Best Practices for Environmental Cleaning Module 4 – General Cleaning Part A - Cleaning Principles Welcome to Module 4 – General Cleaning. This is the 4th module in the training program developed in support of the Best Practices document on Environmental Cleaning for Prevention and Control of Infections in all health care settings, developed by the Provincial Infectious Diseases Advisory Committee.  Health care settings are encouraged to work towards best practices in an effort to improve quality of care.   Module 4 is the largest of the 6 modules and is divided into 3 parts. Part A deals with cleaning principles. My name is insert name and position and I will be your presenter for Part A of this module."

Learning Objectives To identify factors that determine frequency of cleaning. To correctly sequence tasks for cleaning. To demonstrate proper procedures for different cleaning applications. To describe other considerations in environmental management (e.g. waste handling, sharps safety, biological spill cleaning) After completion of this module, you should be able to: 1. Identify . . . 2. Correctly sequence . . . 3. Demonstrate proper . . . 4. Describe other considerations in environmental management such as the handing of waste, the management of sharps and dealing with spills of blood or body fluids. Part A of this module addresses the first objective You are encouraged to take a few moments after this module to review the accompanying DVD which demonstrates a number of cleaning scenarios. Your manager or supervisor may also wish to consider the use of live demos

These principles apply to all settings General Cleaning These principles apply to all settings where “hospital clean” is required. The focus of this module is on hospital clean and the principles we describe apply to all areas of the facility where hospital clean is required.

Hotel Clean & Hospital Clean is a measure of cleanliness based on visual appearance that includes dust and dirt removal, waste disposal and cleaning of windows and surfaces. Hospital Clean is a hotel clean PLUS: High touch surfaces in patient/resident/client care areas are cleaned and disinfected with hospital grade disinfectant Non-critical medical equipment is cleaned and disinfected between patients/residents/clients AND Cleaning practices are periodically monitored and audited with feedback and education Let’s review the definitions of hotel clean and hospital clean - Read slide

Cleaning Frequencies – Factors Influencing Frequency Surfaces high-touch or low-touch Door knob vs window sill Type of activity taking place in the area and risks associated with the activity Critical care vs office setting Vulnerability of patients/residents housed in the area Intensive care vs patient/resident room Probability of contamination based on the amount of body fluid contamination in the area Washroom vs lounge Presence of antibiotic resistant organisms (AROs) There are several factors that influence the frequency of cleaning. Are the surfaces high touch or low touch? A doorknob will require more frequent cleaning than a window sill. What type of activity is taking place in the specific area and are there risks associated with that activity? For example, a critical care area is more likely to have high risk activities than an office area. How vulnerable are the patients/residents in the area? Patients in the intensive care unit may be more susceptible to infection than a patient or resident on another unit. What’s the likelihood that the area is going to be contaminated with body fluids under normal circumstances. This may vary depending on the setting. Finally, are there antibiotic resistant organisms such as MRSA or VRE present? All of these factors must be taken into consideration when determining the frequency of cleaning. Further along in this module, we will review the risk stratification matrix which will assist in making these decisions.

Cleaning Frequencies – Factors Influencing Frequency High-Touch Surfaces: Are those that have frequent contact with hands. Examples: doorknobs, elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards, etc. High-touch surfaces in care areas require more frequent cleaning and disinfection than minimal contact surfaces. Cleaning and disinfection is usually done at least daily and more frequently if the risk of environmental contamination is higher e.g. in intensive care units, during outbreaks. Read slide

Cleaning Frequencies – Factors Influencing Frequency High-touch surfaces How many high touch surfaces can you identify in this picture? Bedrails, the call bell, handles on bedside tables, and bed controls are all high touch surfaces. High-touch surfaces Examples of High-touch Items and Surfaces in the Health Care Environment NOTE: Dots indicate areas of highest contamination and touch Figure 1

Cleaning Frequencies – Factors Influencing Frequency High-touch surfaces More examples of high-touch Items and Surfaces in the Health Care Environment. Note: the dots indicate areas of highest contamination and touch Doorknobs, door frame and light switches are all high touch surfaces.

Cleaning Frequencies – Factors Influencing Frequency Low-Touch Surfaces: Are those that have minimal contact with hands. Examples - floors, walls, ceilings, mirrors and window sills. Require cleaning on a regular (but not necessarily daily) basis, when soiling or spills occur, and when a resident is discharged from the health care setting. Many low-touch surfaces may be cleaned on a periodic basis rather than a daily basis if they are also cleaned when visibly soiled. Read slide

Cleaning Frequencies – Factors Influencing Frequency High-Touch vs Low-Touch Surfaces: The frequency of cleaning and the level of cleaning are dependent upon the risk classification of the area to be cleaned Read the bullet. Let’s review the risk stratification matrix referred to previously.

Factors that Impact Cleaning Factors that will impact the frequency of environmental cleaning include: Probability of contamination with pathogens Vulnerability of clients/patients/residents to infection Potential for exposure The first step is to categorize the factors that impact on the need to clean. Factors to consider include . . . Read 3 bullets. Once you’ve done that you can start to use the charts.

