Transcript Environmental Cleaning-more than

Environmental Cleaning-more
than just good looks!
Vicky Willet R.N., CIC
Network Coordinator NEOICN
Objectives
• To review the PIDAC document for environmental cleaning
• Describe the components of cleaning
• Describe routine cleaning in health care
• Describe the risk matrix for determining frequency of cleaning
• Briefly discuss areas/equipment of special consideration for
cleaning
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The role of the environment …
• Health care associated infections (HAIs) are infections that
occur as a result of health care interventions
• Many factors contribute to this
• A key factor is the cleanliness of the environment around the
client/patient/resident
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Transmission
• Presence of infectious agent on equipment, objects and
surfaces in the health care environment
• A means for the infectious agent to move from patient-patient
patient–staff, staff-patient or staff-staff
• Susceptible person ( clients/patient/resident/staff/visitors)
• Must have all 3 for transmission to occur!
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Public Health Ontario
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Hotel versus Hospital component-how do we
focus
• Hotel component: areas of the facility not involved in
client/patient/resident care such as lobbies, waiting rooms,
offices ,corridors, elevators, stairwells, service areas.
• Hospital component: areas in the facility involved in
client/patient/resident care- such as patient/resident units
(including nursing stations), procedure rooms, bathrooms,
clinic rooms, diagnostic and treatment areas.
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Show me the evidence….
• The health care
environment has been
shown to be a reservoir for
infectious agents
• The presence of
microorganisms alone in the
environment is not
sufficient to demonstrate
that they have contributed
to infection
• Evidence is evolving
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PIDAC: Best Practices for Cleaning for Prevention and Control
of Infections, May 2012,
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Show me the evidence..
• There are many studies which
show:
• Germs survive in the
environment
• Germs can be spread from the
environment to
clients/patients/residents
• Contaminated environment is
associated with infections in
clients/patients/residents
• Cleaning disrupts transmission
of microorganisms
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PIDAC: Best Practices for Cleaning for Prevention and Control of
Infections, May 2012,
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Defining the client/patient /resident
environment
• Client/patient/resident contaminate their environment if they
are coughing, sneezing, have uncontrolled diarrhea, vomiting
or soil the environment with their blood or body fluids.
• Some of the bacteria and viruses contained in these fluids can
live in the care environment for weeks or months
• Environment can also be contaminated by staff who touch
these body fluids and touch environment
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Acute care: patient environment
• The area inside the curtain or in their room including all items
and equipment used in their care and their bathroom
• In the intensive care unit-the room or bed space and items
and equipment inside the room or space
• In the nursery/neonatal-the isolette/basinette and equipment
outside the isolette/basinette used for the infant
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Anderson Ross/Digital Vision/Getty Images
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Long term care…
• The residents’ individual bed space and bathroom (or
commode) and their mobility devices (wheelchair, walker)
Public Health Ontario, 2013
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Other care environments
• Shared spaces such as group rooms, dining areas, play rooms,
central showers
• The immediate area of the examination or treatment table,
chair
Public Health Ontario, 2013
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Items in the environment that harbour microorganisms
• Bed (pillow, mattress, bed rails and frame)
• Chair
• Bathroom
• Telephone
• Toilet or commode
• Computer keyboard
• Call bell
• Bed side table
• Stethoscope, bp cuff, suction, oxygen
Public Health Ontario, 2014
To name a few….
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High touch surfaces
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PIDAC: Best Practices for Cleaning for Prevention and Control of Infections, May
2012
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Finishes and surfaces-important characteristics:
• Cleanable
• Easily maintained and repaired
• Unable to support growth of germs
• Smooth with no openings that would trap germs
• Seamless
• Inspected regularly to ensure they are in good repair
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Can it be cleaned????
Carpeting should :
• Be easily cleanable
• Have a water resistant backing
• Replaced if damaged or wet after 72 hours
• Carpet cleaning programs should ensure immediate cleaning
and disinfection when soiled with blood or body fluids- a
potential reservoir…..
