Healthcare acquired infections (HAIs) are the third leading cause of death in the US, behind heart disease and cancer. One in every 25 inpatients will acquire an infection while being treated. These infections lead to the loss of tens of thousands of lives and cost billions of dollars every year. Since these infections are largely preventable, the federal government has added significant penalties to facilities with high infection rates. The pressure is on to address this issue now.
The science of surfaces as a fomite (object or material that is likely to carry infection) is just now maturing. Research has shown that microbes can live on “clean and disinfected” surfaces for days, weeks and even months. How is this possible when surfaces are being regularly cleaned and disinfected? The goal of this article is to present seven aspects of surface selection and to gain an understanding of why facilities must set surface criteria to not only minimize financial risk, but also to prevent harm to patients, healthcare workers and the general public.
Surfaces are a complicated subject. Most people think of surfaces as part of the design and construction process and not as part of an infection prevention and control program. When selecting materials, a lot of focus tends to be given to colours and textures that create “a healing environment.” Although these aspects of a surface material are certainly important, there are many other surface properties that are of critical importance, yet are not thought about or given proper evaluation. In order for an environment to be “healing” it need to also not introduce the potential for detrimental effects, like infections. After all, the most soothing colour and texture is of little value to a surface that cannot be cleaned or disinfected properly.
People interact with surfaces throughout the day without a second thought. If hands are washed regularly, a person with a healthy immune system has a good chance of reducing his risk of infection. This is not necessarily true for someone with a compromised immune system.
Ironically, surfaces are often cleaned and disinfected based on visual inspection, even though it is commonly understood that microbes cannot be seen. Research has shown that at the microscopic level, microbe counts can quickly rebound, often times to levels seen prior to cleaning and disinfection. This leaves patients, healthcare workers and the general public at constant risk of acquiring and spreading infection. In fact, studies show that patients are at risk of contracting an infection, such as MRSA or C. Difficilie from the patient who previously occupied the same room at a rate of 35% to 50%, depending on the infection, despite routine and terminal cleaning and disinfection.
Selection of Surfaces:
Currently, the surface evaluation and selection process is predominately based on specific design criteria established before any construction or renovation project. The look, feel and where the surface is located are all based on creating a homelike, healing environment. While this is important, the selection of surfaces is complicated and the evaluation process must go far beyond the way it looks and feels. As I see it, the goal is to evaluate ALL surfaces, taking into consideration seven different aspects that contribute to the spread of infection. Ultimately, it is important that surfaces are capable of being effectively cleaned and disinfected. Unfortunately, the majority of surfaces being used in healthcare today are difficult – if not impossible – to clean effectively.
There is a science around the spread of infection via surfaces. It is not enough to learn every physical characteristic of a given surface and surface material, nor to become an expert in the latest disinfection agents and protocols. This data must be combined with an understanding of microbiology, the physical environment and insight into human behaviour. Taking into consideration all seven of the following aspects and entrenching surface selection criteria within healthcare facility construction and renovation specifications will begin to address the critical role surfaces play in reducing HAIs.
1) Materials and
Healthcare facilities are full of many different surface materials, textiles and products. Necessary products, such as chairs, beds, sheets, privacy curtains, and bedside tables are selected by looking at sample books or swatches of material, in addition to special features any of these products may offer. While these properties are important, they are only the tip of the iceberg, providing only a small glimpse of what is truly needed in any healthcare setting.
Project managers, architects and designers must be aware of textured surface materials, such as brushed stainless steel, pebble texture acrylic wall surfaces, fabrics with tight or open weave, and vinyl and plastic materials. These types of finishes may create additional challenges during the cleaning and disinfection process.
There are many critical questions to be asked and answered regarding each surface material being considered. A few important ones are:
- What will it take to clean this surface?
- Can it be cleaned with the products the facility is currently using?
- Has it been tested to verify hospital grade disinfectants can be used without causing damage?