Probability of contamination Heavy – surfaces/equipment routinely exposed to copious amounts of fresh blood or other body fluids (e.g. birthing suite, ER, bathrooms if visible soil) Moderate – surfaces/equipment does not routinely (but may) become contaminated with blood or body fluids (all bathrooms) Light – surfaces not exposed to blood or other body fluids or items that have contact with these (e.g. lounges, libraries, offices) The probability of contamination is categorized as heavy, moderate and light. An area with a heavy probability of contamination would be routinely exposed to large amounts of blood and other body fluids. Two good examples of this are the emergency room and labour and delivery room suites All bathrooms would be classified as moderate risk since under normal use, they may become contaminated with blood or body fluids but not routinely. And of course, areas such as offices and lounges are less likely to become contaminated with body fluids (we hope)

Vulnerability to infection Vulnerability of client/patient/resident More susceptible – those who are susceptible to infection due to medical condition or lack of immunity e.g. elderly individuals who have underlying illnesses Less susceptible – all other individuals and areas Potential for exposure High-touch surfaces – those that have frequent contact with hands Low-touch surfaces – those that have minimal contact with hands The next 2 factors to consider in the risk stratification are the vulnerability of the client/patient/resident population from more to less susceptible and the potential of surfaces to come into contact with hands. As described earlier in the module, high touch surfaces are those that have frequent contact with hands while low touch surfaces have minimal contact

Risk Stratification Determine the risk Probability of Contamination with pathogens High-touch surfaces (score = 3) Low-touch surfaces (score = 1) More susceptible Score=1 Less susceptible Score=0 score=1 Heavy Score=3 7 6 5 4 Moderate Score=2 3 Light 2 Based on the probability of contamination and the susceptibility of your clients/patients/residents you can then use this chart to come up with a total score that can help determine the frequency of cleaning by using the chart on the next slide.

Risk Stratification Matrix Determine the cleaning frequency based on risk stratification matrix Total Risk Score Risk Type Minimum Cleaning Frequency 7 High Risk Clean after each case/event/procedure and at least twice per day Clean additionally as required 4-6 Moderate Risk Clean at least once daily Clean additionally as required (e.g. gross soiling) 2-3 Low Risk Clean according to a fixed schedule This chart will then provide guidance on the frequency of cleaning. Read slide i.e. A risk score of 7 is considered high risk and at a minimum, cleaning should occur after each case, event or procedure and at least twice per day. A score between 4 and 6 is a moderate risk and these areas should be cleaned at least once daily. A score of 2 to 3 is considered low risk and these areas should be cleaned according to a fixed schedule. For example, an office area may be on schedule for a once weekly cleaning. In all cases, the frequency described is a minimum and additional cleaning may be required such as when there is gross soiling.

An Intensive Care Unit: Probability of contamination is heavy = 3 Example - Hospital An Intensive Care Unit: Probability of contamination is heavy = 3 Potential for exposure is high (high touch) = 3 Vulnerability of patients in ICU - more susceptible = 1 Total score = 7 – Clean at least twice per day and additionally as required e.g. if gross soiling Here is an example of how the matrix can be used in a hospital setting. In an intensive care unit, the probability of contamination is heavy, for a score of 3. The potential for exposure is high for another 3 points and the patients in the ICU are more susceptible to infection, so add another point for a total of 7. In this area, clean at least twice per day and more frequently if gross soiling occurs

A Resident Activity Room: Probability of contamination is moderate = 2 Example - LTC A Resident Activity Room: Probability of contamination is moderate = 2 Potential for exposure is high (high touch) = 3 Vulnerability of residents – Those participating in activities may be considered less susceptible = 0 Total score = 5 – Clean at least once daily and additionally as required e.g. if gross soiling In the example of a resident activity room in a LTC home, (read slide)

Learning Checkpoint Here is a learning checkpoint. Ask the group the question on the next slide.

Learning Checkpoint Identify whether the following items are ‘high-touch’ or ‘low-touch’ surfaces. Toilet handle Soap dispenser Baseboard Wall Bathroom mirror Faucet handles Window coverings Ceiling lights Look at the following list of items and identify whether an item is high touch or low touch

Learning Checkpoint Answers The correct answers are: Toilet handle - high Soap dispenser - high Baseboard - low Wall – low Bathroom mirror – low Faucet handles - high Window coverings – high/low depending on setting – use risk stratification matrix Ceiling lights - low The correct answers are . . . . Read list. In some settings these surfaces may be either high or low touch depending on where and how they are used. It is important that the risk stratification matrix be used to identify the frequency of cleaning required.

References Fig 1-2: Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings. 2009 [cited March 27, 2013]:28-29 Available from: http://www.oahpp.ca/resources/documents/pidac/Best%20Practices%20for%20Environmental%20Cleaning.pdf

Thank You! This concludes Part a of Module 4 on Cleaning Principles. Thank you

Image Sources – Module 4A Microsoft Clipart used in Slide 18 Images in slides 7, 8 & 10 are © PHO 2013