1. Recent Advances in Environmental Asepsis
Heather Hohenberger, BSN RN CIC CNOR
Quality Improvement Consultant
Indiana University Health, Academic Health Centers

2. Conflicts of Interest
The presenter has no conflicts of interest to disclose

3. Objectives After attending this course, participants will be able to:
List several recent studies addressing the role that surfaces play in the transmission of healthcare-associated infections
Identify trends in environmental asepsis in the procedural environment
Describe new technologies that can be used to routinely evaluate the quality of environmental hygiene

4. 2014 Updates to the AORN Recommended Practice for Environmental Cleaning

5. Additions Recommendations for cleaning and disinfection in the
Pre/Post operative patient care area
Operating and Procedure Rooms
Sterile Processing areas
Enhanced cleaning recommendations for multi-drug resistant organisms
Quality and process improvement recommendations for evaluation of thoroughness in all applicable areas

6. Multidisciplinary Approach
Strong recommendation for collaboration between Infection Prevention, Environmental Services, and organizational leadership regarding
Selection of cleaning chemicals
Selection of cleaning materials, tools, and equipment
Establishment of cleaning frequencies
When enhanced environmental cleaning procedures should occur
Personnel responsible for cleaning patient care areas and equipment

7. Cleaning Chemicals
Environmental protection agency (EPA) registered hospital-grade disinfectants should be used on environmental surfaces and equipment
Surfaces should be cleaned with a detergent prior to disinfection
Disinfectants should be applied and reapplied as needed to ensure proper dwell time
Spray and misting methods should not be used to apply cleaning chemicals in procedural areas

8. Regulations Safety data sheets must be available and reviewed
Follow manufacturer’s instructions for use along with local, state, and federal regulations for the preparation, handling, storage, and disposal of all chemicals
If the cleaning chemical is removed from the original container, ensure the secondary container is labeled with the chemical name, concentration, and expiration date

9. Patient Safety Assess the environment frequently for cleanliness
Floors should always be considered contaminated
Protective barrier coverings should be used to cover surfaces if the surface cannot withstand disinfection or is difficult to clean
Equipment should be cleaned and disinfected before being brought into the patient care area
All patient positioning equipment should have a moisture-resistant and intact covering

10. Patient Safety
A clean environment should be reestablished after the patient is transferred from the patient care area
Procedural areas should be terminally cleaned
An established schedule should be determined for terminal cleaning

11. Staff Safety
All personnel should take precautionary measures to limit transmission of microorganisms when performing environmental cleaning and handling of waste materials
Appropriate personal protective equipment (PPE) use

12. Education Requirements
All personnel should receive initial and ongoing education and competency verification on their understanding of the principles and the performance of the processes for environmental cleaning
Cleaning / disinfection products available
PPE requirements for chemical use
Reconstitution ratios (if applicable)
Product expiration parameters
Storage, handling, and disposal requirements
Safety data sheet location

13. Cleaning Policies
Policies and procedures for environmental cleaning processes and practices should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting

14. Quality Assurance
Personnel should participate in quality assurance and performance improvement activities consistent with the facility’s plan to improve understanding of and compliance with the principles and processes of environmental cleaning
Ongoing feedback can show if problems are improving, stabilizing, or worsening
Obtaining data from quality assurance or performance improvement tools can
tell if benchmark goals are met
identify areas where additional help is needed

15. Process Monitoring
Process monitoring is a necessary part of every facility’s environmental cleaning program
Process monitoring must include
compliance with regulatory standards
review of products and manufacturers’ instructions for use
cleaning procedures
monitoring cleaning and disinfection practices
reporting and investigation of adverse events
outbreaks, product issues, corrective actions, evaluation
What is process monitoring? This means a standard way to look at what is occurring in the facility; are we following regulations, do we have access to the product instructions for use, and are we cleaning and disinfecting correctly. And if something happens, an “adverse event”, how does this get reported? How is it corrected so it does not happen again? If a procedure is changed, we look at how the change affects our cleaning processes. For example, did the change make a positive difference?

16. How should cleanliness be measured?
Thoroughness of cleaning is the focus of performance improvement
Measure cleaning practices
visual observation of the cleaning process
visual inspection of cleanliness
fluorescent marking
ATP monitoring
cultures
Multiple measures should be used as a comprehensive assessment of environmental cleaning practices. Identify what types of measurement are used in your facility for team members now. Explain the process used at your facility so team members have clear idea and expectations. The information gathered by measuring cleaning practices can be used to drive process improvement activities, encourage compliance with established cleaning protocols, educate team members, and verify the competency of team members.

17. AORN Environmental Cleaning toolkit

18. AORN Environmental Cleaning toolkit
Purpose
educate all team members about the recommended practices on cleaning the perioperative environment
promote patient safety
prevent the spread of infection in the perioperative environment
Available at

19. AORN Environmental Cleaning toolkit
Resources
Modules – Power Point presentations used for orientation, review, annual competencies
Checklists – Specific for each practice setting, the cleaning checklists can be used for documentation and education
Posters – Helpful tools for quick reminders when providing targeted education for staff

20. Toolkit Modules Module 1 - Environmental Cleaning: Basics
Module 2 - Environmental Cleaning: Preoperative and Postoperative Areas 
Module 3 - Environmental Cleaning: OR and Procedure Rooms  
Module 4 - Environmental Cleaning: Sterile Processing Areas  
Module 5 - Special Cleaning Procedures 
Module 6 - Quality and Process Improvement 

21. End of Procedure Cleaning in the OR or Procedural Room
Discuss this slide with personnel. Have them point out objects in the picture and identify the frequency of cleaning. Make this interactive so personnel can really understand the purpose behind the recommended cleaning practices.
Adapted with permission from Perioperative Standards and Recommended Practices. Copyright © 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO All rights reserved.

22. Terminal Cleaning in the Preoperative and Postoperative Care Area
Have team members identify items that are to be cleaned and talk through the process.
Adapted with permission from Perioperative Standards and Recommended Practices. Copyright © 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO All rights reserved.

23. What should be cleaned first?
Clean from
top to bottom
clean to dirty areas
Clockwise or counter-clockwise cleaning may be performed when used along with clean-to-dirty and top-to-bottom cleaning methods

24. Cleaning
Discuss this slide with personnel. Have them explain what this means. Make this interactive so personnel can really understand the purpose behind the recommended cleaning practices.

25. Sample Cleaning Checklist Pre/Post Procedural Areas
Pre- and Postoperative Areas
Cleaning Checklist—Patient Discharge
Completed
Patient monitors
Patient beds
Over-bed tables
Television remote
Call lights
Mobile and fixed equipment
Suction equipment
Medical gas regulators
Imaging monitors
Radiology equipment
Warming equipment
Floors and wall if soiled or potentially soiled (eg, splash, splatter, or spray).
Patient transport vehicles including the straps, handles, side rails, and attachments should be cleaned and disinfected after each patient use.

26. Cleaning & Disinfection
Chain of Infection
Microorganism
Reservoir
Portal of Exit
Means of Transmission
Portal of Entry
Susceptible Host
Cleaning & Disinfection
Hand Washing
The chain of transmission is a series of well defined events or entities that need to occur in a pattern for an infection to happen. We can decrease the chance of a patient getting an infection by breaking any one of the links in this chain. (describe the links) By targeting the means of transmission (the way germs get around) and the reservoir (hiding places where germs can live on surfaces) we decrease the amount of infectious agents (the germs) before they can ever reach the susceptible host (the patient who could get sick).
Waste Removal
Hand Washing

27. Hand Hygiene Hand hygiene must always be performed when you remove PPE
as soon as possible after hands are soiled
Discuss with personnel that hand hygiene is the number one way to stop the spread of infection. Lack of proper hand hygiene can not only potentially infect the personnel, but other patients if a microorganism is on their hands. Talk about hand hygiene using alcohol based hand rubs and traditional hand washing with soap and water. If hands are visibly soiled, washing hands with soap and water is required.

28. Current Discussions in Healthcare Environmental Asepsis

29. Hot Topics One-step vs. Two-step cleaning / disinfecting
ATP testing / Fluorescent marking
Ultraviolet / Solar disinfection
Copper / Silver containing disinfectants

30. One-step verses Two-step

31. Cleaning / Disinfection
The absence of visible dust, soil, debris, blood, or other potentially infectious material
The “first step”
Disinfection
A process that kills most forms of microorganisms on inanimate surfaces
The “second step”

32. One-step verses Two-step
One-step product – combines detergent and disinfectant, typically packaged as single-use wipes
Two-step products – separate detergent and disinfectant, requires user to perform cleaning and disinfection in two separate steps
*Products shown are for demonstration only

33. One-step Wipes
Various terminology used by wipe manufacturers make it difficult to choose which wipe will best fit the organizations needs
Sanitizing
Disinfectant
Germicidal
Sporicidal
Virucidal
Antibacterial
*Products shown are for demonstration only

34. Disinfectant Wipes
While wipes have gained tremendous popularity, there is poor evidence to support efficacy at the point of care
Effectiveness of the wipe depends on…
Detergency – ability to remove dirt on a visibly soiled surface
Wetness – ability to leave a layer of disinfectant on the surface of objects / equipment
Disinfectant efficacy – once the surface is dry disinfection stops, if residue is left behind there is no further antimicrobial effect

36. Wipe it Out
Royal College of Nursing produced “The Selection and Use of Disinfectant Wipes”
Ultimate resource for thorough understanding of benefits and limitations of one-step wipe products
Available at

37. Infection Control Resources
“Proper Use of Healthcare Disinfectants: The Implications Associated with Off-Label Use of Disinfectants”
Available at
“Infection Control Facts: How to Select an Ideal Disinfectant”
Available at

38. ATP testing verses Fluorescent marking

39. ATP testing vs. Fluorescent marking
CDC recommends all facilities develop programs to evaluate the thoroughness of high-touch object cleaning
Emerging technologies take evaluation of cleaning and disinfecting beyond direct observation and checklists
Subjective evidence verses objective evidence

40. Objective Methods for Evaluation
Direct practice observation
Swab cultures or agar slide cultures
ATP bioluminescence
Fluorescent markers

41. ATP Testing
Measurement of adenosine triphosphate (ATP) on surfaces using a luciferase assay and luminometer
Method
Before room cleaning / disinfection occurs, a specialized swab obtains a sample from the surface area or object
The swab is placed in the portable hand-held luminometer which identifies the amount of ATP in the sample
After cleaning / disinfection has occurred, the items are swabbed and analyzed again

42. ATP Testing Advantages Disadvantages Easy to use
Immediate teaching and feedback
Disadvantages
Results vary between systems
A threshold value has not been determined in the healthcare setting for determining clean / contaminated
Significant amount of ATP in the environment is non-microbiological
Bleach based disinfectants alter the bioluminescence reaction
Viruses and bacterial spores do not contain ATP

43. Fluorescent Marking
Fluorescent powder, gel, or lotion can be used to mark objects prior to cleaning
Method
Objects are marked before cleaning occurs
Evaluation occurs by shining a UV (black) light over the object to see if the product has been removed

44. Fluorescent Marking Advantages Disadvantages Ease of use
Immediate teaching and feedback
Disadvantages
Some markers can be seen after the mark is applied, alerting the individual to clean the tagged object more thoroughly
Some marking products can be difficult to remove from surfaces and equipment, leaving permanent stains

45. Comparison Method Ease of Use Identifies Pathogens Useful for Teaching
Directly Evaluates Cleaning
Direct Observation
Low No
Yes
Swab cultures
High
Unknown
Not determined
Agar cultures
Good
Limited
ATP
Fluorescent marking

46. Comparing ATP Monitoring Units
Article on ISSA Web site “Using an ATP Monitoring System in Healthcare Settings”
Representatives from each major industry provider of ATP monitoring systems in healthcare contributed their perspective of ATP integration into practice
Available at

47. Current Research - ATP
Sciortino, C.V., & Giles, R.A. (2012). Validation and comparison of three adenosine triphosphate luminometers for monitoring hospital surface sanitization: A Rosetta Stone for adenosine triphosphate testing. American Journal of Infection Control, 40(8), pp. e233.
Validation occurred for all three meters tested, but only one could be verified due to variations in system performance between units
Recommends careful consideration of technologic application in the healthcare environment

48. Current Research – Marking
Presentation at the International Conference on Healthcare-Associated Infections (2010) by Rupp, M.E., Adler, A, Schellen, M., Cassling. K., Lyden, E., Fitzgerald, T., Sholtz, L., & Carling, P. “Hospital-wide Assessment of Patient Room Environmental Cleanliness”
With the use of fluorescent marking, 10 high-touch surfaces were evaluated for cleaning efficacy
74% of high-touch surfaces were adequately cleaned

49. Several studies have shown us two certainties…
Cleaning practices are often subpar
Improvements made through education and feedback do not last
This leads us to reach out for new technologies that can be applied to the healthcare environment

50. Ultraviolet verses Hydrogen peroxide

51. Ultraviolet vs. Hydrogen peroxide
Manual cleaning / disinfection relies on the individual to follow manufacturer’s stated contact time and appropriate distribution of the chemical across surfaces
Even with vigorous cleaning, multidrug resistant organisms (MDROs) can remain in the environment for months
Both methods have published evidence of reduction of contamination in the healthcare setting

52. Ultraviolet Light
Acts by breaking down the molecular bonds of DNA, causing cell destruction
Requires appropriate intensity, exposure time, air movement, and bulb strength
Can be used as an adjunct to manual cleaning / disinfecting practices

53. Hydrogen peroxide
Acts by releasing the oxygen (oxidizing) from within the cell membrane of organisms, leading to cell death
Available as a vapor, aerosolized dry mist, and vaporized hydrogen peroxide
Active against bacteria, fungus, viruses, and spores
Numerous systems available in various price ranges
Can be used as an adjunct to manual cleaning / disinfecting practices

54. Comparison Method Advantages Disadvantages UV light
Effective against a wide range of organisms
Ease of use
No need to seal off air supply
Expense
Requires furniture movement
Must be placed in middle of the room
Use in unoccupied room only
Hydrogen peroxide
Effective against a wide range of pathogens
More effective than manual disinfection
No toxic by-products
Disinfection of complex equipment
Room must be unoccupied
Requires sealing room and air supply
Time
Logistical issues

55. Current Research – UV light
Rutala, W., Gergen, M., & Weber, D. (2010). Room decontamination with UV radiation. Infection Control & Hospital Epidemiology, 31(10), pp
Boyce, J., Havill, N., & Moore, B. (2011). Terminal decontamination of patient rooms using an automated mobile UV light unit. Infection Control & Hospital Epidemiology, 32(8), pp
Both studies showed significant reduction of organisms despite high levels of contamination, including C diff spores

56. Current Research – Hydrogen peroxide
Falagas, M., Thomaidis, P., & Kotsantis, K. (2012). Airborne hydrogen peroxide for disinfection of the hospital environment for infection control: A systematic review. Journal of Hospital Infections, 78(3), pp
Study shows vapor or dry mist distribution of hydrogen peroxide can effectively disinfect the hospital environment

57. Copper verses Silver-containing Disinfectants

58. Copper
Acts by altering the structure of proteins, leaving them unable to perform their natural functions (inactive)
Used in self-disinfecting surfaces
Not a cleaning / disinfection strategy, rather this is a proactive approach to decreasing microbial load

59. Silver Containing Disinfectants
Action is not entirely understood, but believed to have a germicidal effect on some bacteria, viruses, algae, and fungi
Not toxic to humans
Testing and standardization is difficult in the healthcare setting
Used in self-disinfecting surfaces
Not a cleaning / disinfection strategy, rather this is a proactive approach to decreasing microbial load

60. Comparison Method Advantages Disadvantages Copper Not user dependent
Continuous action
Corrosion
Can irritate skin
Expense
Few studies available for result validation
Silver
No studies in the healthcare environment

61. Current Research – Copper
Karpanen, T., Casey, A., & Lambert, P. (2012). The antimicrobial efficacy of copper alloy furnishing in the clinical environment: A crossover study. Infection Control and Epidemiology, 33(1), pp. 3-9.
Study found a reduction in organisms in the healthcare environment with the use of copper alloy materials
However, the items must contain greater than 58% copper

62. What is on the horizon for cleaning and disinfecting in healthcare?

63. Healthcare Cleaning “Bundles”
Havill, N.L., (2013) “Best practices in disinfection of noncritical surfaces in the health care setting: Creating a bundle for success” American Journal of Infection Control, 41(5), supplement, pp. S26-S30.
Steps include
Creating policies and procedures
Selection of cleaning products
Determining method of application
Education
Monitoring
Providing feedback

64. References
AORN Recommended Practices for Environmental Cleaning (2013).
AORN Environmental Cleaning toolkit (2014).
Association for the Healthcare Environment of the American Hospital Association. (2012) Practice Guidance for Healthcare Environmental Cleaning (2nd Ed.)
Royal College of Nursing. (2011) Wipe it out; One chance to get it right.

65. Questions?

66. Contact Information
Heather Hohenberger, BSN RN CIC CNOR
Quality Improvement Coordinator
Indiana University Health, Academic Health Centers
(317) – office