Abstract
For healthcare facilities, environmental hygiene protocols must accomplish a dual goal: helping prevent the spread of pathogens, while safeguarding the surfaces and equipment involved in the cleaning and disinfecting processes. Through recent product innovations and reformulations, manual surface cleaners and disinfectants on the market today allow healthcare facilities to leverage powerful, fast-acting chemistries to kill pathogens, with fewer compromises on surface compatibility and aesthetics. Striking the balance between disinfectant efficacy and surface compatibility is possible, but requires a holistic view of facility maintenance. Healthcare facilities should carefully consider the various characteristics of cleaners and disinfectants, and the surfaces, materials and equipment on which they are used.
Main Article
Today’s healthcare facilities need disinfecting solutions that can address a wide range of pathogens, from seasonal viruses like those from common colds and the flu, to drug resistant organisms like Clostridium difficile (C. difficile), Vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA).
Unfortunately, the fight against healthcare-associated infections (HAIs) has proven more challenging than originally thought. The reality is that pathogens can linger and spread in healthcare facilities long after patients are discharged (Shaughnessy, 2011) and can be found throughout facilities; not just in patient isolation rooms where they may have originated. A study published in the American Journal of Infection Control found that C. difficile spore cultures are found facility-wide, as 33 percent of non-C. difficile infection (CDI) rooms tested positive for C. difficile (Smith, 2009). Another study published in the New England Journal of Medicine found that genetically diverse sources of C. difficile accounted for 45 percent of CDI cases, suggesting involvement of sources beyond symptomatic patients in the CDI transmission process (Eyre, 2013).
C. difficile can survive on surfaces
for up to five months
Healthcare-associated pathogens can survive on environmental surfaces, equipment and medical devices for extended periods of time. For example, C. difficile can survive on surfaces for up to five months (Gerding, 2008) while MRSA can survive on surfaces for up to seven months (Kramer, 2006). As a result, thorough cleaning and disinfection is critical for effective infection prevention and control protocols, preventing organisms from being picked up and transferred to the next patient.
Many healthcare facilities (particularly those battling high rates of healthcare-associated C. difficile infection) have sought to expand the use of sporicidal disinfectants beyond patient isolation rooms to better address the role of the environment in pathogen transmission and acquisition (Orenstein, 2011). Interest in expanded sporicidal use is also a trend in high-risk areas, from intensive care units to surgical suites and post-operative care areas (Hayden, 2006; Eckstein, 2007; Hacek, 2010). However, one challenge healthcare facilities face because of this is how to balance the potential benefits of expanded and more frequent use of sporicidal disinfectants with the compatibility concerns sometimes associated with powerful disinfectant chemistries.
The rise of this challenge among others, such as time constraints and budget cuts, has spurred numerous new trends within the healthcare industry and in healthcare disinfectants to help healthcare facilities more effectively combat the spread of HAIs. Many new products on the market are formulated as cleaner-disinfectants allowing for one-step cleaning and disinfection. Other technological advancements in disinfectant chemistries have enabled the development of pre-mixed, ready-to-use, shelf-stable solutions that harness the power of fast-acting oxidative chemistries like bleach and hydrogen peroxide. Some newer products have been optimized for broad surface compatibility to permit usage on a variety of surfaces found in the healthcare environment (Donskey, 2017). As made evident, over time, surface disinfectants have evolved to better suit the needs of a changing healthcare environment and balance two of the key priorities for environmental hygiene: efficacy and surface compatibility.
Confronting the Compatibility Challenge
While effective disinfection of healthcare surfaces is essential for reducing the risk of HAIs, appropriate consideration and care must be taken to protect surfaces. The proper care and maintenance of healthcare surfaces and equipment plays an important role in preventing damage, including device malfunctions and/or failures that may negatively impact patient care (ECRI Institute, 2016). It also has important implications for costs, patient satisfaction scores and public perceptions.
Among the most common compatibility issues associated with cleaning or disinfecting products is residue left behind on surfaces after a solution dries. Similar to water, cleaning and disinfecting products have the potential to cause residue if they contain dissolved ingredients such as detergents, stabilizing agents, or soluble active ingredients like sodium hypochlorite or quaternary ammonium salts. These remnants may remain on surfaces in solid form after the liquid components of the solution evaporate. For example, sodium hypochlorite, the active ingredient in most bleach-based products, can sometimes leave a whiteish salt residue behind. Residues can also be streaky or sticky due to ingredients in the formula such as surfactants or detergents – the same ingredients that give many disinfectants cleaning properties. All disinfectants have the potential to leave behind residue on surfaces, however most residues are easy to mitigate. To address residue, in addition to purchasing low-residue formulas, healthcare facilities can use a clean, damp cloth to wipe down surfaces at the end of their regular disinfection routines (i.e., after contact times have been observed). We typically recommend using a water-dampened low-linting cloth such as microfiber or disposable wipers made of synthetic materials, and avoiding using another cleaning product (such as a neutral cleaner) to wipe down surfaces after disinfection, as it may leave additional residue behind. Implementing this practice broadly will help with the residue and any associated visual build up over time.
Corrosion is another common concern in healthcare facilities today. Corrosion can compromise the integrity of surfaces, making them increasingly difficult to clean and disinfect properly. To prevent corrosion, facilities should purchase disinfectants with anti-corrosive properties and ensure that protective coatings present on surfaces are intact. It is also important to ensure that disinfectants are being used appropriately. Inappropriate use (e.g. applying too much product such that excess liquid pools on surfaces during cleaning and disinfecting procedures) may exacerbate corrosion. Best practices for how a product should be used or best practices to prevent corrosion will vary for each product. This may require additional training for proper use.
To mitigate surface compatibility issues without ceding ground in the fight against HAIs, healthcare facilities need disinfecting solutions that have both broad efficacy and broad compatibility. While there is currently no standard test method or requirement for surface compatibility, many manufacturers have done testing to show how their products perform on a variety of surfaces. For example, Clorox Healthcare’s surface compatibility results are here: https://www.cloroxprofessional.com/industry/health/surface-compatibility.
For medical devices and equipment, manufacturers can provide details on which disinfectants can safely be used to clean and disinfect equipment on a regular basis. If a product is not listed in the manufacturer’s Instructions for Use (IFU) or Cleaning and Care Guide, a call to a device or equipment manufacturer can provide an answer.
Putting it All Together
Of course, balancing efficacy and surface compatibility is only part of the challenge. Here are four key characteristics to keep in mind when selecting surface disinfectants for a facility:
- Efficacy: It is important to select U.S. Environmental Protection Agency (EPA)-registered surface disinfectants designed specifically for healthcare facilities. In healthcare settings, the types of pathogens and levels of contamination present on surfaces is often unknown, and the susceptibility of healthcare-associated pathogens to commonly used disinfectants can vary widely. For this reason, it is important to select disinfectants that are EPA-registered to kill a wide range of common healthcare-associated pathogens including bacteria, enveloped and non-enveloped viruses, fungi and difficile spores.
- Compatibility: Look for products that offer broad surface compatibility. By selecting disinfectants that offer both broad efficacy and compatibility, healthcare facilities can minimize the number of disinfectants needed.
- Contact Time & Ease of Use: Healthcare facilities should select ready-to-use, cleaner-disinfectants with short contact times (e.g., 30 seconds to three minutes). Ready-to-use cleaner-disinfectants allow for cleaning and disinfecting in one-step, facilitating faster room turnover and greater compliance. Typically, the easier a product is to use, the greater the likelihood it will be used correctly. Facilities should also select disinfectants with a wet-contact time greater than or equal to kill times listed on their label – if the product evaporates from the surface before the kill time is achieved, it may be less effective.
- Protocols & Training: In addition to selecting the right products, protocols and ongoing education, training and monitoring of everyone that is responsible for cleaning and disinfecting in a facility, from EVS to clinical staff, is important to ensure proper usage. Even the best products won’t work as intended if they are not implemented correctly. The importance of proper cleaning and disinfection needs to be understood and advocated for facility-wide.
Despite the challenges, achieving balance between all of the competing priorities in healthcare today and reducing HAIs is possible. The balance between efficacy against difficult to kill pathogens and surface compatibility can also be reached, but requires a holistic view of facility maintenance and careful consideration of cleaning and disinfecting products as well as the surfaces, materials and equipment on which they are used. With prudent purchasing decisions and consistent, compliant use, healthcare facilities can better protect patients from pathogens and preserve the medical equipment and environmental surfaces that are vital to delivering quality care.
References
Donskey, C.J. (2017). An equally effective but better tolerated formulation of bleach. Open Forum Infectious Diseases, 4(1), S185.
Eckstein, B.C. (2007). Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infectious Diseases, 7, 61.
ECRI Institute (2016). Top 10 Health Technology Hazards for 2017, a report from Health Devices and ECRI Institute. ECRI Institute; Accessed Jul 5, 2018. https://www.ecri.org/Resources/Whitepapers_and_reports/Haz17.pdf.
Eyre, D.W. (2013). Diverse sources of C. difficile infection identified on whole-genome sequencing. New England Journal of Medicine, 369, 1195-1205.
Gerding, D.N. (2008). Measures to control and prevent Clostridium difficile infection. Clinical Infectious Diseases, 46, S43-S49.
Hacek, D.M. (2010). Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile. American Journal of Infection Control, 38, 350-353.
Hayden, M.K. (2006). Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clinical Infectious Diseases, 42, 1552-1560.
Kramer, A. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases, 16(6), 130.
Orenstein, R. (2011). A targeted strategy to wipe out Clostridium difficile. Infection Control and Hospital Epidemiology, 32(11), 1137-1139.
Shaughnessy, M.K. (2011). Evaluation of hospital room assignment and acquisition of Clostridium difficile infection. Infection Control & Hospital Epidemiology, 32(3), 201-206.
Smith, B.A. (2009). The role of environmental services in a collaborative infection prevention model to reduce Clostridium difficile in the greater New York region. American Journal of Infection Control, 37(5), E189-E190.
