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11/19/2015
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Disclosures
• Conflict of interest
�The following members of the Planning Committee and Faculty report no conflict of interest
-Carol McLay DrPH, MPH, RN, CIC
�Lead Nurse Planner, subject matter expert
-Bill Bridges Ph.D
�Planning Committee member
-Linda Lybert
�Faculty
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Successful Completion
• View entire webinar
• Complete online evaluation
Continuing Nursing Education
The Association for Professionals in Infection
Control and Epidemiology is accredited as a
provider of continuing nursing education by the
American Nurses Credentialing Center’s
Commission on Accreditation.
Contact Hours Awarded: 1.0
Expiration Date: November 19, 2018
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How clean is clean?
The challenges of disinfecting porous
and non-porous surfaces in healthcare
environments
Linda Lybert, President/Surfaces Expert
Healthcare Surface Consulting
I would like to know about you
• What is your particular area of expertise?
– Infection Prevention
– Facilities Management
– Environmental Services
– Architect/Design
– Research
– Manufacturer
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Learning Objectives
• Describe pathogen movement and persistence
in healthcare environments
• Identify surfaces of increased concern for
pathogen survival and transmission
• Discuss strategies to improve cleaning
protocols for mixed textile environments
What we know
• There has not been a sustainable long term
reduction in the number of HAI’s to date
• Microbes are much harder to kill
• Surfaces are active in the spread of infection
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Research shows us
• Surfaces are microbial reservoirs – transmission of pathogen
– Patient
– Indirectly through contamination of health care worker hands and gloves
• Microbes survive on surfaces for days, weeks, even months
• Cleaning and disinfecting a patient room reduces bioburden immediately
– Rebound is an issue
• Biofilm forms on dry surfaces
• Patients are at risk of contracted infections from previous patients occupying the same room despite terminal cleaning
Research also shows us
• Bioburden is high within 3 feet of patient
• Cross contamination happens when patients come in
contact with environmental surfaces or indirectly
through contamination of health care workers’ hands
and gloves.
• Soft surfaces often neglected – University of Arizona
tracer study
• There are still many questions needing to be
answered
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Hurdles to Success
Communication, education and
understanding
Information Silos
Complicated and many stakeholders
Administration
Facilities Management
Infection Prevention
Environmental Services
Architect and Design
General Contractors
Regulation and Government
Agencies
Many areas of expertise are stakeholders in infection prevention
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Solutions to achieve success
Healthcare Surfaces Summit Mission
Reducing preventable infections through collaboration
of industry, science, regulatory, and service sectors by
interrupting the transmission of surface related
pathogens in healthcare in support of community
health.
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Healthcare Surfaces Summit
• Held October 16th and 17th
• Unique cutting edge collaboration that will address the
complex and critical role of surfaces in the spread of
healthcare associated infections (HAIs).
• Multidisciplinary group of experts and thought leaders with a
focus on collaboration, working with multiple stakeholder
organizations, researchers, industry experts, regulating
agencies, healthcare professionals and manufacturer
partners.
Surfaces
A complex Issue
Not addressed
Deep dive
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Many surface materials and textiles
Combined in the same space
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Cannot all be cleaned the same way
How are surfaces selected in your facility?
– Surfaces and finishes committee which includes IP, EVS and
Facilities Management
– Architect and Designers
– Not exactly sure
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Selection product and samples
IT’S NOT ENOUGH
“It is not enough to learn every physical
characteristic of a given surface material or
even all surface materials.
It is not enough to become an expert in the
latest disinfection agents and protocols. This
data must be combined with an understanding
of the patient care process, microbiology and
insight into human behavior patterns. “
….Linda Lybert
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Science behind the surface issue;
Seven critical aspects for evaluation
• Location
• Microbiology
• Surface materials & textiles
• Surfaces as assembly
• Human behavior
• Cleaning and disinfection
products and process
• Manufacturer cleaning
recommendations and
warnings
Location
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Location
Nursing station patient
careHandwashing station just outside
of ED bay
Patient bathroom bone
marrow transplant
Location
• Emergency department
– Trauma area or exam room
– How often is this room turned over and by who
• Front lobby
– Patient waiting area
• High traffic hallway with heavy equipment
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Microbiology
Microbiology
E coli attached to rough textureC. difficile
Microbes cannot be seen! SO they must not be there.