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Can it be cleaned??
Furniture:
• Wherever feasible, an alternative to cloth surfaces should be
used
• The coverings on soft furniture must be cleanable with a
hospital-grade disinfectant
• Replace worn, stained or torn items as soon as possible
• Do not use upholstered furniture and other cloth or soft
furnishings that cannot be cleaned in care areas, particularly
where immunocompromised patients are located
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Can it be cleaned
Other Considerations:
• Clean plastic coverings (e.g., mattress covers, keyboard covers)
with hospital-grade disinfectants that are compatible with the
covering
• Inspect for damage:
• Replace mattress and pillow covers when torn, cracked or when there is
evidence of liquid penetration. The mattress or pillow should be
replaced if it is visibly stained.
• There must be a process to enable reporting, removal and replacement
of torn, cracked or otherwise damaged coverings.
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Electronic equipment
• Electronic equipment that cannot be adequately
cleaned, disinfected or covered to allow appropriate
cleaning, should not enter the immediate care
environment.
Public Health Ontario 2013
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Detergents and cleaning agents
• Remove soil and other materials such as blood or body fluids.
• Detergents and cleaners in health care must:
• Be approved by ES,IPAC and Occupational Health
• have a drug identification number (DIN) from Health Canada if it
contains a disinfectant
• Be used according to the manufacturers recommendations for dilution,
temperature and use.
Public Health Ontario 2013
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Disinfectants
• Disinfectants rapidly kill or inactivate most infectious agents
• Only use to disinfect and not used as a general cleaning agentunless it is a combined “cleaner-disinfectant”
Public Health Ontario 2013
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Choosing a disinfectant
• Consider the following when choosing a product:
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It must have a DIN
The nature of the item to be disinfected
the amount of organic soil present
The innate resistance of expected microorganisms to the inactivating
effects of the disinfectant
Contact time
Manufacturer instructions
Occupational health considerations
Environmental considerations
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Using disinfectants wisely
• Item or surface must first be free of visible soil (unless using a combined
cleaner/disinfectant
• Use according to manufacturer instructions:
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Right dilution
Right temperature
Right contact time
Right amount-needs to stay wet on surface
• Minimize contamination-no double dipping
• Use proper PPE to prevent exposure to chemical
• Quality monitoring system-ensure efficacy of the disinfectant
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A word about disinfectant wipes…
• When using disinfectant wipes:
• The active ingredient must be an appropriate hospital-grade disinfectant
• Wipes must be kept wet and discarded if they become dry
• Wipes must have an MSDS and be used according to the MSDS (e.g.,
wear gloves when handling, if recommended)
• Disinfectant wipes are used for:
• Items in the care environment that will not tolerate soaking
• Small items that must be disinfected between clients/patients/residents
at the point-of-care (e.g., stethoscope)
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Commonly used disinfectants
• http://www.publichealthontario.ca/en/ServicesAndTools/Tools
/Pages/Dilution-Calculator.aspx
PIDAC: Best Practices for Environmental Cleaning for Prevention and control of Infections, May
2012, p.p. 31
http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/Diluti
on-Calculator.aspx
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Equipment selection and purchasing
• Consider occupational health requirements, patient safety,
IPAC and environmental safety issues
• Items purchased must be readily cleaned and disinfected
according to the recommended standards
• Must have specific written instructions for how to clean and
disinfect
• Items brought in from other facilities (loaned or shared) must
follow same standards
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Routine practices
• Assume that all clients/patients/residents are potentially
infectious
• Safe practices should be used routinely by anyone providing
direct care on any resident
• Includes:
• Risk Assessment
• Proper hand hygiene
• PPE use
• Environmental cleaning
