1. Clean Equipment & Environment Knowledge and Practice
Training Module # 2 for the LTC Core Team
Welcome to training module 2 titled, “Clean Equipment & Environment Leads: Knowledge and Practice.” This is the second training module of the series for the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care: Healthcare-associated Infections/CAUTI. This brief module is intended for facility team leads and core team members. It will introduce you to how the environment and equipment in a facility can be a source of potential bacterial and viral infections. Additionally, this training will highlight how to educate and engage all facility staff on this issue as you actively participate with all staff in the second video.
[This content was developed under the expertise and clinical guidelines of the national project team as of July 2015.]
Current as of July 2015

2. Learning Objectives
Upon completion of this session facility team leads and core team members will be able to:
describe the chain of infection and identify key strategies to break the chain;
explain catheter care and maintenance strategies facility staff can use to prevent residents from acquiring a catheter-associated urinary tract infections (or CAUTIs);
explain the role of the environment as a place where pathogens can become a source of infection for residents and staff; and
summarize strategies to improve cleaning and disinfecting practices using the training materials for all facility staff.
Concerns about a facility’s infection prevention program may point to practices and policies surrounding cleaning and disinfecting surfaces, supplies and equipment. However, it’s important to remember that knowledge of how to clean and disinfect surfaces only goes so far. During this presentation, we are going to review how to break the chain of infection through catheter care and maintenance strategies; review the role the environment plays for pathogens to become a source of infection for residents and staff; and review strategies that facility teams can deploy to ensure staff have access to cleaning and disinfecting surfaces, as well as ways to monitor cleaning and disinfection.

3. Protecting Residents Against Infection
The Chain of Transmission: 6 Links
Each link stands for something (or someone) that helps pass on an infection.
An infection can be passed from one person to another person as long as the links of the chain are joined together.
Chain of
Infection
Infectious Agent
(Viruses or Bacteria)
Resident
(Reservoirs)
Exit Resident
(Portal of Exit)
Mode of Transmission
Entry of New Resident
(Entry Portal)
New Resident
(Susceptible Host)
Let’s start with this picture that shows the chain of infection.
[CLICK]
It demonstrates how infectious agents can move from one person to the next and possibly spread throughout an entire facility. Residents and staff can act as pathogen reservoirs and then infectious agents can be released via an open wounds, bodily fluids, stool, etc. This is know as the portal of exit. Next these pathogens “go mobile.” In other words, they are transmitted by our hands, a contaminated surface or a piece of equipment that is used between residents (mode of transmission). Next the pathogen enters the body of a new person in the chain, continuing and spreading the infection.
Indwelling urinary catheters are important medical devices that can be essential to provide high quality resident care; however, improper care and maintenance can introduce infections in residents, leading to CAUTIs and other healthcare-associated infections (HAIs).
Essentially, catheters can provide a portal for microorganism’s to gain entry when proper care and guidelines are not maintained.
Siedlaczek G. SJMHS

