1. Environmental Cleaning
David Woodard, MSc, CIC, CPHQ, CLS

2. Objectives
Discuss the role of environmental cleaning and disinfection in the prevention of HAIs.
Identify evidence-based methods and best practices for environmental cleaning in healthcare facilities.
Discuss controversies and challenges for infection control managers and resources for effective management.

3. Outline of today’s presentation
Issues with terminology
Why terminal room cleaning is important
Addressing suboptimal cleaning practice
Does enhanced cleaning make a difference?
Conventional vs. enhanced environmental cleaning monitoring
Where are we going with surface disinfectants and new technologies?

4. Is the Environment Important in HAI Acquisition ?
Aside from the fact that many healthcare experts since Florence Nightingale have said so, what is the evidence base for optimizing healthcare environmental hygiene?
Instructor Note:
Use this slide as a transition in to the presentation of the evidence for optimizing healthcare environmental hygiene.

5. Improved thoroughness of hygienic cleaning is a worthy goal given the billions of dollars involved…but will it impact transmission of HAPs ?

6. CMS cleaning expectations
Cleaning of Patient Care Equipment
Privacy Curtains – Cleaning Schedule and Precaution Room
Environmental services procedures
Use of disinfectants and germicidal wipes (contact times)
Laundry handling procedures
Cleaning of blood spills
Facilities;
HVAC system, refrigeration, ice machines, scrub sinks, faucet aerators, eye wash

7. Surface Disinfection – CMS Citation
Exposure Time
CMS surveyors (CA) have been paying closer attention to cleaning the environment, including a determination if hospitals are following manufacturers’ directions for disinfectant contact time
Hospitals cited for using shorter contact time than manufacturers’ directions
Appealed based on published peer-reviewed literature supporting shorter exposure times
Appeal denied
Background:
These slides may seem out of context to the presenter and the audience, but they serve a valuable purpose to identify current and very practical challenges; namely, the conflict between product labeling, regulatory requirements and practical cleaning processes. This provides an overview of the recent California issues related to dwell time. The illogical issues surrounding the CMS decisions and the regulatory issues involving the California hospitals brought to everybody’s (CMS, EPA, SHEA, APIC, etc.) attention the need to have an objective evaluation of the basis for such rules. Note that this issue also arose in in Massachusetts.
Key Points:
How much time should the disinfectant be left on the surface?
Joint Commission believes that it should be left on for several minutes.
The problem arises from the differences in product labeling, which is often based on non-real world application and dwell times, and the actual practice in institutions.
Instructor Notes:
Reflect on a situation and requirements in your institution.
Rutala W,2010 7

8. Disinfection cleaning – Implies the use of a low level disinfectant to decrease bio-burden
Environmental cleaning – (in Healthcare) – surface cleaning to reduce bio- burden
Hygienic cleaning – New, more specific term – surface cleaning to reduce bio- burden (confusion with hand hygiene?)

9. Descending Order of Resistance of Microorganisms to Sterilization/Disinfection
Key points:
The need to address a broad range of pathogens was mentioned and this slide depicts a wide spectrum of disinfection and sterilization need.
For example, the most difficult organism that we deal with when addressing sterilization needs involves the prion responsible for CJD. This organism is resistant to traditional sterilization methods and, if done incorrectly, the wrong methods may actually “protect” the organism from the effects of sterilization. Therefore, specific measures are indicated.
Information that demonstrates the order of resistance of microorganisms to sterilization and disinfection is included in the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities.
Biological indicators are the only process indicators that directly monitor the effectiveness of a given sterilization process.
Spores used to monitor a sterilization process have demonstrated resistance to the sterilizing agent and are more resistant to sterilization than the bioburden found on medical devices.
Bacillus atrophaeus spores are used to monitor ethylene oxyide gas and dry heat.
Geobacillusstearothermophilus spores are used to monitor steam sterilization, hydrogen peroxide gas plasma and liquid paracetic acid sterilizers.

