Without proper cleaning practices in place, health care environments can quickly become contaminated with nosocomial pathogens, such as Clostridium difficile (C. diff), vancomycin-resistant enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), norovirus and more. These pathogens can survive for some time on surfaces, which can be hazardous to patient health. In fact, the Centers for Disease Control and Prevention (CDC) reports nearly two million patients contract secondary infections during hospital stays each year.

The best defense to this is a good offense. But cleaning for health is only as good as the cleaners themselves and the products they use. A new study published in January's issue of "Microbiology" highlights that cleaning operations failing to use enough disinfectant to kill every last bacterium on a given surface can create ideal breeding grounds for new superbugs. The article further predicts that these mutations could eventually become virtually immune to prevention and treatment.

It's critical to use disinfectants properly, stressed lead author Gerard Fleming in a recent interview. "The first line of defense is disinfection."

This is definitely the case in restrooms where the very nature of the environment provides fertile ground for nasty germs and bacteria to breed. Selecting the right disinfectant and training housekeepers to use it properly helps keep disease-causing pathogens at bay.

Sanitizers vs. Disinfectants

"Everyone should use a hospital-grade disinfectant to clean restrooms — it kills the organisms you need to kill," says Darrel Hicks, director of environmental services at St. Luke's Hospital in St. Louis, Mo.

Sometimes cleaning operations struggle with differentiating between disinfectants and sanitizers. Many times cleaners even use the words interchangeably. But there is a difference, stresses infectious disease specialist Mark Warner.

An industrial or institutional sanitizer must be capable of killing 99.999 percent of a specific bacterial test population, and do so within 30 seconds. A sanitizer may or may not destroy pathogenic or disease-causing bacteria. A disinfectant, meanwhile, is capable of destroying disease-causing bacteria or pathogens, but not spores and not all viruses. These products must be capable of reducing the level of pathogenic bacteria by 99.99999 percent within 10 minutes.

The difference seems small until put into perspective. Let's say a surface has 1 million bacteria per square inch. After using the sanitizer, which kills 99.999 percent of bacteria, cleaners would have 5,000 bacteria per square foot left behind. These remaining microorganisms reproduce by splitting into two every 15 minutes. The result is that those 5,000 bacteria per square foot has now become 1 million bacteria per square foot within a period of only five hours.

"The point is when you sanitize a restroom, millions of bacteria are left behind," Warner says. "Using a disinfectant, you leave zero bacteria behind. A disinfectant at 99.99999 percent cleaning effectiveness is essentially 100 percent."

Hospital-Grade vs. Other Disinfectants

There's also a difference in disinfectants approved for hospital restroom use versus those sold in the industrial and institutional markets. Industrial/institutional disinfectants make 100 percent kill claims on their labels, but only eliminate a set number of pathogens. Hospital disinfectants must also attack those pathogens typically only existing in hospitals, including antibiotic-resistant microorganisms such as VRE and MRSA. They must eliminate graham negative and graham positive bacteria.

"There are so many germs out there that we need to kill," says Jack VanReeth, manager of environmental services at Geisinger Health System in Danville, Pa. "We always want a product that is labeled to be effective against a wide range of graham negative and graham positive bacteria and makes an HIV claim."

At minimum, hospital disinfectants must show efficacy in eliminating three primary organisms: Staphylococcus aureus, Salmonella and Psuedomonas aeruginosa. However, today's hospitals generally require disinfectants with even more efficacy.

"In the past, these three organisms met the criteria," says Roger McFadden, a chemical scientist charged with developing cleaners and disinfectants. "Today a lot of hospitals say that's not good enough and disinfectants must go beyond these basic three organisms."

Many hospitals also require disinfectants that act as cleaners as well as disinfectants. This means they must also be effective in the presence of organic soil to clean and disinfect simultaneously, McFadden states.

Quaternary vs. Phenolic

Choosing between quaternary and phenolic disinfectants becomes the next chemical choice.