4. Breaking the Chain of Infection The Role of LTC Facility Staff
The Chain of Transmission: 6 Links
How Can HCW Break the Chain of Infection?
Education
Hand hygiene
Gloves
Clean rooms
Disinfect surfaces
Proper medical device care and maintenance
Ensure residents have:
Good personal hygiene
Covered cuts/wounds
Isolation when necessary
No unnecessary antibiotics
Proper waste disposal
Chain of
Infection
Infectious Agent
(Viruses or Bacteria)
Resident
(Reservoirs)
Exit Resident
(Portal of Exit)
Mode of Transmission
Entry of New Resident
(Entry Portal)
New Resident
(Susceptible Host)
So how do we keep our residents and ourselves safe?
[CLICK]
Long-term care staff play a crucial role in breaking the chain of infection. Proper education and training are key at every point in the chain. Education and training allow staff to:
Understand which infectious agents pose a threat to residents.
Identify which residents are at risk to act as reservoirs.
Describe how residents might release these pathogens and what precautions should be taken.
Recite how these organisms “go mobile” and what can be done to prevent it.
Recognize how to protect other residents who are not sick.
Know what steps should be taken if a resident is exposed to a new infectious agent.
Proper indwelling catheter care by the staff is vital at breaking the chain of infection because catheters provide a portal for microorganism entry when proper care and guidelines are not maintained.
Staff also interrupt the chain of infection by helping to prevent residents from being a portal exit. Front- line staff help residents with good personal hygiene, proper waste disposal and dressing open wounds or sores—all of which help prevent pathogens that are in one individual from exiting the body and spreading to another person.
Finally, staff are key in breaking the chain of infection by preventing pathogens from “going mobile” or spreading throughout the facility. Good hand hygiene, proper glove use, cleaning resident’s rooms, disinfecting surfaces and equipment and using isolation precautions when necessary are just some of the ways staff prevent pathogen transmission.
Today’s training module will focus on how staff can prevent the entry of pathogens into residents and disrupt pathogen transmission.
Siedlaczek G. SJMHS

5. The Usual Bacteria Suspects: Multidrug-resistant Organisms (MDROs) Common in LTC
What pathogens are we talking about? Here’s a closer look at the types of bacteria that often lead to HAIs and CAUTIs in long-term care facilities. Many of them have noted antibiotic resistance. They include:
Methicillin-resistant Staphylococcus aureus—a bacteria better known as MRSA, which is very resistant to antibiotics.
The family of bacteria called Enterobacteriaceae, which are often carbapenem-resistant. These bacteria are commonly called CRE.
Clostridium difficile or C. diff
Pseudomonas; and
Vancomycin-resistant Enterococcus or VRE
One recent study found these antibiotic resistant organisms are more likely to be present in or on a resident if they have an indwelling urinary catheter or other internal device, like a feeding tube. It is important to note that these organisms can stay on surfaces much longer than one might think. Training Module 4 will provide more details about the growing problem of antibiotic resistance.
Residents with a indwelling catheter are more likely to have one of these MDROs
Mody L, et al. Clin Infect Dis 2011;52:654-51

6. Front-line Staff Training Recap
Microbes can enter an indwelling urinary catheter’s closed system during insertion, care and maintenance of the catheter and drainage bag
Conduct routine hygiene of the resident and remember hand hygiene
Stabilization devices reduce irritation that may increase the risk for serious infection
Urine measuring devices should never be shared, and should be cleaned and dried between use
In the all staff training video on environment and equipment we review in greater detail how indwelling urinary catheters can be pathways for microbe entry into residents.
Microbes can enter an indwelling urinary catheter’s closed system during insertion, care and maintenance and through the drainage bag, so it is important that staff conduct routine hygiene of the resident. It is also important to remind staff that they should be performing hand hygiene both immediately before and after caring for the resident or handling their catheter.
Staff should ensure that the catheter is stabilized and that the drainage bag is below the bladder and secured.
It is also important to only have one urine measuring device per resident that is cleaned properly between use. If this is not common practice in your facility, now is the time to make the change so that facility staff can follow proper safety measures to reduce the spread of HAIs and CAUTIs.

7. Entry Pathways for Microbes
Aseptic technique plays a key role in preventing catheter or drainage bag contamination
Routine hygiene is important
Disinfect the port before obtaining a urine culture
Check catheter, tubing and drainage bag for disconnection, kinks
As we noted, proper catheter care and maintenance are essential to reduce pathogens entry into the closed catheter system.
[CLICK]
I mentioned on the previous slide that the catheter itself can act as a key highway for microbes to get into that resident. Using aseptic technique when inserting a urinary catheter is very important. Getting a buddy to assist is helpful.
Once the catheter is in place the best way to limit pathogen entry is to provide routine hygiene for the resident. Remember hand hygiene practices before and after caring for the resident and handling the catheter or drainage bag.
There is no need for daily cleansing with an antimicrobial soap or anything like that. Staff should clean around the urethra where the device has been placed as they would normally do. It is also important to remember hand hygiene practices.
The sampling port of the indwelling urinary catheter is another way that contamination can be introduced to the closed system. Staff should disinfect the port with an alcohol swab for 15 seconds before collecting a urine specimen. It’s important while caring for the resident to ensure the catheter has not become disconnected from the drainage system.
If the drainage bag is open, say for emptying, and if it is not resealed properly, as the arrow indicates, then this can be another potential way for bacteria to get into that patient's bladder. Staff should make sure to clean the outlet after emptying the bag and restore it back to its holding position. Review and follow the instructions specific to the catheter bag your facility uses. It may be useful to have the instructions available during the all staff training to review with them.