- How often will it need to be cleaned and disinfected to reduce bio-burden and prevent cross-contamination?
- Will the use of UV light damage cause cracking and damage?
2) Surface Assemblies
Selecting a surface based on sample swatches alone does not provide enough insight into what the potential challenges might be. It is critical that during the evaluation process, the assembly of surfaces is understood. Different materials and textiles are often combined into a single product, making the final product difficult (or even impossible) to clean/disinfect. It is true that some of this is completely unavoidable. However, it is possible to reduce the number of products in a room that present difficult or impossible disinfection challenges.
Studies have shown that the area within three feet of the patient in a hospital room is typically heavy with bio-burden, due to patient shedding (see Microbiology section). Cross-contamination can easily occur if levels of bio-burden are not continually reduced to safe levels by cleaning and disinfection. An evaluation of assembled surfaces surrounding the patient will provide insight into the challenges faced when trying to clean and disinfect the many combinations of materials, textures and textiles. Seams, baton strips and connects between surface materials create additional microbial reservoirs that often can be completely avoided when this problem is understood.
A person typically sheds some 37 million bacteria every hour into the surrounding air and onto environmental surfaces that are continually being touched. Patients are a major source of contamination, and bio-burden is heaviest within three feet of the patient. If the patient is mobile, the patient bathroom is also an area where bio-burden is high. With the knowledge that pathogens survive for days, weeks and months, these areas absolutely need to be able to be effectively cleaned.
Patient shedding is not the only contamination threat. Toilet spray (also referred to as “toilet plume”) plays a major role in the transmission of infectious diseases. Ironically, patient toilets do not typically have lids, due at least in part to the difficulty in cleaning them. After discarding objects laden with viruses and bacteria into a toilet, the toilet is flushed. As a result, these microbes are released into the air and land on surfaces at a relatively high concentration within a three-foot radius of the toilet. This area typically includes a variety of ceramic tiles and many grout lines. Other materials assembled in this area include towels, shower curtains, sinks with faucets. As a result, these surfaces become microbial reservoirs that provide safe harbor where disinfectant products cannot reach their intended target.
The location of a surface matters. Different departments within the hospital require different surface selection criteria. In areas such as the Emergency Department or Surgery, healthcare professionals are faced with the need to turn over rooms quickly. Often this means that healthcare workers with a primary responsibility for patient care must also clean, disinfect and turnover a room.
I have had many discussions with these professionals who do not understand how critical it is to effectively clean/disinfect all surfaces. A quick tour of these areas immediately reveals a plethora of mixed surface materials and, ultimately, microbial reservoirs. The requirement to turn over rooms quickly in high traffic, highly contaminated areas sets healthcare professionals up for failure.
Recently, a facility was confronted with a community-based outbreak of C. Difficle that had started in the ER and was spreading through the facility. The Infection Prevention staff sent out a protocol that covered personal protective equipment (PPE), hand hygiene, patient assessments and disinfection protocols, but failed to address the evaluation of surfaces and the manner in which they are cleaned. These surfaces may have been a major contributor to persistence of the outbreak.
5) Human Behaviour
Patients, healthcare workers and visitors interact with surfaces in many ways. Clothing, equipment and hands become contaminated and move pathogens throughout the patient room and the entire facility.
While being an advocate for a patient during a 3-day acute care hospital stay, I took the opportunity to observe and document human behaviour around surfaces. The behaviour of healthcare workers was fairly common. “Pumping in” by using the hand sanitizer was routine and a good start. However, the very next action was, nearly universally, to reach into a pocket in their scrubs to retrieve a pen and paper. I am sure this happened in every patient room.
Most healthcare workers interacted with surfaces in similar ways and in usually in the same order: computer, mouse, nurse call button, controls on the IV and IV pole, catheter bag, bed, bedding, etc.
