU Disinfecting Wipes do not employ the use of MicroFiber technology!
A recent study conducted by a team of researchers from Cardiff University School of Pharmacy revealed that clinical detergent wet wipes spread hospital superbugs.
Seven commercially available wet wipes were tested on the most common hospital infections, including MRSA and C.difficile.
In “every instance”, the wipes actually spread potentially deadly infections from one surface to another, researchers said.
The findings of the study can be found here:
http://www.cardiff.ac.uk/news/view/110032-wiping-out-superbugs
One can interpret through this study, that the failure to stop the spread of superbugs by the seven commercially available ready-to-use wet wipes tested, is not necessarily the failure of the liquid disinfectant used to saturate the wipe, but the failure of the ability of the wipe substrate itself, to lift, trap, and remove the invisible pathogens from the surface. I am sure there are those who will find studies to contradict the findings of this study!
“So, if what you’re saying is true, what’s the solution?”
If you continue to struggle to bring C.diff rates down, or perhaps you’ve made some progress, but have hit a plateau, wouldn’t it make sense to try something different, rather than continue to repeat the same process over and over again expecting a different result?
I have a suggestion for you to consider, and it doesn’t involve a change in your current chemicals. It involves the applicator you’re using to apply the chemicals.
It is well established that nonwoven, true MicroFiber cloths outperform woven textile cloths, when it comes to trapping and removing harmful pathogens embedded in surface biofilm. I emphasize true because not all microfiber cloths are created equally! There are many different grades, which contributes to the user’s false sense of security.
Even more impressive is the finding that Disposable/Single-Use nonwoven textiles reduced infection by 2.5 times compared to Reusable woven textiles. http://www.ncbi.nlm.nih.gov/pubmed/3813865
What if you were to combine the superior Trap & Remove capabilities of true microfiber and the superior performance of a Disposable/Single-Use applicator?
What if this Disposable/Single-Use true microfiber cloth also demonstrated, through independent third-party testing labs, to Trap & Remove greater than 99.99% (that’s >4Log) of surface pathogens, including C.diff spores, using just water alone? Just imagine how this could “boost” the performance of the cleaners and disinfectants you’re currently using! And what if I told you this cloth can be delivered at a fraction of the cost of inferior single-use microfiber cloths currently available in the market? Would you be skeptical? Would you be curious? Would you say….I’ve got to see it to believe it?
Ongoing research points to such a disposable microfiber technology and it’s called the Xcel Micro-Dynamic Disposable/Single-Use MicroFiber Cloth! I invite you to learn more about the Xcel Micro-Dynamic Disposable/Single-Use MicroFiber Cloths by visiting: http://www.dghaglobal.com/micro-dynamic-clean-xcel-microfiber.html and click on the pdf Xcel MicroFiber Presentation link on the page!
And then after review, consider this: would integrating Xcel Micro-Dynamic MicroFiber Cloths into your standard cleaning and disinfection protocols become one of the most important tools in your arsenal to combat HAI’s?! I’m not talking about adding more toxic chemicals into your environment, I’m talking about reducing the amount of chemicals introduced into the environment and relying more heavily on the “applicator”…the Cloth…to do its job of cutting through years of cleaner and disinfectant buildup that is actually compromising the effectiveness of your disinfectant, and must be removed for the disinfectant to work as intended.
When all costs associated with reprocessing reusable cloths are taken into account, you will find that Xcel Disposable MicroFiber Cloths are actually less expensive to use. Especially when you take into account that Disposable/Single-Use nonwoven textiles have been shown to reduce infections by 2.5X, as indicated by the 29 year-old study referenced above. Multiple sources, both in-house as well as out-sourced laundering facilities, all report that the all-in cost of reprocessing a single reusable cloth is, on average, $0.08 for every cycle. Add that to the per use cost of a reusable cloth, and you’ll quickly find that the cloth you paid $3.00 to $7.00 for, is actually costing you well in excess of $11.00 to $15.00 over the life span of 100 reprocessings! And that’s assuming strict reprocessing protocols have been followed and audited after each cycle to validate and guarantee that the cloths are sterile before they’re placed back into service. If a large percentage of your reusable cloths are found to contain contaminants, like the study reported above, even after the reprocessing cycle, is that potentially contributing to your infection rates?
Thank you for your interest in this topic, and I welcome your comments and feedback on what I have presented here today!