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Clostridium difficile (C. diff), Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are just some of the latest infections bugging custodial departments in healthcare facilities and wiping surfaces with hospital-grade disinfectants is not always sufficient to prevent their spread. As viruses like these become more resistant, the right hand tools and proper cleaning procedures are equally important to eradicate outbreaks — and custodians need to be trained accordingly.
"You've got to know your employees, and you've got to make sure they have the tools to do the job," says Doug Green, director of environmental services for Mercy Hospital Springfield in Springfield, Mo. "This is a crucial job, and we need to treat our employees with great respect for the work they do."
Educating employees on the importance of their jobs should go hand in hand with training them on the proper products and procedures to use, according to Darrel Hicks, director of environmental services and patient transportation at St. Luke's Hospital, Chesterfield, Mo.
"They are the one thing that stands between the spread of infection from one patient to another," he says. "You don't want to get sick and you don't want to take [infections] home to your family. Follow the procedures and you'll break that chain of infection."
The C. diff Difference
Custodial departments typically rely on a quaternary-based disinfectant to clean and disinfect patient rooms — regardless of whether or not an outbreak has occurred. However, in the case of C. diff, the bacterial spores are hard to kill and a high-level chlorine disinfectant is necessary. Custodians rely on a product with a kill claim specific to these microorganisms and often follow a two-part cleaning process.
"We use a quaternary disinfectant for all infections except C. diff," says Margie Bruckner, manager of environmental services for Aurora Sheboygan Memorial Medical Center in Sheboygan, Wis. "When we have a C. diff outbreak we use the quaternary disinfectant to remove the bioload, and then we go back over the room with a bleach-based cleaner."
When cleaning isolation rooms, Green's staff cleans the room twice — first with a quaternary cleaner and then with bleach wipes to disinfect all high-touch surfaces.
Similarly, Hicks' environmental services department cleans C. diff isolation rooms twice a day: "We clean with bleach wipes each time," he says. "At discharge, we clean the whole room and then go over it with bleach wipes again as a final step."
Despite the need for bleach-based products to fight infections like C. diff, Hicks frowns upon excessive use of disinfectants in hospitals.
"If we did a better job of cleaning, we wouldn't have to use as much disinfectant," he says. "It's like pouring perfume on cow manure and expecting it to smell better. We're dumping disinfectant on things and thinking we're killing them when we should do a better job of removing them."
The Power Of Microfiber
In addition to quaternary-based disinfectants, custodial departments rely heavily on microfiber to apply chemicals and remove soils and microorganisms.
"Microfiber cloths will remove almost 98 percent of the soil," says Hicks. "You're also removing the spores and microorganisms so there's not much left on the surface."
In fact, Hicks has used an ATP meter to test the level of microbial contamination in rooms that were cleaned using microfiber and water and found the results comparable to rooms that were cleaned with a regular rag and a cleaner or disinfectant.
But even microfiber cloths must be used correctly to prevent cross-contamination. Managers recommend using multiple cloths, one for each surface of the room to be cleaned. Eric Bates, director of hospitality for Jewish Senior Living in Milwaukee, trains his staff to use three separate microfiber cloths for each room.
"We use one cloth for contact points in the resident room, and then we have a separate cloth for the sink and another for the toilet," he explains. "Then the cloths get bagged up and taken down to our laundry room at the end of the day."
While Bates finds spraying disinfectant on cloths and wiping surfaces down with a microfiber cloth to be most effective, others prefer a "bucket and rag" method or a flip-top dispenser. To avoid contaminating disinfectant in a bucket, Hicks cautions his staff not to dip a dirty microfiber cloth back into the bucket for reuse.
"We give them about 20 microfiber cloths," he says, "and when they're done wiping a surface, that cloth goes into a separate bag." Similarly, dirty microfiber mops are never dipped back into the disinfectant water.
In addition to using clean cloths to avoid contaminating disinfectant, Green's employees do not soak cloths in disinfectant.
"We used to soak our cloths in whatever disinfectant we were using," he says. "But we stopped that based on quat binding."
This phenomenon happens when fabrics have a strong attraction for the active ingredient in quat-based disinfectants, thereby causing the solution's efficacy to decrease. Green is purchasing a titration test kit to verify the disinfectant's active ingredient levels.
When cleaning and disinfecting patient rooms, custodians are trained to pay close attention to high-touch surfaces. Bruckner provides custodians with a list of touch points: Bed rails, over-the-bed tables, light switches, doorknobs, sink faucets, remote controls, toilet handles and call buttons.
Usually disinfecting high-touch surfaces is confined to patient rooms but in some instances may extend to adjoining areas.
"When we've had a C. diff patient, we know people are going into and out of the room, so we'll do the handrails outside the room," says Bruckner. "We'll also do surfaces in a family lounge area."
For Bates, on the other hand, disinfecting handrails outside of patient rooms is done on a daily basis.
"Most people don't think about the rails or the countertops at the nurses' station," he says. "You would not believe the germ count on these."
Countertops are disinfected three times a day while handrails are cleaned on the night shift — a routine that has decreased germ counts significantly.
Dwelling On Timing
While custodial departments generally agree on what high-touch surfaces require the most attention, they are often divided about dwell times. Most hospital-grade disinfectants registered by the U.S. Environmental Protection Agency (EPA) have a label contact time of 10 minutes. However, studies have shown the effectiveness of these disinfectants against pathogens with a contact time of at least one minute.
"In the real world we can't wet a surface three times to give it a 10 minute dwell time, because we can't wait around for it to dry," says Hicks.
At St. Luke's Hospital, staff aims for a three minute dwell time and takes care of other tasks while the surfaces are wet.
Similarly, Bates' custodial team will apply disinfectant to contact points in the patient's restroom and bedroom, and then take care of vacuuming and emptying trash.
"You're better off allowing that kill time as long as possible," says Bates. "We use a product with a 99 percent kill for C. diff in all patient rooms and let it sit on that surface for five minutes."
With the pressure to turn rooms around quickly, allowing for appropriate dwell times can be challenging. Proper training can help ensure that staff doesn't sacrifice quality for speed.
"If you train your people to do a good job of soil removal, set your cloths and mops up so you're not cross-contaminating surfaces, and give them enough time in a room so they're not rushed, you should be able to do a very good job and reduce the infection rates in hospitals," Hicks says.
KASSANDRA KANIA is a frequent contributor to Housekeeping Solutions.