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Microbial attachment to surfaces
• Biofilm establishes a protected mode of growth
allowing bacteria to survive in hostile environments
• Recent research out of Australia by Vickery et al.15 ‘destructively sampled’ (i.e. cut the materials out of the hospital environment and
undertook laboratory analysis) several hospital surfaces after cleaning and bleach
disinfection. Scanning electron microscopy was used to examine the surfaces for
biofilms, which were identified on five of six surfaces. Furthermore, viable meticillin-
resistant Staphylococcus aureus (MRSA) was identified in the biofilm on three of the
surfaces.
• Research has evaluated the impact of established biofilms on biocide susceptibility
• More research is needed to understand the susceptibility of surface-attached cells
that have not yet formed established biofilm
Microbial attachment in patient bathrooms
Issues
• Toilet plume
• 4 different types of tile
• Unlimited grout lines and
seams
• Grab bars brushed stainless
steel
• Fabric nurse call cord
• Sink, shower and drain are
within a few feet
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Surface materials and textiles
Surface materials and textiles
• Soft, hard
• Porous and non porous
• Textured, smooth
Whether a material is soft or hard does not determine if the
material is porous or non-porous
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Hard surfaces
Tile
Laminate
Solid Surface
Stainless Steel
Quartz
Granite
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Selection of right surface material doesn’t insure
correct construction
Walls
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Soft surfacesShower curtains
Privacy curtains
Fabric
Vinyl
TexturedSmooth
Overlooked
soft surfaces
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University of Arizona soft surface transmission
study
• 300 beds/rooms skilled nursing attached
independent living facility
• Seeded nursing station & lounge chair
• Within 4 hours tracer was detected through
out the unit, patient rooms, physical therapy,
administrative office, lounge areas, TV
common areaRapid Microbial Tracer Movement to Soft Surfaces Throughout Patient Care Areas and the Role of Mixed Surfaces in Infection Prevention
Jonathon Sexton, PhD, Research Specialist, The University of Arizona, Kelly Reynolds, PhD Associate Professor, The University of Arizona
Assemblies
Many different surface material
combine on one product and within
the healthcare environment
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Assemblies of different surface materials
Medical devices
9 connection points
At least 7 surface materials
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Assemblies
PatientTable
Chair
Window
Sill
Table
Curtain
Hand Wash Station
Computer
Day Bed
Room layout
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Typical patient room
Could this present a problem?
Over 60 different
surfaces and
connections.
Combination of
soft, hard,
smooth, textured,
porous and non
porous. All
needing to be
cleaned daily!
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7 different surface materials
• Rough texture
• Smooth texture
• Seams
• Not an area of focus
for cleaning despite
constant contact
Problem areas
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Human behavior
Human Behavior
• Patient was in bed 2 of 3 days
• Open wound
• 3 days 7:00 a.m. to 11:00 p.m.
• Health care workers, visitors and patient
• Interaction with all surfaces soft and hard
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How many surfaces are touched?
