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Environmental Services
Breaking the Chain
By Steve Davis
Eight strategies for reducing risk of hospital-acquired infection
The Centers for Disease Control and Prevention (CDC) has estimated that nearly 2 million patients each year acquire
an infection that is linked to a hospital visit. Of those, about 90,000 result in death.
In October, the CDC released new guidelines, Management of Multidrug-Resistant Organisms in Healthcare Settings,
that outline strategies to prevent the spread of drug-resistant infections in health care settings. The goal of the
guidance is to prompt hospital leaders to make their infection control program—and adherence to it—a priority, says
Jennifer Morcone, a CDC spokesperson.
The guidelines—combined with a growing emphasis on infection control throughout the industry—is certain to help
environmental services staff gain respect from other departments, says Judene Bartley, CIC, vice president of
Beverly Hills, Mich.-based Epidemiology Consulting Services Inc.
Contaminated surfaces in the hospital environment, she explains, increase the risk of transmitting infectious agents,
which makes environmental services staff a very critical line of defense. Bartley is a member of the Communications
Task Force for the Association for Professionals in Infection Control and Epidemiology.
The C. difficile threat
One of the biggest hospital infection risks is Clostridium difficile (C. difficile). While the bacterium has been an issue in
health facilities for the past 25 years, it has recently become a top infection risk due to the emergence of an epidemic
strain with increased virulence and increased resistance to fluorquinolone antibiotics. Compared to C. difficile strains
previously identified, this strain produces 16 times more toxin A and 23 times more toxin B—the two primary virulence
factors of this bacterium, according to Lynne Sehulster, a microbiologist in the CDC’s Division of Healthcare Quality
Promotion Epidemiology & Laboratory Branch.
“In the late ’70s and early ’80s, [C. difficile] was the emerging pathogen of the day, the ‘new kid on the block,’ as it
were,” Sehulster says. “All fingers now point to prior antibiotic use—primarily broad-spectrum antimicrobial agents—
as the main risk factor associated with susceptibility for C. difficile-associated disease.”
Antibiotics can lower the natural intestinal populations of beneficial bacteria, which can create an environment where
strains of C. difficile flourish. If C. difficile bacteria are ingested by a susceptible patient whose normal intestinal flora
are disrupted, the resulting infection can produce symptoms that range in severity from watery diarrhea and cramping
to pseudomembranous colitis and fulminant colitis, Sehulster says.
C. difficile typically is in a vegetative state when it’s in the intestine. The organism is shed from the body in feces.
Once exposed to air, the bacterium converts to its spore form, which can be difficult to eradicate from the
environment. The spores can remain on some surfaces for months if left undisturbed. Reducing the levels of spore
contamination is important, and can conceivably be done with “frequent and rapid cleaning after episodes of fecal
incontinence,” says Sehulster. However, while such a cleaning strategy can reduce the need for harsh chemicals, the
approach may not be easily implemented.
Sehulster says there are five links in the infection chain. They are: (1) an active pathogen sufficiently virulent to cause
infection; (2) a mode of transmission for the pathogen to reach the patient; (3) quantities large enough to cause
infection; (4) a susceptible host; and (5) the correct portal of entry (e.g., an open cut, mouth or eyes). “Break any of
these links, and infection will not take place,” Sehulster says.
Eight strategies
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Here’s a look at eight strategies that Sehulster and other experts suggest for reducing the risk of hospital-acquired
infection through environmental management:
1. Target high-touch areas Shrinking budgets make it difficult for ES departments to clean rooms more than once
every 24 hours. If more frequent cleaning isn’t possible, staff should target high-touch areas (e.g., doorknobs, bed
rails, light switches, call buttons, bed trays and bathrooms), says ASHES Technical Advisor Mark Regna. “As soil
loads build up on surfaces, disinfectants have to work harder,” he explains. “The more often you clean, the less there
is to clean, but you have to determine what is economically feasible.” Regna is director of health care service with
Dallas-based Jani-King International Inc.
2. Stress technique over chemicals Instead of focusing on the type of disinfectant being used, ES directors should
focus on the cleaning technique used by their staff. “If you simply have a cloth that’s sufficiently wet and has good
contact with the surface, it can make a huge difference,” Bartley says.
3. Follow the directions It’s important for ES staff to understand that the Environmental Protection Agency (EPA)
requires disinfectant manufacturers to specify the appropriate use conditions of their products and to determine the
strengths at which the chemicals are most effective. Some disinfectants, for example, have maximum microbial
inactivation properties at specific concentrations and might actually be less effective at higher concentrations.
The idea that a stronger concentration of a chemical makes it more effective is a common misconception, Sehulster
says. “If the label requires the product to be diluted, there’s a reason,” she adds. “Deviations can throw off the ionic
balance.”
During an outbreak of C difficile, Bartley suggests that surfaces be cleaned with a solution that is a 1:10 dilution of
chlorine bleach (sodium hypochlorite). Higher concentrations of bleach won’t make the solution any more effective
against the C. difficile spores, she adds. And while bleach can be an effective disinfectant, it isn’t very good for
routine cleaning. In general, disinfectants don’t clean and cleaners don’t disinfect, Sehulster adds.