Visitors interacted with many of the same surfaces, but they also used areas, such as the windowsill, bed and chair next to the patient bed, which was often covered with a blanket for the patient to sit on. Visitors also used the patient bathroom.
From my observations, specific surfaces that should have been considered “high touch” were not easy to identify, since many people touched virtually every surface within three feet of the patient frequently. On a side note, it is interesting to note that my observation of Environment Services staff in that facility revealed that they cleaned only a few surfaces and ignored other highly touched surfaces during the daily cleaning process. In the absence of thorough cleaning and disinfection, bioburden would have continued to accumulate for days.
6) Cleaning and Disinfection
This is an aspect that is obviously critical, but is often misunderstood. Everyone knows it is important to clean and disinfect everything. However, can each surface be cleaned and disinfected effectively in the timeframe set for completing that task? The typical response a manufacturer would give is “yes, you can use anything to clean all surfaces.” Clearly, this is not the case. Not all surfaces of a bed, for instance, can be effectively cleaned and disinfected the same way. Further questioning often begins to reveal a lack of understanding of infection prevention protocol and cleaning and disinfection products that are being used at different times and in different situations.
Surface manufacturers don’t know what they don’t know, particularly when it comes to infection control strategies, processes and products. The recent issue faced by manufactures of ERCP scopes has sent some back to find ways to effectively sterilize their products.
Many different cleaning products are used, some of which can cause serious damage to surfaces. Often, this damage is unseen and creates a microbial reservoir that harbors pathogens that can proliferate, untouched by disinfection products.
7) Manufacturer Warnings
Finally, it is extremely important to request and understand manufacturer warnings. Surface materials often come with warnings about using cleaning and disinfection products commonly used in healthcare facilities. Unfortunately, this information is often not documented properly and the knowledge is not passed down to those in charge of cleaning staff. Even with this information, it is important to test surface materials as an assembly, not just the individual components. Testing individual materials will give one result but combined materials cleaned and disinfected can produce an entirely different result. Equipment may include many different surfaces that cannot be cleaned and disinfected the same way. If they are damage could occur, thereby opening areas for microbes to harbor and hide from biocides.
It is not unusual to find that a manufacturer has tested specific chemicals on their product, but has not tested disinfection products. Results can vary when an actual disinfectant product is tested, since it may be composed of multiple active and inactive chemicals. Even if your cleaning products are not called out in manufacturer warnings, make sure to confirm that they are safe to use for each product and surface.
Clearly, environmental surfaces play a critical role in the transmission of HAIs. By being aware of the seven aspects presented here, my hope is to provide a clear understanding of why facilities must set surface criteria to minimize risk and prevent harm to patients, healthcare workers and the general public. By using the seven aspects to create surface selection criteria, facilities will lay the foundation for sustainable reductions in the number of HAIs.
Over 60 surfaces
Curtis J. Donskey MDa, b. (n.d.). Does improving surface cleaning and disinfection reduce health care-associated infections? http://www.ajicjournal.org/article/S0196-6553(13)00055-2/pdf.
David J. Weber, M. W.-B. (n.d.). Role of hospital surfaces in the transmission of emerging health care-associated pathogens: Norovirus, Clostrimdium difficile, and Acinetobacter species. http://www..ajicjournal.org/article/S0196-6553(10)00408-6/abstract.
J.A. Otter a, b. K. (n.d.). Surface-attached cells, biofilms and biocide susceptibility: implications for hospital cleaning and disinfection. http://www.processcleaningsolutions.com/pdf/Surface attached cells biofilms.pdf.
Jonathon Sexton, P. R. (n.d.). Rapid Microbial Tracer Movement to Soft Surfaces Throughout Patient Care Areas and the Role of Mixed Surfaces in Infection Prevention. AJIC Journal, http://www.ajicjournal.org/article/S0196-6553(15)00275-8/abstract.
Vickery K, D. A. (n.d.). Presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit. http://www.ncbi.nlm.nih.gov/pubmed/21899921.