10. Levels of Decontamination
Cleaning
Removal of dirt, debris, material
Manual or mechanical (detergents/enzymes)
Critical component to all levels of disinfection
Must precede disinfection and/or sterilization
As soon as possible after item has been used
Disinfection
Removes most or all micro-organisms except spores
Liquid chemicals or wet-pasteurization
Success depends on prior cleaning, microbial burden, time
Low-level disinfection
Rapid (<10min), kills most bacteria, some viruses, some fungi
High-level disinfection
Longer (~20min), kills all pathogens except large spore burden
Instructor Notes:
We have talked about different types of items and their uses which determine their classification (non- critical, semicritical, critical) and the rationale behind the disinfection process. Let’s now work through these levels of organism removal.
Key Points:
In general, the term used for removal of microorganisms is decontamination. Decontamination removes pathogenic microorganisms from objects so they are safe to handle, use, or discard.
Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products.
Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Cleaning should be done as soon as possible after the item has been used.
Disinfection removes most microorganisms except spores. Disinfection uses liquid chemicals or wet- pasteurization.
Pasteurization is exposure of the item to conditions of sterilization, usually heat, for a sufficient period of time.
Wet pasteurization is exposure of the item to a pasteurization process involving a liquid such as hot water.
The extent that the item was cleaned prior to disinfection often determines how successful the disinfection steps are.
Within the domain of disinfection, there is low-level and high-level disinfection.
Low-level is faster (usually taking less than 10 minutes) and kills most bacteria, some viruses, and some fungi.
High-level disinfection takes longer, usually about 20 minutes, and kills most all pathogens except for some spores, especially when the spore bioburden is large. 10

11. How to Mechanical process Friction Detergent Carrier (water) Detailed
Make fats soluble or “isolate”
Carrier (water)
Detailed
Use standard process
Monitor activity
Use only the very best products

12. Disinfecting
A process that eliminates living pathogenic microorganisms on inanimate objects –
Does not work on most virus
Does not work on most spores
Does not work on “prion”?
May have other limits (high level vs. low level)

13. Dr. Earle Spaulding
“You can clean without disinfecting, but you cannot disinfect without cleaning”

14. Spaulding Scheme: Types of Items
Non Critical Items
Contact with intact skin
Requires removal of common pathogens
Patient rooms and their contents (e.g., surfaces, BP cuffs, stretchers)
Semi-Critical
Contact with non-intact skin or mucous membranes
Requires removal of all micro-organisms, but small numbers of bacterial spores are permissible
Endoscopes, intubation blades, ultrasound probes
Critical
Contact with sterile sites
Requires removal of all micro-organisms and spores
Surgical instruments, vascular catheters
Key Points:
Some of the most common questions you will likely address come from healthcare personnel who have questions about how to approach disinfection of commonly used items. Therefore, it is important to have a conceptual understanding to guide your recommendations. Make sure you are familiar with the Spaulding criteria.
Critical items are those that have come into contact with sterile body sites and so confer a high risk for infection if they are contaminated with any microorganism. Thus, objects that enter sterile tissue or the vascular system must be sterile because any microbial contamination could transmit disease.
Examples: surgical instruments, cardiac, vascular and urinary catheters, implants, and ultrasound probes used in sterile body cavities.
Most of the items in this category should be purchased as sterile or be sterilized with steam if possible. Heat-sensitive objects can be treated with EtO, hydrogen peroxide gas plasma; or if other methods are unsuitable, by liquid chemical sterilants. Germicides categorized as chemical sterilants include >2.4% glutaraldehyde-based formulations, 0.95% glutaraldehyde with 1.64% phenol/phenate, 7.5% stabilized hydrogen peroxide, 7.35% hydrogen peroxide with 0.23% peracetic acid, 0.2% peracetic acid, and 0.08% peracetic acid with 1.0% hydrogen peroxide.
Liquid chemical sterilants reliably produce sterility only if cleaning precedes treatment and if proper guidelines are followed regarding concentration, contact time, temperature, and pH.
They require removal of all microorganisms and spores.
Semicritical items are those that have contact with non-intact skin or mucous membranes. These items require removal of all microorganisms but stop short of sterilization.
Examples: endoscopes, intubation blades, ultrasound probes.
Non-critical items are those that come into contact with intact skin. The methods for cleaning and disinfection (remember that cleaning always precedes disinfection unless your cleaning agent combines both steps) should be those that address the removal of common pathogens. Whatever you are most likely to see in your facility.
Examples: bed, tables, phone, cables, BP cuffs, stretchers, wheelchairs and other patient furniture. 14

15. Efficacy Number and location of organisms
Meticulous cleaning!
Innate resistance of organisms
Concentration and potency of disinfectants
Concentration
Exposure time
Physical and chemical factors
Temperature pH
Relative humidity
Water hardness
Organic and inorganic matter
Duration of exposure/contact time
Biofilms
Key Points:
Efficacy of sterilization depends upon a number of factors:
The level of contamination that is present.
How many organisms are involved and where are they located.
Cracks, crevices, hinges, channels all represent challenges to cleaning and disinfection.
The type of organisms involved. For example, recall our discussion of prions. These organisms require additional time and attention in order to achieve sterilization.