• Door
• Keyboard
• Mouse
• Computer monitor
• Paper in pocket
• Pen
• Scrubs
• Blood pressure cuff/machine
• Stethoscope
• Over-bed table (3x)
• Nurse call/TV control
• Faucet handle (2x)
• Sink
• Waste disposal door (3x)
• Chair
And
• IV Pole
• IV Control
• Injection into IV
• IV Bag
• IV Tube
• Move drink or food from bedside table
• Bed railings (2x)
• Privacy curtain
• Water pitcher
• Patient glass
• Soda can
• Sheets
• Blanket
• Bandage
• Drainage tube
• Catheter bag
• Catheter Tube
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Patient (washed hands once a day)
• Bed railing
• Chair
• Linens
• IV Pole and pump
• Bedrails
• Over bed table
• Blanket
• Bed control/Nurse call
• Telephone
• Cords on bed
• EKG cords
• Velcro on nurse call
button
• 3 day ambulate moved
within room and patient
bathroom
Visitor (Rarely washed hands)
• Door
• Bedrails
• Over bed table
• Bedding
• Daybed
• Glass pitcher
• Food tray
• Towel/washcloth
• Windowsill
• Nurse call/TV buttons
• Faucet
• Privacy curtain
• Waste bin flap
• Wipe down of surfaces
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Hand Hygiene Training
• Health care worker
• Patient
• Visitors
Cleaning and disinfection
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Cleaning and disinfection
• Ability to effectively clean and disinfect surfaces is
challenging
– Time requirements for room cleaning and disinfection
– Assume things are clean can’t see soil, damage, microbes
– Surfaces cannot all be cleaned the same way
– Reduction in staff
– Confusion about who is responsible
• Depending on location nursing staff
Brand new laminate Same laminate scrubbed once
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Acrylic Scrubbed normal use Polyester scrubbed normal use
Manufacturer Warnings
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Manufacturer recommendations
• Cubicle Curtain: Wash Cycle – Wash as any standard colored fabric, with
water temperature not to exceed 160˚F
Detergents: Use a synthetic detergent. DO NOT use a caustic soap or
bleach. Do not add softener
• Antimicrobial Fabric or Cubicle Curtains: Wash Cycle – Spot clean with
damp sponge/cloth with general detergent or germicidal cleaner. It is
recommended to spot test the cleaner if the effect on polyester fabric is
not known. Fabric may be laundered by steam cleaning or commercial
washing where water temperature does not exceed 160°F. Commercial
detergents will not harm properties. Do Not add fabric softeners. Repeated
washing does not destroy inherent properties of the… (what about
bleach?)
Manufacturer Warnings
• Laminate: WARNING – Prolonged exposure of the laminate surface with
bleach will cause discoloration. Always rinse laminate surfaces after
cleaning! If a small amount of cleaning solution remains on the surface,
moisture can reactivate it and result in permanently etched scars.
Acidic or abrasive cleaners can damage laminate surfaces; do not use
them.
• Stainless Steel: PRECAUTIONS – Avoid prolonged contact with chlorides
(bleaches, salts), bromides (sanitizing agents), thiocyanates (pesticides,
photography chemicals, and some foods), and iodides on stainless steel
equipment, especially if acid conditions exist
• Solid Surface: Avoid harsh chemical such as drain cleaners and paint
removers. Bleach and water are suggested cleaners for sinks and
countertops.
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Manufacturer Warnings
• Wall protection: DO NOT USE methyl ethyl ketone (MEK) cleaners
containing harsh solvents on any Product. Powdered cleansers are not
recommended as they are abrasive and tend to leave a troubling reside if
not utilized properly. DO NOT USE Scotch-Brite®, Brillo®, S.O.S.® pads or
steel wool on any Products.
• ASK FOR TESTING DATA AND DOCUMENTATION
Antimicrobial Surfaces
• DO NOT SELF CLEAN!!!!!!!!
• Most are 99.999% effective in a laboratory
– What are the testing results in active environment
– Data on the number of infections they have
reduced
• Reduce bioburden hoping cleaning and
disinfection will be more effective
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Antimicrobial questions
• What does antimicrobial mean??
• What inhibits them from effectively reducing
bio-burden
• Will microbes become resistant
• Test data on safety
• A lot of research still needs to be conducted
Recommendations to achieve success
• Set specific criteria for the selection of surfaces
– Not necessarily to select specific surface materials
• Develop a team that includes IP, EVS, Facilities
Management for surface approval
• Look at assemblies to verify ability to clean them
• Review all research and data to verify products can
be cleaned/disinfected and sterilized effectively
• Work closely with manufacturers