• Good polices & procedures
• Education and monitoring
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Hand hygiene
• Strict attention to hand hygiene
Public Health Ontario, 2013
• If possible, should not be carried out in resident sink
• ABHR is the preferred method for cleaning your hands
• Four Moments
Public Health Ontario, 2013
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Personal protective equipment
• Gloves• Risk of hand contact with blood ,body fluids, secretions ,excretions or
items contaminated with these
• Gowns• If contamination of uniform is anticipated
• Mask and Eye protection
• To protect the mucous membranes of the eyes, nose and mouth during
activities involving close contact (within 2 metres) of sprays/splashes of
secretions ( coughing, sneezing)
See PHO Core Competencies
http://www.publichealthontario.ca/en/LearningAndDevelopment/OnlineLe
arning/InfectiousDiseases/IPACCore/Pages/default.aspx
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Routine cleaning
• Routine cleaning is necessary to maintain a measure of
cleanliness
• Must be effective and consistent to reduce transmission of
microorganisms
• Frequency of cleaning is dependent upon the risk
classification of the surface or item to be cleaned
• 2 measures of cleanliness• Hotel clean
• Hospital Clean
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Hotel clean
PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections. May 2012
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Hospital clean
PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections. May 2012
p.p 40
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Outbreaks and additional precautions
• Outbreak
• Additional cleaning may be required
• Environmental services (ES) management should be part of the
outbreak committee
• Policies should allow for surge capacity of ES staff
• Additional Precautions
• Appropriate signage affixed to the entrance to the room that indicates
the PPE required when carrying out activities inside the room
• When Additional Precautions require extra cleaning practices, a process
should be in place to ensure that this is communicated to ES staff
http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/DilutionCalculator.aspx
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Determining how often to clean
Factors to consider:
• Are surfaces high touch or low touch?
• What type of activity takes place in the area?
• What is the risk of infection to persons in that area?
• Are the persons in that area already vulnerable to infection?
• How likely are the surface in that area to be contaminated
with blood or body fluids?
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High touch or low touch surfaces
High Touch (score=3)
• Frequent contact with hands such as doorknobs, elevator buttons, call
bells, bed rails, light switches, areas around the toilet
• Require more frequent cleaning and disinfection –clean at least daily
and more frequently if risk of contamination higher
Low touch(score=1)
• Minimal contact with hands such as floors, walls ,ceilings, mirrors
• Require cleaning on a regular ( not necessarily daily) basis or when
soiling/spills occur, and on discharge
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Vulnerability of the population
• More susceptible (score=1)
• Immunocompromised ( e.g. transplant or oncology patients, neonates,
burns)
• Undergoing invasive or operative procedures ( e.g. hemodialysis)
• Less susceptible (score=0)
• All other individuals
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Probability of contamination
• Heavy contamination ( score =3)
• Surfaces/equipment exposed to copious amounts of blood or other
body fluids examples include
• Birthing suites, autopsy suite, cardiac catheterization laboratory,
hemodialysis unit, Emergency department, bathrooms if
client/patient/resident has diarrhea or is incontinent
• Moderate contamination(score=2)
• Surfaces/equipment may be contaminated with blood or body fluids as
part of routine activities and substances can be contained or removed
(e.g. linen). All client/patient/resident bathrooms should be considered
at least moderately contaminated.
• Light contamination (score=1)
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Risk matrix to determine how often to clean
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Determining the cleaning frequency with the
risk matrix
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Some examples
• Patient\resident washroom in general care area:
• Moderate contamination
• High touch
• Less susceptible
Total Cleaning score: 2+3+0 = 5
Therefore: clean at least once daily and when soiled.