16. Important disinfecting thoughts
Proper dilution – more is not better!
Employee safety
Environmental safety
Exposure limits (Permissible exposure level)
Compatibility (gloves, basins, other products) [chlorine and ammonia]

17. Basic elements
Cleaning
Disinfecting
Evaluation
Follow-up
Retraining

18. Cleaning Remove all visible soil Decrease the bioburden
Increase workers safety
Do early to avoid dried on materials.
Safe compounds
NOT intended to disinfect or sterilize

19. Disinfecting
A process that eliminates living pathogenic microorganisms on inanimate objects –
Does not work on most virus
Does not work on most spores
Does not work on “prion”?
May have other limits (high level vs. low level)

20. Different types (US) Phenolic – “gold standard” Quaternary ammonium
Smells “like a hospital”
Toxicity
Won’t kill spores
Quaternary ammonium
Specific pathogen approvals (read the label!)
Affected by water hardness
Affected by bioburden

21. Newer products Hydrogen peroxide Peracetic acid
Oxidizer (may harm some instruments)
Reverts to hydrogen and oxygen (safe?)
Explosive at concentration
Peracetic acid
Rapid action
Works in presence of organic materials

22. Other products Aldehydes Gluteraldehyde
Good product, sporicidal; tuberculocidal; viricidal
Characteristic unpleasant odor
Environmental issues
Toxicity
Exposure levels
Clean-up requirements

23. Other products Chloramine-T Alcohol Retains more chlorine
More bactericidal
Alcohol
Not sporicidal
Flammable
Incompatible with many items

24. Halogens Iodine (Iodophore) Chlorine
Good killer – usable in food preparation
Inactivated by organic materials (blood)
Stains
Chlorine
Corrosive
Bleach!

25. All things wise and wonderful
Make a “cleaning matrix” showing:
Who cleans post discharge e.g. EVS
Who cleans when in use.
How often “general use equipment” is cleaned
Who cleans “general use equipment”
Identification of cleaned items
Rags, tags and bags.

26. Don’t forget the Rutala Equation
Effective Disinfection Cleaning Product + Practice

27. Does education work?
We developed a new method using an invisible fluorescent marker to target standardized high-touch surfaces in hospital rooms. Evaluation of surface objects in 157 rooms in 3 hospitals revealed that 47% of targets had been cleaned.
Educational interventions were implemented, leading to sustained improvement in cleaning of all objects and a 12-fold improvement in cleaning of surfaces previously cleaned <85% of the time (P .001).

28. Carling & Bartley AJIC 2010 (83) S41-S50.

30. Summary of five methods used in evaluating environmental hygiene

31. Nothing new under the sun
Fogging
Aerosolization of disinfectant to kill pathogens on contact.
Variety of chemicals used
Formaldehyde (carcinogenic, odourous)
Peracetic acid (PAA) (low 1.4 ppm concentration)
Hydrogen Peroxide (explosive at concentration)

32. A fogging machine is useful to quickly disperse disinfectant into a room. The mist released by the machine rapidly saturates the air, causing the dangerous droplet nuclei to settle. An appropriate disinfectant used in the fogging machine will decontaminate potentially infectious droplet
nuclei as they settle on floors and bench tops. The fogging machine should always be kept ready with an adequate volume of freshly-prepared
disinfectant.”
WHO information

33. Fogging limitations Penetration of disinfectant (particle size)
Removal of gross contamination (bioburden)
Contact time (kill time)
Toxicity to personnel
Chemical damage to equipment
Room preparation
Fire alarms
Air conditioning
Which rooms to do

34. Fogging Advantages Penetration into nooks and crannies (no shadows)
Underneath and above
Chemical choice
No hazards to touch screens (PAA)
No hazards to electrical equipment
Time – minutes

35. UV light Effective kill of most organisms and spores Shadow
Necessity of multiple devices/room or multiple cycles per room (bathroom)
Nooks and crannies – penetration vs. fog

36. All things great and small
Cleaning and disinfecting of patient care equipment –
Who cleans the:
Ventilator
IV pole
Rolling Stock (wheel chairs, suction machines)
How do you know it clean?