8. Hand Hygiene Good Better Best Plain soap Antimicrobial soap
Much of what was mentioned on the last slide goes back to the fundamentals of hand hygiene. You may want to briefly review with staff the hand hygiene techniques and principles discussed during Training Module 1.
The are four main opportunities for hand hygiene:
Before initial contact with the resident or their environment. This includes hygiene of the resident, caring for the catheter or drainage bag, when handling the urine collection measuring device.
Before aseptic or clean procedures, such as placing a urinary catheter or a peripheral IV.
After body fluid exposure risk, including after emptying a urinary catheter collection bag and handling the urine collection measuring device
After any contact with the resident or his/her environment as you are exiting the room.
And for almost all pathogens found in the LTC environment, alcohol-based hand rubs are superior to antimicrobial soaps and should be used to maintain proper hand hygiene.
Good
Better
Best
Plain soap
Antimicrobial soap
Alcohol-based hand rub

9. Protecting Residents Against Infection Role of Clean Equipment and Environment
Factors associated with increased risk of infection in
residents include1:
Lower level of cleanliness
Higher frequency of odors
High turnover rate of nurses
Fewer certified nurses’ aides/100 beds
The importance of maintaining both clean and disinfected equipment as well as the environment will prevent germs from going mobile.
Preventing pathogen transmission is another key interruption point in the chain of infection.
Evidence shows that the environment and equipment in residents’ rooms and common areas can increase their risk of infection. Studies have found that low levels of cleanliness and high frequency of odors are associated with the resident’s increased risk of infection.
Zimmerman S, et al. JAGS 2002;50:

10. MRSA and the Environment
Methicillin-resistant Staphylococcus aureus (MRSA) is a growing problem in LTC
A study of 10 long-term care facilities found MRSA present on 16% of surfaces tested.
MRSA was more often present in residents’ rooms that were cleaned less frequently and for less time
Methicillin-resistant Staphylococcus aureus
MRSA
Methicillin-resistant Staphylococcus aureus or MRSA, is frequently present on surfaces or equipment in long-term care facilities. MRSA often causes skin infections because it is primarily present on the skin. If there are breaks or redness in the skin, MRSA can get into deeper layers and cause more serious infection, including bloodstream infections. MRSA can also cause pneumonia.
One study of 10 long-term care facilities in California found that MRSA was present on 1 of every 6 surfaces they tested. Contaminated surfaces included everything from health care equipment to dining room tables and chairs to handrails and doorknobs.
MRSA is transferred to these surfaces from individuals that have an active infection or the bacteria on their skin. MRSA can survive on surfaces for as long as several months, spreading the bacteria to other residents and staff at the facility.
Murphy CR, et al. JAGS 2012;60:

11. Survival of Select Microbes on Environmental Surfaces
Microorganism
Survival on Environmental
Surfaces
Bacteria
Clostridium difficile (C. diff.) spore
> 1 yr.
Vancomycin-resistant Enterococci (VRE)
5 days – 4 months
Methicillin-resistant Staphylococcus aureus (MRSA)
7 days – 7 months
Viruses
Hepatitis B virus (HBV)
> 1 week
Human immunodeficiency virus (HIV)
3-4 days
Norovirus
8 hrs – 7 days
This table highlights common long-term care facility pathogens:
Clostridium difficile (C. diff)
Vancomycin-Resistant Enterococci (VRE)
MRSA
Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV) and
Norovirus
Research has shown that these bacteria and viruses are present in or on the surfaces in a long-term care facility. But how long can they really survive on exposed surfaces?
The short answer is…a pretty long time, depending on the microbe. For example, C. diff can form a spore, which can last a year or more on surfaces. Although most bacteria survive from a couple days to several months. Viruses can also be present in long-term care facilities and they tend to last for several days.
Proper cleaning and disinfecting are important ways keep surface pathogen levels low and prevent infections from spreading to other residents.
Kramer A. BMC ID 2006; McFarland L, et al. AJIC 2007

12. represents positive VRE culture sites – ready for next patient?
MDROs Can Hang Around
represents positive VRE culture sites – ready for next patient?
The picture highlights how microorganisms can “hang around” without proper cleaning and disinfection.
This picture comes from a study in a hospital that was investigating pathogen contamination on surfaces even after the room had been “cleaned” with disinfectant. The green bacteria show all of the sites that were still contaminated even after the room was cleaned and disinfected. This study and picture highlight the need to pay close attention to cleaning rooms and making sure a disinfectant is in contact for a long enough time to kill bacteria and viruses.
This same study found that when hands of 131 health care workers (HCWs) were cultured before and after routine care without gloves, 75% of the workers tested had a bacteria called vancomycin-resistant Enterococcus (VRE), on their hands. Even when workers wore gloves, 9% had this same pathogen contamination on their gloves. And after touching only the environment or equipment, 21% of ungloved and 0% of gloved HCW’s hands were contaminated. This study illustrates that surfaces and equipment can be contaminated and play a role in the transmission of diseases.
Vancomycin-resistant Enterococci (VRE) detected on surfaces indicated – cultures done AFTER discharge cleaning/disinfection
Duckro AN, et al. Arch Intern Med 2005;165:302-7

13. Is It Really Clean? Experience With Fluorescent Marker in Long-term Care
Similarly, another study looked at use of the fluorescent dye in a long-term care facility to simulate pathogen contamination and how effective the cleaning/disinfection process was. At baseline, you can see that the dye was only removed from about 27% of surfaces where the dye was placed. After sharing this data with the environmental services, CNAs and RNs there was a big increase in the percentage of pathogens removed, with over 70% of the die being removed once the issue was brought to the staff’s attention. This educational test and knowledge sharing was able to keep staff focused on proper environmental cleaning even six months later.
This might be something you could consider trying in your facility if you have fluorescent markers available.
Applegate D, et al. Evaluation of environmental cleaning in LTC Facilities, ID Week 2012

14. Disinfection of the Environment & Equipment
Why is it important to disinfect surfaces in the LTC facility?
Surfaces that are touched frequently increase the chance that microorganisms could be spread to residents or staff
While surfaces may look clean, pathogens may be lurking
What can LTC front-line staff do?
Cleaning/disinfection offers extra margin of safety
Disinfectant kills bacteria and viruses that can’t be seen
Focus disinfection on surfaces that are touched a lot
Let’s talk about how can we protect residents and staff from these microbes.
We know that staff are very busy taking care of residents, but you can’t stress enough the importance of clean environment and equipment. As we saw on a previous slide, surfaces that look clean may still be contaminated.
Cleaning refers to the removal of visible soil from objects and surfaces and normally is done by using a detergent. Cleaning is very important because soil, like body fluids, can interfere with how disinfectants work.
Disinfection, on the other hand, is the process of eliminating bacteria, viruses and other pathogens on surfaces. Some products are all-in-one, meaning they can clean and disinfectant, but even with these products, spills of blood or body fluids need to be removed first before trying to disinfect.
Cleaning and disinfecting products can be done with disposable wipes that are wet with the disinfectant, a pump spray where the disinfectant is at the right concentration or even in a concentrated solution that then needs to be diluted with water. It is important that you are familiar with the products used at your facility so that you can safely and properly use them to be sure the disinfectant is killing the pathogens. It is particularly important to know how long the surface needs to be wet with the disinfectant to kill or lower the level of pathogens on the surface.
Also, consider where supplies are kept; are they easy for facility staff to access? Review your facilities supplies and cleaning and disinfecting practices before leading the all staff training on this topic.