• Dialysis station
• Heavy contamination
• High touch
• More susceptible
Total cleaning score: 3+3+1 = 7
Therefore: clean after each case and at least twice daily, additionally as required
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Equipment cleaning
Non critical equipment and devices
Public Health Ontario, 2013
• Includes items that touch intact skin or the environment
• If it is in the client/patient/resident environment and sharedrequires cleaning and disinfection after each use
• Process in place to identify equipment that has been cleaned
and disinfected
• Clear written policies and procedures for equipment
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Laundry and bedding
• Soiled linen is rarely the cause of infection spread
• All linen that is soiled with blood or body fluids should be
handled using the same precautions regardless of the source
• Linen that is wet should be contained in a leak proof bag
• No double bagging, no dissolvable/water soluble bags
• No need to cover hampers or linen carts
• Special handling of linen for individuals on Additional
Precautions is not required
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Waste management
• Waste should be segregated at the point of generation
Red bag
Yellow bag
Black or green bag
• Anatomical waste:
• body parts
• tissues
• organs
• Fluid and
microbiologic
waste:
• items soaked with
blood or that would
drip blood if
compressed,
suction containers,
blood and blood
products,
• sharps containers,
lab specimens or
cultures,
• General waste:
• Dressings
• Sponges
• Diapers
• Dialysis, IV tubing,
• Isolation waste
• Waste from offices,
kitchens, public
areas
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Care and storage of cleaning supplies
• Chemical cleaning agents should be properly labelled and
stored following WHMIS guidelines
• Automated dispensing systems should be used to ensure
integrity of dilution ratios –calibration should be monitored
regularly
• No topping up or refilling solutions unless container is cleaned,
disinfected and dried before reuse
• Equipment used to clean toilets should not be carried from
room to room
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Floods and water damage
• Assume contaminated until determined otherwise-contact
Infection Prevention and Control (IPAC)
• If area involves food preparation- contact local public health
unit
• Contain, soak up/absorb and dry—then clean and disinfect as
needed
• If carpets, soft furniture still wet after 48 hours –high risk of
mold—remove if still wet after 72 hours.
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Types of flood water
Category
Examples
Action
Clean Water
Broken pipes, tub
overflows, sink overflows,
appliance malfunctions,
rain water, broken toilet
tanks
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•
Allow materials to dry before use.
Remove carpet if still wet after 72 hours
Gray Water ( some degree
of contamination present)
Overflow from dishwasher,
washing machine, toilet
bowl(not containing
feces),broken aquarium.
Gray water in a flooded
structure in aggravated by
time and temperature.
•
•
Allow materials to dry before use.
Remove carpet if still wet after 72 hours
Black water heavily and
grossly contaminated
Water containing raw
sewage, overflow from a
toilet bowl containing
faeces, broken sewer line,
backed up sewage, ground
surface water rising from
rivers or streams.
•
Remove and discard carpet, dry wall,
furniture and other materials
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New and evolving technologies
• Microfibre
• Air disinfection/fogging
• Hydrogen peroxide systems
• Ozone gas
• Super-oxidized water
• Ultraviolet irradiation
• Steam Vapour
• Antimicrobial impregnated supplies and equipment
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Education
• Must have a training program
• At orientation and ongoing
• Must include:
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•
•
Public Health Ontario 2013
Written plan
A way to check if workers doing right things right
Written training records
All aspects of cleaning and disinfection
• Collaborate with the IPAC and OH&S departments
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Assessment and quality control
Monitoring & auditing
• Checklists and documentation
• Ensures standards are maintained
• Tools available
Measures of cleanliness
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Direct and Indirect observations
Public Health Ontario 2013
Environmental cultures not generally recommended
May use “environmental marking”
ATP Bioluminescence
Patient/resident satisfaction surveys
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Resources
Best Practices for Environmental Cleaning for
Prevention and Control of Infections (PIDAC)
• Environmental Cleaning Toolkit
Annex C: Testing, Surveillance and Management
of Clostridium difficile in All Health Care Settings
(PIDAC)
Annex A: Screening, Testing and Surveillance for
Antibiotic-Resistant Organisms (AROs) (PIDAC)
PHO Core Competency on line training
http://www.publichealthontario.ca/en/Pages/defa
ult.aspx
http://www.publichealthontario.ca/en/ServicesAn
dTools/Tools/Pages/Dilution-Calculator.aspx
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Questions
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