37. Sax H, Pittet D et al. JHI September 2007
Terminology - new
Sax H, Pittet D et al. JHI September 2007

38. How Clean is the Clean Appearing Hospital Environment ?
Visually clean surfaces may be contaminated.
82% of sites visually clean
24% clean by ATP bioluminescence
30% clean using microbiological techniques
Some “clean” surfaces had organism counts > 40 cfu/cm2

39. Increased acquisition risk from prior room occupant 6 studies as of January 2011
Carling PC, Bartley JM. Am J Infect Control 2010;38 S41-50.

40. Hospitals Environmental Hygiene Study Group 36 Hospital Results
Post Intervention

41. Group Benchmarking

42. Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program
Subjective visual assessment
Deficiency oriented
Episodic evaluation
Problem detection feedback
Open definition of correctable interventions
Enhanced Program
Objective quantitative assessment
Performance oriented
Ongoing cyclic monitoring
Objective performance feed back
Goal oriented structured Process Improvement model

43. Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program Advantages
An established model
Enhanced Program Advantages
Direct evaluation of practice
Uses a standardized, consistent, objective and uniform system of monitoring
Provides regular and ongoing performance and positive practice based feed back results to ES staff
Facilitates the monitoring of many data points to optimize performance analysis
Allows for objective remedial interventions
Easily adaptable to existing PI modalities
Compliance with JCAHO standards and CMS CoP
Intrinsic internal benchmarking
External benchmarking, reporting and recognition feasible

44. Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program Limitations
Inability to evaluate actual practice
Based only on negative outcome analysis
Limited generalizability of findings
Poor specificity and low sensitivity
Subjectivity with a high potential for observer bias
Poor programmatic specificity
Potential for observer bias
Only evaluates daily HP
Limited ability to support JCAHO standard EC EP2
Limited ability to demonstrate compliance with CMS CoP
Benchmarking not feasible
Enhanced Program Limitations
Requires a new program implementation
Ongoing administrative support critical to success
Potential resistance to objective monitoring and reporting
While useful, the covert baseline evaluation may be difficult to implement effectively
Monitoring tool considerations

45. Quaternary ammonium Advantages Disadvantages
Bactericidal, fungicidal, virucidal against enveloped viri (HIV)
Not sporicidal, generally not tuberculocidal,
Generally not good against non-enveloped viri
Good cleaning agent **
High water hardness issues
Cotton may affect actions
Affected by organics
Surface compatible
Rare cases of respiratory asthma
EPA registered

46. Alcohols Advantages Disadvantages Microbicidal Fast Acting Easy
Good for small surfaces
No toxic residue
Not sporicidal
Affected by organics
No cleaning properties
Not EPA registered
Damages some materials
Flammable
Rapid evaporation
Cannot be used on large surfaces

47. Iodophores Advantages Disadvantages
Bactericidal, mycobactericidal, viricidal
Prolonged contact for fungi
Not sporicidal
Damage silicone
Antiseptic vs. disinfectant

48. Chlorine Advantages Disadvantages Broad spectrum
5% can cause tissue damage
No toxic residue
Fast acting
Inexpensive
Corrosive to metals (>500 ppm)
Inactivated by organics
BLEACH!
Unaffected by water hardness
Low incidence of serious toxicity
Reduces biofilms
Stable
Used in potable water
EPA registered
Toxic gases if mixed with ammonia
Hazard is trihalomethane

49. Phenolic Advantages Disadvantages
Bactericidal, mycobactericidal, viricidal, fungicidal $
EPA REGISTERED
Skin irritant
Problem for infants
Not sporicidal

50. Improved H2O2 Advantages Disadvantages 30-60 second bactericidal
5 min mycobacterial claim
Safe (low EPA toxicity category)
Benign
No organic issues
Surface compatible
Non-corrosive
Non-staining
EPA REGISTERED
$$$$

51. Evaluating Patient Zone Environmental Cleaning
Method
Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in Programmatic Improvement
Covert Practice
Low No
Yes
1 Hospital
Swab cultures
High
Not Studied
Potentially
Agar slide cultures
Good
Limited
Fluorescent gel
49 Hospitals
ATP system

53. Swab surface luciferace tagging of ATP Hand held luminometer
What is clean?
Swab surface luciferace tagging of ATP Hand held luminometer