4. Consider the risks associated with sporicides Most surface disinfectants used in hospitals are relatively
ineffective against C. difficile spores. While some products claim an ability to deactivate C. difficile, they generally are
only effective against the vegetative form of the bacterium, says Sehulster, who adds that there are no disinfectants
registered with EPA that can completely inactivate C. difficile spores. Some chemicals, such as gluteraldehyde, are
effective sporicides but can’t be used on open surfaces because the vapors can be harmful. A solution that includes
sodium hypochlorite (i.e., bleach) might have some sporicidal properties, but might not be potent enough to
completely eliminate the spores, she adds.
5. Determine the effect chemicals have on materials, patients and staff ES directors need to select not only the
most effective cleaning and disinfection products, they must also consider the amount of wear and tear those
products will have on the areas being cleaned, Sehulster says. If a hospital administrator requests that the floors be
regularly disinfected, the ES director should explain that the chemical could cause the floor covering to wear out more
quickly, she says. Hypochlorite-based solutions also can be corrosive to certain metals.
6. Assemble multidisciplinary teams Sehulster recommends that hospitals form multidisciplinary teams to target
infection risks. Clinical staff, for example, are trained to understand health issues, but might not know how dust from a
construction project travels through a health care facility’s ventilation system or be familiar with the safety issues
associated with cleaners and disinfectants.
That’s something the environmental services directors can explain. “The more confident they are in the knowledge
base, the more their leadership skills will show through,” Sehulster says. ES directors should have some training in
chemistry, infection control, industrial hygiene and materials science. Those who don’t have such training should
consider continuing education courses to help broaden their expertise, she suggests.
7. Check each other’s work Environmental services departments should develop checklists that outline each step
involved in cleaning a room. Those lists can then be used by staff to make sure that all of the steps were followed,
Bartley suggests. “Then you increase the likelihood that there won’t be a gap [in cleaning] that might allow
transmission of infectious agents.” Bartley admits, however, that such strategies can be difficult to implement
because there are pressures on ES staff to turn rooms around quickly.
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8. Emphasize hand washing among staff and visitors ES managers need to reinforce the importance of personal
hygiene among their staff. “Microorganisms don’t travel from point A to point B by themselves. They tend to be moved
by the air, by people touching surfaces or by people exposed to coughs and sneezes, Sehulster says. Clean hands
can help to minimize microbial contamination on frequently touched surfaces. While alcohol-based hand cleaners are
excellent for killing bacteria and viruses, they aren’t as effective as soap and water for killing C. difficile spores;
however, use of alcohol-based hand cleaners and gloves can help to reduce the bacteria on the hands, Bartley adds.
And while hygiene among staff and patients is important, patient family members and other visitors pose an
enormous infection threat, Regna says. Hospital staff should remind visitors of infection risks and urge them to wash
their hands. Signs posted in patient rooms can be used to convey the link between hand washing and infection, he
suggests.
“We tell doctors and nurses to wash their hands and to clean their stethoscopes before touching a patient,” Regna
says, “but we need help from the patient to tell their visitors to wash their hands.”
Important role
The battle against hospital-acquired infections is a top priority at every facility, and ES managers are becoming
increasingly recognized for their important role in this fight. The eight steps covered in this article will help them
expand this role and improve patient health, too.
Steve Davis is a Washington, D.C.-based freelance writer and a frequent Health Facilities Management magazine
contributor with extensive health care industry experience.
CDC disinfection, sterilization guidances provide practical advice
The Centers for Disease Control and Prevention (CDC) is expected to release its Guideline for Disinfection and
Sterilization in Health Care Settings late in the first quarter of 2007.
The document, which will likely top 120 pages, has been approved by the CDC Hospital Infection Control Practices
Advisory Committee (HICPAC). HICPAC is a federal advisory committee made up of 14 external infection control
experts who provide advice to the CDC and the secretary of the Department of Health & Human Services regarding
health care infection control, strategies for surveillance and prevention and control of health care-associated
infections. The guidance will be published in the CDC’s publication, Morbidity Mortality Weekly Report, and alerts can
be accessed at www.cdc.gov/mmwr/index.html.
The new guidelines—due out in early 2007—probably won’t require hospital ES staff to change their procedures
because much of the focus is on medical instruments and devices, says Lynne Sehulster, a microbiologist in the
CDC’s Epidemiology & Laboratory Branch. Earlier guidance, which deals with cleaning, disinfecting, medical waste
and laundry, is a more comprehensive document for hospital ES departments, she adds.
On Oct. 19, the CDC released guidelines that outline strategies to prevent the spread of drug-resistant infections
(e.g., Clostridium difficile) in health care settings. The 73-page document, Management of Multidrug-Resistant
Organisms in Healthcare Settings, is available at www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.
Other sources of infection control information include the following:
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Premier Safety Institute: www.premierinc.com/safety;
Association for Professionals in Infection Control and Epidemiology: www.apic.org; and
Center for Infectious Disease Research & Policy: www.cidrap.umn.edu/index.html.
This article 1st appeared in the December 2006 issue of Health Facilities Management Magazine.
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