15. What Role Does Leadership Play in Cleaning and Disinfecting Practices?
What can leadership do to make disinfection a priority and easily accessible to staff?
Take a moment to brainstorm what leadership can do to make disinfection a priority and easily accessible to staff.
Are any of the things you listed already occurring in your facility? What have you identified that leadership can do, that you believe will be easy to adopt? What other ideas can you discuss with members of your safety team or administration to develop a plan?
________________
Facilitator Notes
Some things leadership can do to make disinfection a priority and easily accessible to staff may include:
Identifying easily accessible areas for cleaning and disinfecting supplies
Considering walking rounds to celebrate staff successes and provide non-punitive responses to mistakes
Developing transparent guidelines for disinfection policies at your facility
Posting reminders or disinfecting logs in each area of the facility

16. Examples of Surfaces that are Frequently Touched
Door Handles
Call Button
Telephone
Bed Rail
Tray Table
Bedside table
Light Switches
Bedside commode
Another way to improve efficiency and better protect residents and staff is to clean and disinfect surfaces that are touched more often. Some surfaces include:
Door Handles
Call Button
Telephone
Bed Rail
Tray Table
Bedside table
Light Switches
Bedside commode
Take the opportunity to discuss with all the staff what surfaces they think are touched frequently in your LTC facility by staff, residents and families.

17. Challenges and Solutions to Ensuring a Clean and Disinfected Environment for Residents and Staff
What cleaning and disinfecting challenges do you experience in your facility?
What solutions do you propose to address these challenges in your facility?
How can you support a culture of safety around cleaning and disinfection?
One of our recommended exercises is to lead a discussion with staff to identify challenges to cleaning and disinfection that staff might experience in your facility and collaboratively identify solutions to those challenges that will work in your facility.
In addition to the barriers described on that slide, other issues to explore include:
Do staff know where the cleaning and disinfection supplies are located? Availability and accessibility within your building is a very important piece of your disinfection program. You may want to just walk around and ask yourself, "How easy is it for staff members to obtain cleaning and disinfecting supplies?" That's an important issue to address. In particular, look at access in the resident care rooms.
Another strategy to consider is to ask staff what their role is to ensure surfaces are kept clean and disinfected appropriately?
Have staff think of ways that they can support each other to develop a culture of safety around cleaning and disinfecting. Possible ideas could be to identify champions for cleaning and disinfecting to serve as mentors/role models; develop a phrase or signal as a friendly supportive reminder for others to clean and disinfect supplies and surfaces; and/or monitor compliance with feedback to each unit/individual on their performance and you can make it a contest with prizes.
_________________
Facilitator Notes
From these discussions identify a plan that includes 3 simple actions that staff/administration can implement to improve cleaning and disinfecting at your facility.

18. Get Prepared to Engage LTC Staff in Skills Practice
Obtain the cleaning products and read the instructions on the labels.
What PPE needs to be worn?
What’s the contact time?
How do you properly store the cleaning product?
How do you properly dispose the cleaning product?
Another activity the core team can do is to read the instructions on cleaning product labels and ensure that the appropriate procedures are being conducted.
Review what PPE needs to be worn?
It is important to note that personal protective equipment (PPE) will be covered in greater detail during training module 3.
Do you have these supplies readily available and accessible?
What the contact time is for the product? How are you monitoring that cleaning and disinfection practices are meeting this requirement?
How do you store the product and is this in an easy, yet safe storage area for staff to obtain?
And how do you properly dispose of the cleaning product? For example, disposable wipes should not be flushed down the toilet, so what is your recommendation to staff?