54. ATP Bioluminescence Testing in Healthcare Settings
Potential usefulness:
Has been used as a surrogate for environmental culturing
Evaluates cleanliness
Can rapidly define how clean an object is…. but non-microbial ATP is also evaluated
Standards to optimize predictive values are still being evaluated
Can be used to do one-on-one education of ES staff

55. ATP Bioluminescence Testing in Healthcare Settings
Potential limitations:
Secondary cleaning of the site is required to remove disinfectant induced signal decay or enhancement.
Involvement of the ES staff is implicit since evaluation must be done within minutes of cleaning.
Pre-intervention evaluation of disinfection cleaning is difficult without inducing a Hawthorne effect
Results are individual ES staff / time specific.
Many manufacturers of luminometers and ATP swabs makes interinstitutional standardization difficult

56. The challenge of using a cleanliness tool to evaluate cleaning
Sherlock O, O’Connell N, Creamer E, Humphries H. J Hosp Infect (2009)72;

57. http://www. cdc. gov/HAI/toolkits/Evaluating-Environmental-Cleaning

58. When in darkness so deep I move with an especially slow foot.
Remember:
While surface cleaning in the patient zone is important, we really don’t know:
How important which disinfectant is;
How much better microfibre is than traditional cloth for surface cleaning;
When to use bleach and when not to;
When technological interventions should be considered

59. Fluorescent markers Advantages Disadvantages Inexpensive
Minimal equipment investment
Improve practices
Covert marking of systems
NB: do not use oil-based or powder based products

60. Important disinfecting thoughts
Proper dilution – more is not better!
Employee safety
Environmental safety
Exposure limits (Permissible exposure level)
Compatibility (gloves, basins, other products) [chlorine and ammonia]

61. Musing Cleaning and disinfecting of patient care equipment –
Who cleans the:
Ventilator
IV pole
Rolling Stock (wheel chairs, suction machines)
How do you know it clean?
How frequently should it be cleaned
Should it be cleaned or disinfected

62. Cleaning/Disinfecting Strategies in Surgical Care Areas
Train and verify competency of staff
End of the day terminal cleaning for Every OR, scrub room, and service room.
-Lights and horizontal surfaces of equipment.
-Anesthesia cart
Guidelines: AORN, AAMI

63. EPA
To effectively regulate pesticides, it has always been important that we understand how they are used

64. Sterilant EPA definition
A substance that destroys or eliminates all forms of microbial life in the inanimate environment, including all forms of vegetative bacteria, bacterial spores, fungi, fungal spores, and viruses (sic)”

65. What did Sir Thomas Sydenham have to say about evolving new technologies to replace or enhance healthcare environmental hygiene?

66. When in darkness so deep I move with an especially slow foot.
What did Sir Thomas Sydenham have to say about evolving new technologies to replace or enhance healthcare environmental hygiene?
When in darkness so deep I move with an especially slow foot.

67. Syntax for cynics
Fogging
Vapor
Mist
2003 CDC guidelines

68. Considerations for new products
Implementation and training plan
Facility and room preparation
Costs of equipment and consumables
Costs of supervision and training
Changes in existing protocols and processes
Turn-around time
Advertising

69. Vaporized Hydrogen Peroxide
Advantages
Disadvantages
Efficacious against wide range of pathogens
Role of environment is very small compared to other things
Surfaces and equipment decontaminated
Cannot be done daily or in occupied room
Decrease incidence of disease
Environment is easily recontaminated
Little or no residue, minimal health concerns
Not safe for use around people
Uniform distribution (no shadows)
Increase in time required for process
Useful with complex equipment
Need to control dispersal (HVAC)
Broad spectrum
Costs
Not cleaning
Physical variables (concentration, temperature, humidity)
Unknown effects on equipment
After: AJIC WA Rutula, DJ Weber 41 (2013) s36-41

70. Vaporized hydrogen peroxide
Hydrogen peroxide (H2O2)
Gaseous phase
Registered by the EPA as a sterilant
H2O2 first registered in 1977 (antimicrobial pesticide)
Indoor use only
Hard and non-porous surfaces
Generated by device specifically created to make a vapor

71. H2O2 vapor Circulated at programmed concentration Catalytic convertor
H2O2 > H2O + O2 (non-toxic)
Vented outside, no degradation necessary
PEL - <1 ppm
NIOSH – immediate danger to life and health (IDHL) <1 ppm (TWA)

