One of the most common observations our team is making during our survey activity is the challenge that organizations are experiencing with infection prevention, specifically with general cleaning and disinfection. Having and maintaining an environment that is uncluttered and clean is the basis for all infection control principles. The delivery of safe healthcare must be performed without the presence of dust, debris or other environmental factors detrimental to sound infection control practice. Florence Nightingale realized this over 150 years ago and promoted basic environmental hygiene as a weapon to fight infection during the Crimea War. These practices ring true even to this day, especially as we move into the third year of the COVID19 pandemic.
Here are a number of our most common infection control observations related to the environment along with some suggested mitigating actions to take:
Expired supplies are most often found in specialty carts, caddies or other containers used for special purposes such as phlebotomy, resuscitation, or line placement. The monitoring for expiration of these items are not part of the responsibility of the Materials Management as they are usually not considered in the central stock. The clinical team of the unit typically has the responsibility of keeping up with expiring items in this category. The demands of patient care coupled with staffing shortages may explain the frequency of our observations. Additionally, we are noting that bulk supply items such as glucometer lancets, EKG pads, etc. are often found opened without indication of the beyond use date. The beyond use date is the time frame allotted by the manufacturer for product expiration once a bulk packaged product is opened. These may be the original expiration date on the package but may be more restrictive to ensure the product remains viable and infection free. Other observations we have made include finding supply bins with heavy dust and debris buildup and missing splash shields on lower wire rack shelving.
Mitigation: Whenever possible, restrict the use of specialty carts, caddies and containers to only the absolute minimum. For the most part, materials management will not maintain inventory of supplies in these locations. Clinical staff must decide the risk/benefit of setting up these supply systems against their convenience. Time and personnel are required to maintain these that may be better suited for direct patient care tasks. Know the beyond use date requirements for bulk supplied items as per the IFU. Have a system where staff can reference the beyond use dates and label packaging as necessary to know how long a product can be used once opened. Consider purchasing single patient use packaging instead. Organizations should also establish a process to clean supply areas including shelving and bins.
Our most common observations include heavy dust build up on tops of cabinetry, shelving and beneath automated medication dispensing machines. With EVS requiring monitored access to these specialty rooms, it makes it difficult to keep these areas clean when staff are not available. There are also opportunities with cleaning and disinfecting medication preparation surfaces including preparation devices such as pill splitters and crushers.
Mitigation: As indicated, EVS should be supported in accessing the medication rooms frequently to address dust and debris build up. There should be thorough cleaning on top of high surfaces and underneath equipment. Staff should also ensure they are cleaning and disinfecting surfaces used to prepare medications. Also, use of single patient use crushers and splitters can prevent cross contamination but if not feasible, these devices should be cleaned and disinfected per the IFU.
During survey we often find refrigerators and freezers with spills or dust/debris in drawers or in the bottom of the compartment. Opened containers of product (juice, milk, etc.) are present without indication of expiration date. Gaskets that ensure a tight seal to maintain proper temperature are damaged and/or with heavy dirt and debris buildup. Gaskets with improper seal have been observed creating moist conditions for the formation of mold. Our most common observation is where temperature logs are not maintained per organizational policy or with temperature excursions that are not addressed. We are also noticing thermometers with expired calibration.
Mitigation: Organizations should have a policy for routine cleaning of refrigerators and freezers. Staff should ensure they clean up spills and debris immediately to prevent infection risk. Periodic inspection of refrigerator/freezer gasketing should be included in cleaning procedures. Temperature logs should be complete and without gaps in documentation. Any excursions from acceptable temperature ranges should have documented actions taken to correct them to include any follow up temperatures. Thermometer IFU should be checked to see if they require periodic calibration and, if necessary, placed on a maintenance schedule as with medical equipment.
Environmental Services Carts:
We still find these carts in hallways, unlocked, allowing full access by visitors and other unauthorized personnel to the chemicals and cleaning solutions contained therein. Environmental Services (EVS) staff do not have access to safety data sheets on the chemicals they use or understand the PPE they must wear in handling these dangerous substances. We often find buckets/containers of cleaning solutions without indication of the chemical or its concentration or when it was mixed (or expires). EVS staff are sometimes unaware of when to change out cleaning solutions.
Mitigation: EVS staff should be trained in security of chemicals to prevent unauthorized access. Additionally, EVS should have ready access to safety data sheets and be trained on proper PPE use and chemical handling procedures including spill procedures. Procedures should include dilution of chemicals for cleaning, determining when solutions should be changed out and how to identify cleaning solutions.
Patient Care Equipment:
Items such as beds, infant warmers, bedside tables, IV poles and gurneys have been observed with dust and debris buildup especially on high level surfaces or lower surfaces such as framework or equipment undercarriages. Staff and EVS are often not in agreement with cleaning responsibilities. Damaged surfaces including wood furnishings with worn/damaged coating, rips in cushioning or rusted metal are considered an infection control risk as these cannot be effectively cleaned and disinfected.
Mitigation: Organizations should determine and communicate cleaning responsibilities to clinical and EVS staff. Equipment should be cleaned per the IFU including use of the product listed by the IFU. Cleaning should be from the top of the device working down to the lower sections, never from the bottom up. Devices should be inspected when cleaned to ensure there are no damaged or rusty surfaces.
These represent the most common environmental cleaning and disinfection observations we have found during client surveys. These do not include observations with cleaning of medical equipment or in specialty areas such as surgical/procedural suites. Given the number of observations we make, we will be addressing these topics in coming newsletters.
Good infection control starts with the basics of cleaning. Ensure your team is well prepared. Use IFUs as applicable, engage with your Infection Prevention team on best practices and encourage all to be aware of these common opportunities to improve on their practice.