VanReeth specifies quaternary disinfectants at Geisinger Health System. He maintains that while these products are by no means green, they are less harsh on the environment than their phenolic counterparts.

"We are looking for a neutral pH quaternary product that does minimal damage to the surfaces it cleans while being safer for the environment," he says. "Phenolics do a wonderful job of disinfecting, but a mediocre job of removing soil."

Quaternary products also maintain a high level of safety for employees. "When there is a spill of a quaternary concentrate, it's much less harmful than a spill of a concentrated phenolic," VanReeth says. "Phenolic products are much more likely to burn or injure an employee in a splash exposure."

Train, Train, Train

"The Achilles heel in most cleaning operations is human error," says McFadden. The training housekeepers receive ranks as high in importance as the chemicals they use. Effective health care restroom training programs address chemical dilution, application and dwell times.

If cleaners fail to dilute products correctly, they will not work as intended. Disinfectants work at carefully diluted ratios and when diluted incorrectly put public health at risk. If a housekeeper uses 1/4 ounce per gallon instead of the recommended 1/2 ounce per gallon, it is only half of the antimicrobial needed to kill the germs it is intended to kill.

"Though they would be using a hospital-grade disinfectant to clean the restroom, it wouldn't be enough to validate the killing of the organisms," McFadden says.

Housekeepers may also incorrectly apply the products or not leave them on surfaces long enough, he adds. Killing some microorganisms requires longer contact times. For instance, most disinfectants eliminate HIV within 30 seconds, but tuberculosis requires 10 minutes.

"Workers need to be taught to apply the products to the surfaces where these microorganisms are likely to be found, and then let the product remain on the surface long enough to kill them," McFadden says. Current CDC guidelines recommend a 10-minute dwell time when employing disinfectants.

Geisinger Health System trains its housekeepers to first spray surfaces, such as sinks, commodes and high-touch surfaces, throughout the restroom with disinfectant. While the disinfectant dwells, cleaners tackle mirrors and other less critical areas, then follow up by wiping down the surfaces they originally sprayed. Cleaners should then go back to perform a more thorough disinfection of toilets and toilet seats. Finally, they stock supplies, then mop the floor with a disinfecting cleaner.

A solid training program and follow-up ensures housekeepers adhere to these practices each and every time they clean, VanReeth adds. In his facility, new hires must complete computerized training courses on basic environmental services competencies and infection control issues, as well as view a video demonstrating how to properly clean a restroom. They then train with a veteran employee before working along side a supervisor for a few days. Regular work inspections ensure housekeepers continue to maintain exacting standards after their training ends.

St. Luke's Hospital crews also learn to train a critical eye on commonly overlooked surfaces, for example, the backside of restroom stall doors.

"I tell them they almost need to sit on the toilet and look around to see what the person using it would see," Hicks says. "The same thing with the restroom door. Housekeepers often prop the door open with their carts and forget to look at the backside of that door or the corner behind it."

This hospital also employs ATP meters to quantify clean surfaces after workers are finished. ATP meters help teach workers what surfaces carry the most bacteria, adds Warner, who points out cleaners often don't recognize the worst places for germs. Their focus tends to be above the floor and on touch points, but an ATP meter typically shows a restroom's most germ-ridden spots as: floors; above-floor horizontal surfaces; and touch points.

"Cleaners are typically running around focusing on touch points and don't think about the other two surfaces," he says. "But any germ in the air ends up on the floor and on above-floor horizontal surfaces."

Floors especially need thorough disinfecting and workers should be taught as much. Bacteria counts on floors are typically 10 to 20 times higher than on touch points.

"Infectious diseases travel on the floor; it's their super highway," says Warner. "They travel that highway to work spaces, to your hands and from your hands to your mouth where they can spread disease."

As superbugs move into hospitals near you, cleaning operations must exercise some due diligence in chemical selection and training. As McFadden points out, "Failing to do so, and then having an outbreak occur, opens a hospital up to enormous liability."

Ronnie Garrett is a freelance writer based in Fort Atkinson, Wis.