72. Danger
Pesticide laws
Application of agent in a manner inconsistent with labeling
Monmouth-Ocean Hospital Corporation – ambulance fogging
Sporicidin ® as well

73. Decontamination with H2O2
Disadvantages:
Only done at terminal disinfection (i.e., not daily cleaning)
All patients and staff must be removed from the room/area
Capitol equipment costs are substantial
Does not remove dust and stains which are important to patients/visitors
Sensitive use parameters (e.g. dose delivered)

74. uV light Wave length specific Multi-factorial efficacy
Destroy DNA of host organisms ( nm)
Multi-factorial efficacy
Intensity
Exposure time
Lamp placement
Air movement patterns

75. uV light Not a new concept Disinfection of stuff Radiation sensitivity
Operating rooms
Microbiology hoods and laboratories
Disinfection of stuff
Air
Water
Radiation sensitivity

76. UV susceptibility S.Aureus S.Pyogenes E.Coli P.Aeruginosa S.Marcescens
Least susceptible
Most Susceptible
S.Aureus
S.Pyogenes
E.Coli
P.Aeruginosa
S.Marcescens
M.Tuberculosis
B.Anthracis
B.Cereus
A.Versicolor
P.Chrysogenum
S.chartarum
Infection Control Today, November 2011: Pyrek, KM:

77. Decontamination with UVC
Disadvantages:
Do not know if use decreases the incidence of HAIs
Only done at terminal disinfection (i.e., not daily cleaning)
All patients and staff must be removed from the room/area
Capitol equipment costs are substantial
Does not remove dust and stains which are important to patients/visitors
Sensitive use parameters (e.g., UV dose delivered)

78. The future Antimicrobial “self disinfecting” surfaces
Air disinfection units
Early identification of at risk patients
Single rooms
Source control
Better staff education

79. Issues with disinfectants, detergents, cloths, etc.
What is the true role of bleach in disinfection cleaning?
How effective will new green disinfectants be?
When is it okay to use detergents?
Where are we going with dwell time?
Where does microfibre fit in?
If effective killing with bleach takes many minutes, what is the clinical efficacy of bleach wipes?
What is the correct amount of quat?
Are disinfectants being mixed accurately?
Background:
This slide provides a summary of the state of the current confusion regarding how to maximize surface disinfection with respect to products used in such practices. Over the past few years we’ve really come to a much clearer understanding that we have very little practical clinical “evidence based” information to provide guidance to healthcare workers when it comes to these issues. Hopefully, studies which are now being started to be carried out which will evaluate both thoroughness of cleaning as well as various products and approaches will start to shed some light on the relative importance of product vs. practice in the real world of HAP transmission prevention.
Key Points:
We do not have the answer to any of these questions, but scientists are working to answer them in the next 5 years. 79

80. Considerations for bacteria
ICU room cleaning decreased MRSA transmission
VRE carriers contaminated the room in spite of environmental cleaning
VRE persists x 3 cleaning episodes
Multi-faceted problem
Data for other pathogens

81. Key References
Dancer SJ. The role of the environmental cleaning in the control of hospital acquired infections. J Hosp Infect. 2009; 1-10.
Carling PC, Bartley JM. evaluating hygienic cleaning in healthcare settings: What you don’t know can hurt your patients. Am J Infect Control 2010;38 S41-50.
CDC/HICPAC. Guidelines for environmental infection control in health care facilities. MMWR 2003;52:No. RR-10.
Cleaning.html. October 2010.
Rutula WA, DJ Weber. Disinfectants used for environmental disinfection and new room decontamination techology. AJIC 2013; 41 S36-41

82. Attribution
The core materials were prepared by the Society of Healthcare Epidemiology of America (SHEA) for use by the CMS to train state HAI coordinators.

83. Conclusions
It is very likely that surfaces in the Patient Zone are highly relevant in the transmission of Healthcare Associated Pathogens.
While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.

84. Now is the time to carefully evaluate the role of product and technology in the clinical setting
Old assumptions and new claims of effectiveness of all tools, chemicals and technological interventions must:
be quantitatively evaluated clinically while objectively analyzing the thoroughness of cleaning practice
Key Points:
It’s important that any evidence of effectiveness for new technologies (tools, chemicals, interventions):
Be evaluated in a clinical environment
Provide quantitative data on outcomes of relevance to clinical settings
Include objective analysis of the thoroughness of cleaning practice 84