19. Engagement Activity How Clean is it Really?
Fluorescent marker; if present after
cleaning indicates need to repeat.
Environmental cultures;
surface sampling for bacteria
Adenosine triphosphate (ATP); measures level of
soil on a surface
There are also a variety of activities you can conduct with staff to assess if a surface is really clean. There are tools that can help you check on how well a surface is clean and disinfected. While not all facilities may have fluorescent markers to measure the amount of adenosine triphosphate (ATP) or be able to culture bacteria from different facility surfaces, some facilities may want to explore this activity.
This simple method includes a fluorescent dye that can be put on a surface—it is not visible without a black light. The idea is to see if it has been removed after someone says the surface has been cleaned. If the black light shows it is still present after cleaning, it means cleaning needs to be repeated. Other methods include the use of an Adenosine Triphosphate or ATP meter that gives a number on how much soil is on a surface. If the number is over a certain level it means cleaning needs to be repeated or was not thorough enough. Last we showed that you can culture surfaces for bacteria like MRSA. Each of these can provide useful information, but they also all have limits. Work with your facility team leader and environmental services leaders to see if any of these would be helpful to demonstrate and practice with all facility staff before training them on this topic or as a way to keep the conversation about how important it is to have a clean and disinfected environment and equipment throughout the facility.

20. Wrap-Up
Clean environment and equipment keep residents safe and things that may look clean can still have germs on them
Know how to safely and properly use disinfectants utilized at your facility
READ THE LABEL!
Clean and disinfect surfaces that are touched a lot and any time you see a surface that is soiled with body fluids
Follow routine catheter care and maintenance to prevent catheters from becoming an entry portal for bacteria
Remember that clean environment and equipment will keep the residents safe. Things that may look clean can still have bacteria, viruses and other germs on them.
Know the instructions on how to use disinfectants at your facility safely and properly—READ THE LABEL!
Clean and disinfect surfaces that are more frequently touched AND anytime you see a surface that is soiled with body fluids.
And finally, follow routine catheter care and maintenance to prevent catheters from becoming an entry portal for bacteria.

21. Take the Pledge…
As you may recall from training module 1 the LTC program, along with APIC has developed an infection prevention tool, titled “Take the Pledge.” This tool contains information on the four infection prevention skills covered in the LTC Program Training Modules, including skills to keep the environment and equipment clean. We encourage all facility leaders to personalize and share this tool with all staff in their long-term care facility. In fact, your organization’s name in the lower left-hand corner indicates that all your staff “pledge” to support these skills and improve resident safety in our facility. This tool can be printed, displayed or disseminated as appropriate in your facility to encourage proper infection prevention skills.

22. Stay Updated with Useful Resources
CatheterOut.org
Take the Pledge… to Practice All Infection Prevention Skills
As we wrap up today’s discussion, I’d like to thank you for viewing this presentation. The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project.
Resources:
The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety.
The second resource is a link to the TeamSTEPPS for Long-term Care web page. TeamSTEPPS is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment.
The third resource is a link to the website CatheterOut.org. This website has a lot of resources about catheter care to help reduce CAUTIs.
The fourth resource is a link to a downloadable version of the Take the Pledge resource.
We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety.

23. References
Applegate D, et al. Evaluation of environmental cleaning in LTC Facilities, ID Week 2012 Catheterout.org CMS, State Operations Manual, 2014 Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April Duckro AN, et al. Arch Intern Med 2005;165:302-7 Kramer A. BMC ID 2006; McFarland L, et al. AJIC 2007 Maki, D. and Tambyah, P. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April Mody L, et al. Clin Infect Dis 2011;52: Murphy CR, et al. JAGS 2012;60: Siedlaczek G. SJMHS Zimmerman S, et al. JAGS 2002;50: Murphy CR, et al. JAGS 2012;60: