1. DISINFECTION AND ENVIRONMENTAL DECONTAMINATION IN NEONATOLOGY UNITS Dr Anjum Hashmi CCS(USA),MPH. Infection Prevention & Control Specialist, Director Employee's Health, Advisor Quality Management Department East Najran Hospital Najran, Saudi Arabia

2. A TRIBUTE TO IGNAZ PH. SEMMELWEIS Hungarian physician now known as an early pioneer of infection control procedures.

4. ENVIRONMENTAL SURFACES A SOURCE OF INFECTION The contamination of the environment (surfaces in patient care areas and mobile medical equipment) play a major role in the transmission of potential pathogens. Numerous studies have demonstrated that contaminated environmental surfaces in healthcare facilities can contribute to the transmission of infectious pathogens and the cleaning and disinfection of these high-touch surfaces is necessary.

5. TERMINOLOGY Antisepsis: Chemical destruction of vegetative pathogens on living tissue. Degerming: Mechanical removal of microbes from limited area. Sanitization: Lowering microbial counts on eating and drinking utensils to safe levels. Sepsis: Bacterial contamination. Asepsis: Absence of significant contamination. Aseptic technique: Minimizes contamination.

6. CLEANING Physical removal of foreign material, e.g., dust, soil, organic material such as blood, secretions, excretions and microorganisms. Cleaning generally removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action.

7. DECONTAMINATION Decontamination: The removal of disease-producing microorganisms to leave an item safe for further use.

8. DISINFECTION Disinfection: Defined as cleaning some or all pathogenic organisms from an article of which may cause infection. Perfect disinfectant should offer complete and full sterilization, without harming other forms of life, be inexpensive, and non-corrosive. Unfortunately ideal disinfectants do not exist.

9. ANTISEPTICS & DISINFECTANTS Antiseptics: Use on skin and mucous membranes to kill microorganisms. Not for use on inanimate objects. Disinfectants: Use to kill microorganisms on inanimate objects. Not for use on skin or mucous membranes. Disinfectants according to chemical nature & duration of contact time results in disinfection, which may be of High, Intermediate and Low levels.

10. HIGH LEVEL DISINFECTION High level disinfection processes destroy vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and nonenveloped (non lipid) viruses, but not necessarily bacterial spores. High level disinfectant chemicals (also called chemical sterilant) and are capable of sterilization if contact time is extended. All items must be thoroughly cleaned prior to high level disinfection.

11. INTERMEDIATE LEVEL DISINFECTION Intermediate level disinfectants kill vegetative bacteria, most viruses and most fungi but not resistant bacterial spores.

12. LOW LEVEL DISINFECTION Low level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses (e.g., hepatitis B & C, hantavirus and HIV). Low level disinfectants do not kill mycobacteria or bacterial spores. Low level disinfectants are typically used to clean environmental surfaces.

13. SPAULDING CLASSIFICATION of DEVICE CATEGORIES Critical Device enters sterile tissue or vasculature, therefore pose a high risk of infection if contaminated with microorganisms: Require Sterilization Semi-critical Device comes in contact with mucous membranes or skin that is not intact, therefore pose a moderate risk of infection if contaminated with microorganisms: Require High Level Disinfection Non-critical Device comes in contact with intact skin but not with mucous membranes, therefore, pose little to no risk of infection if contaminated with microorganisms: Require Disinfection

14. DISINFECTANTS USE IN NEONATOLOGY UNITS

15. ALCOHOLS Alcohol refers to two water-soluble chemicals: Ethyl Alcohol and Isopropyl Alcohol. Alcohols are bactericidal against vegetative forms of bacteria (Gram +ve & -ve); they also are tuberculocidal, fungicidal and viridical against enveloped viruses. Disadvantage: Alcohols are not effective against bacterial spores and have limited effectiveness against nonenveloped viruses. Expensive.

16. QUATERNARY AMMONIUM COMPOUNDS (PHENOLICS) Examples: Benzyl-4-chlorophenol, Amyl phenol, Phenyl phenol, Lysol. Good general purpose disinfectants. Not readily inactivated by organic matter. Active against wide range of organisms Gram +ve & -ve (including mycobacterium). Usually used in hospital environment. Disadvantage: Not effective against non- enveloped viruses and spores.

17. MODE OF ACTION OF QACs The components of the cell membrane vary by organism type and can inhibit the effects of QACs. QACs take longer to affect the cell. In the laboratory, some bacteria have developed resistance to QACs over time.

18. SODIUM HYPOCHLORITE Advantages: They have a broad spectrum of antimicrobial activity. Unaffected by water hardness. Inexpensive. Fast acting, and have a low incidence of serious toxicity.. Readily available as “household bleach”.

19. SODIUM HYPOCHLORITE Disadvantages: Corrosiveness to metals in high concentrations. Inactivation by organic matter so cleaning must precede. Discoloring of fabrics. Staining of plastic tubing on long exposure. Pungent odor of chlorine gas.

20. HYPOCHLORITE’S MODE OF ACTION Clorox /Bleach is effective against a broader range of microorganisms and needs less contact times. Bleach tears apart the microbe’s cell walls & deactivates proteins required for bacterial growth (by destroying molecular structure).

21. HYPOCHLORITE’S MODE OF ACTION As a strong oxidizer, bleach reacts with nucleic acids (DNA / RNA), lipids and fatty acids associated with the cell membrane and destroys the cellular activity of structural and functional proteins in membrane.

22. CDC GUIDELINES FOR HOSPITAL SURFACE DISINFECTION Clorox/ Bleach Disinfecting Formulas at or above the 1:10 Concentration Meets CDC Guidelines for Hospital Surface Disinfection and OSHA Bloodborne Pathogen Standards. At a target level 5000ppm or above as CDC recommended, Clorox Healthcare Bleach Germicidal Wipes and Dispatch products kill the pathogens of most concern in healthcare settings.

23. NO RESISTANCE REPORTS There is no scientific based evidence of bacteria or viruses developing resistance to the powerful oxidizing action of bleach when used at recommended dilutions.

24. CLOROX PRODUCTS Ready made products contain chlorine at concentration 5000 ppm so can be readily use to disinfect hospital environment.

25. RECOMMENDED DILUTIONS FOR DISINFECTION For routine solid surface disinfection e.g., floor, walls; 40-50 ml of Clorox / bleach in 1 liter tap water (2500-2700 ppm chlorine) is required (freshly prepared). For disinfecting a blood stains items, blood and body fluid spills, 100 ml of bleach in 900 ml of tap/distilled water to have an approximate 10% / 1:10 concentration or 5000-6000 ppm chlorine (freshly prepared).

26. CDC 2003 Guideline For Interventions Relating Surface Decontamination Rate at which organisms suspended in the air are removed, and type of surface and orientation [i.e., horizontal or vertical]. Potential for direct patient contact. Degree and frequency of hand contact. The potential contamination of the surface with body substances or environmental sources of microorganisms (such as soil, dust, and water).

27. CDC 2003 Guideline For Interventions Relating Surface Decontamination Healthcare professionals should consider the number and types of microorganisms present on environmental surfaces, depends on following factors: Number of people in the environment. Amount of activity. Amount of moisture. Presence of material capable of supporting microbial growth.

28. Major Considerations Related To Proper Surface Decontamination What to clean: environmental surfaces, such as bedside tables, if soiled, could become a source of contamination to hands or other objects which may have contact with the patient. The CDC recommends environmental surfaces (especially high-touch surfaces) should be cleaned regularly with an EPA- approved, hospital-grade disinfectant.

29. Major Considerations Related To Proper Surface Decontamination The bugs Taking into account the types of organisms commonly found on surfaces where healthcare is delivered. Different types of microorganisms vary in how easy they are killed by disinfectants. Some are very hard to kill, while others can easily be killed by many disinfectants, even simple soap and water.

31. Strategy & Approaches to Cleaning The methods, thoroughness and frequency of cleaning and the products used are determined by healthcare facility policy according to risk category & in line with 2003 CDC guideline. Surfaces with minimal hand-contact (such as floors and ceilings) and those with frequent hand-contact (―high- touch surfaces‖) require different approaches for cleaning.

32. Strategy & Approaches to Cleaning Infection control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff. High-touch housekeeping surfaces in patient- care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patient’s room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact.

33. EQUIPMENT DISINFECTION PROTOCOL IN NEONATOLOGY

34. A SIMPLE 3-STEP EQUIPMENT DISINFECTION PROTOCOL For small surfaces and medical equipment, disinfect after each patient use by following this protocol to help ensure effective disinfection and reduction of cross- contamination. Sanitize hands, then put on gloves. 1. Thoroughly wet the exterior of the equipment or surface.

35. A SIMPLE 3-STEP EQUIPMENT DISINFECTION PROTOCOL 2. Observe contact time to ensure the surface stays wet for the required amount of time. 3. Dispose wipes and gloves in infectious waste bin.

37. ENVIRONMENTALDECONTAMINATION IN NEONATOLOGY

38. Infection Control Risk Assessment of Hospital Areas

40. ENVIRONMENTAL DECONTAMINATION Cleaning MUST precede decontamination Disinfectant is ineffective if any organic matter present. Use mechanical force – Scrubbing – Brushing – Flush with water Wipe nonporous surfaces with sponge or wet cloth – Allow to dry Use fresh diluted Clorox/bleach daily ! 40-50 ml Clorox + 1 liter water (2500-2700 ppm Chlorine)

41. UNIT CLEANING PROTOCOL UNIT CLEANING PROTOCOL Always prepare to clean by washing hands, donning gloves and appropriate PPE (personal protective equipment), thoroughly clean and disinfect the room, following cleaning path (clockwise, top to bottom). Step 1 | Remove trash and soiled linens: Place them into appropriate receptacles. Clean and disinfect the surfaces of the waste and linen receptacles and allow to air dry. Step 2 | Dust overhead: Using a high duster, dust hard-to-reach areas such as above the high wall vents, curtain rods, tops of doors and lights.

42. UNIT CLEANING PROTOCOL Step 3 | Clean and disinfect area: Remove gross soil (e.g., areas with blood, tissue or body fluids). Clean and disinfect all hard, nonporous room surfaces including: Patient’s bed area, headboard, mattress, side rails, bed frame, footboard and over-bed table. Furniture and high-touch areas: TV, remotes, light switches, door handles, lamps, window & window blinds.

44. ISOLATION ROOM CLEANING ISOLATION ROOM CLEANING Using a clean mop, mop the entire floor surface, working your way from the far corner back to the entrance. Visually inspect the room and ensure all surfaces have been cleaned and disinfected. Then disinfect any cleaning equipment (like mop handles) before returning to the cleaning cart. Remove PPE and put in a yellow trash bag prior to leaving the room. Wash hands.

45. CLEAN AND DISINFECT BATHROOM Make Clorox sol (40-50 ml Clorox + 1 liter water) Clean and disinfect all precleaned hard, nonporous bathroom surfaces. Start with the highest surface (like the mirror) and leave the toilet for last. Ensure that all surfaces, including the sink area, mirrors, grab bars and shower fixtures, are thoroughly disinfected. Disinfect and clean toilet exterior, toilet seat surface, and outer of bowl. For inner use 250ml pure bleach contact time 5 min. Ensure all surfaces stay wet.

46. THE CLEAN TEAM Establish better communication with environmental services & include them in the patient care unit team – as they are a critical member of the team. The 'Clean Team' includes representatives from nursing, environmental services and infection prevention and control. This type of collaboration enhances problem solving – and reduces infections.

47. EDUCATING THE CLEAN TEAM Infection preventionists has to provide continuous training to nurses and housekeeping personnel. First and foremost is fundamental education of staff about infection prevention and control basics such as hand hygiene, clean and dirty are located in separate areas, standard precautions /isolation, proper cleaning, disinfection, and sterilization etc.

48. MISCONCEPTION AMONG HCWs Many HCWs don’t realize that they have germs on their hands because they underestimate transmission from various environmental surfaces. Some environmental surfaces may be perceived as being less likely to harbor bacteria but healthcare workers can get thousands of bacteria on their hands after touching these surfaces.

49. SIMPLE TASKS CONTAMINATES HANDS - Pulling up patients in bed. - Taking a blood pressure or pulse. - Touching a patient’s hand. - Rolling patients over in bed. - Touching the patient’s gown or bed sheets. - Touching equipment like bedside rails, over-bed tables, IV pumps.

50. A HYGIENIC AND SCIENTIFIC HAND WASHING CONTINUES TO BE BEST PRAYER IN THE HOSPITAL

51. STAFF MUST BE TRAINED TO CLEAN HIGH-TOUCH AREAS ALL THE TIME Hand hygiene is the No.1 way to prevent infections, but it’s not a complete solution. If hospitals are inadequately cleaned, doctors’ and nurses’ hands will become contaminated seconds after they are washed.

52. THANK YOU Contact: anjumhashmi61@hotmail.com