For more than 20 years, healthcare has seen many iterations to the ‘recommendations’ on how to conduct cleaning and disinfecting processes. We started with just environmental surfaces, moved to noncritical environmental surfaces, then to high touch surfaces, next was Targeted Moments of Environmental Disinfection and today is Enhanced cleaning. Let’s take a moment to review the importance for cleaning, sanitizing, and disinfecting during a pandemic.
BIOFILMS
Cleaning and Disinfecting must start with an understanding of Biofilms and Biofilm formation. Some pathogens are hardy organisms which display the ability to survive on inanimate objects (fomites) for extended periods of time (i.e., MRSA – days, Covid-19 – hours, C-diff – days)1. To prevent the formation of biofilms, the CDC has always recommended a two-step process of cleaning first and then disinfecting. Throughout the years, this recommendation has been modified to allow for cleaning and disinfecting to occur simultaneously if the disinfectant product of choice has a ‘cleaning agent’ incorporated into its formula. Many professional agencies (APIC, AORN) recommend that thorough assessments be conducted by a multi-disciplinary team to ensure that both steps (cleaning and disinfecting) are being achieved through product selection, staff education and implemented processes.
CROSS CONTAMINATION
Regulatory and accrediting agencies are highly focused on cross-contamination these days and rightly so. Cross contamination can occur anywhere from any source. All that is needed for an organism to cause an infection in a patient is a mode of travel and a susceptible host. Cleaning and disinfecting processes for environmental surfaces have changed in the past couple of years and may not be utilized throughout all areas of the healthcare facility.
As a 
former surgical technologist, I was partly responsible for cleaning and maintaining the surgical environment. This included opening the surgical room for the day, conducting in-between turnover, end of the day cleaning and terminal cleanings. Our process at the time was to start with the surgical bed, considered the dirtiest item in the room, and then work our way out of the room. That practice was recommended and followed by healthcare organizations for many years. Recently, AORN and other professional associations made a major change to this practice. The change was to prevent cross-contamination from occurring by transferring pathogens from dirty locations to clean locations within a given space. Instead of cleaning dirty to clean, the new recommendation is to work top down, clean to dirty. Staff who are performing the cleaning/disinfecting task are to use one cloth or wipe and start at the top of equipment and wipe downward to the bottom and then dispose of the cloth or wipe. Then acquire another cloth or wipe and clean the next piece of equipment in an established pattern working around the room until all clean items have been touched, then begin inward toward dirty items. This methodical process is designed to reduce the chance for cross contamination if the process is strictly adhered to. The challenge in healthcare organizations today is that this cleaning and disinfecting practice is not followed throughout the entire organization. This practice is often isolated to surgical procedure areas – but why? This is the reason for the new recommendations of ‘enhanced cleaning’.
ENHANCED CLEANING
This practice recommendation has not been well defined yet but remains the current recommendation for Covid-19. Enhanced cleaning indicates that high touch surfaces be frequently cleaned and disinfected but there is no direction provided on how to truly integrate this practice into daily routines. Does enhanced cleaning mean increasing the frequency or does it mean to clean and disinfect better? The last recommendation that was published by any organization was the Targeted Moments of Environmental Disinfection (TMED) by Diversey. TMED showed, for example, that a patients side bed rail was touched up to 250 times per day – yet only cleaned once per day. The authors then went on to show that other high touch surfaces were contaminated, including the floor, yet only cleaned a few times per day.
The consideration healthcare organizations have to account for is this: does enhanced cleaning mean that cleaning and disinfecting occurs more frequently throughout the day or does it mean that more surfaces are cleaned and disinfected more thoroughly on a more frequent basis? Healthcare organizations need to identify and define how surfaces are to be cleaned, sanitized, and disinfected, as well as how often this is to occur and detail out the methodical approach (pattern) to be used to prevent cross-contamination.
Join us next month for Part II: Environmental Cleaning, Sanitizing and Disinfecting during Covid-19 and learn more about the team process, selection of products and managing in the world of micro-organisms.
References
1) How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
Axel Kramer; PubMed 2006: https://pubmed.ncbi.nlm.nih.gov/16914034/
2) Guideline for Disinfection and Sterilization in Healthcare Facilities (US CDC -2008)
3) A Guide to Selection and Use of Disinfectants (BC CDC – 2003)
4) Selected EPA-Registered Disinfectants. https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants
5) Targeted Moments of Environmental Disinfection (TMED) – Diversey. https://cleaningbytheprofessionals.co.uk/targeted-moments-environmental-disinfection-knowlex
6) AORN Guideline for Environmental Cleaning, January 13, 2020
For additional information on this topic, go to The Courtemanche & Associates Quality Academy and select Managing the Physical Environment During the Covid-19 World Crisis for an on-demand presentation.
