Each year, an estimated 722,000 healthcare-associated infections occur in U.S. hospitals.
As many as 75,000 patients die each year — and even more suffer serious consequences — due to infections they picked up while in the hospital.
The Centers for Disease Control and Prevention (CDC) and World Health Organization have identified hand hygiene as the number one way to prevent infections. Although multiple compliance programs and interventions have been implemented, studies have shown an overall estimated median hand hygiene compliance rate of only 40 percent.
Pathogens can survive on environmental surfaces and equipment for days, and even months. Studies have shown that if environmental surfaces are contaminated, and are subsequently touched by healthcare workers, a healthcare worker's hands can become contaminated.1
An estimated 20 to 40 percent of HAIs result from transmission of pathogens by a healthcare worker after touching another patient or contaminated surface.2
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Studies have also shown evidence that a patient's risk of acquiring an infection, especially a multidrug-resistant infection, is higher if the prior-room occupant was infected or colonized, further implicating the role of the environment in the spread of infection.3 Carling's studies have demonstrated that on average, less than 50 percent of surfaces in patient rooms and 25 percent of high-touch surfaces in operating rooms were cleaned thoroughly. Shared medical equipment is often not cleaned between uses.4
Every Moment Counts
As reimbursement becomes more closely aligned with quality of care, there has never been a more compelling business case for healthcare institutions to focus on preventing infection. Reimbursements are now tied to quality metrics: healthcare-associated conditions, infection rates and readmissions can cost hospitals up to 6 percent of their revenues.
Healthcare consumers are educating themselves with published data and perception to guide their choices about where to spend their healthcare dollars. Recent data published in the 2016 Patient Satisfaction Horizon Report showed that patients most valued a visible commitment to cleanliness and infection prevention.
While there are several factors that impact infection rates, including early identification of infected or colonized patients and antibiotic stewardship, a focus on both hand hygiene and improved cleaning and disinfection practices is warranted.
Making Each Moment Count
Establish risk-based cleaning frequencies. Each day environmental services teams are tasked with cleaning patient rooms. On average, they spend 20 to 30 minutes in an occupied patient room collecting trash and dirty linens, cleaning the patient room and bathroom and attending to other needs.
The reality is the minute they leave that room, it begins to become re-contaminated.
This creates a compelling argument to consider the other 23.5 hours after the environmental services staff member leaves the room. What may surprise you is how quickly the room can become re-contaminated, and the level of activity in a standard patient room. Cohen et. al. studied the number of people entering a patient room. Their 2012 data showed the average number of room entries was 5.5 per hour, conducted across a 15-hour waking day for the patient.
In a separate study of high-touch surfaces, Huslage et. al. investigated which surfaces staff touched while in both an ICU and a general medical-surgical room. In medical-surgical rooms, they reported that bedrails were the most commonly touched surface, averaging 3.1 touches per interaction.5
When you combine the data from both studies, it suggests that the typical patient bedrail is touched, on average, 256 times per day. Other studies on these topics suggest that 256 touches per day may be conservative.
Further, a recent research article in BMC Infectious Diseases discussed the effectiveness of whole room cleaning, even with 100 percent cleaning efficiency, versus the incorporation of frequent wiping of high-touch surfaces during the day on the potential risk of transmission of methicillin-resistant Staphylococcus aureus.6 The study demonstrated the effectiveness of surface disinfection throughout the day to decrease the risk of transmission.
Another consideration is the types of activities being done in a patient room, and the relative level of contamination associated with those activities. For example, there is a relatively high risk of environmental contamination after any procedure involving feces, productive coughing or patient hygiene, such as bed baths. This may warrant additional cleaning of the environment between daily environmental service activities.
The question you need to ask is, does your cleaning frequency align with the risk, or are you counting on that one intervention a day to ensure a safe environment of care?
"Diversey Care sees a trend in this area. More facilities see the need to address risk with a change of practice in this area, and we are helping them build resources and tools to better train staff as well as patients and visitors on what they can do to help prevent the spread of infection," says Carolyn Cooke, Diversey Care's Vice President of Healthcare in North America.
Every Moment Counts — Considerations
Ensure product is available when and where it is needed. There has long been a focus on ensuring that hand hygiene products are available in each patient room. Lately, there is an even greater focus on ensuring that these products are available at the point of care to ensure greater hand hygiene compliance. However, the same level of focus has not been applied to disinfectants.
Ensuring that disinfectant wipes are available to clean shared patient care equipment and the patient care environment will help improve disinfection compliance and enable the frequent cleaning of high-touch surfaces.
Engage other stakeholders in the battle against germs. As mentioned earlier, some care activities are more likely than others to create contamination in the patient care environment. When procedures, such as bed baths and/or changing of incontinence products, are performed, it should be part of the standard protocol for the clinician to disinfect the surfaces that were potentially soiled during the process or near the patient after the task is completed to help reduce the contamination in the environment.
Since a key route of transmission for many pathogens found in the environment is fecal-oral, it may also be prudent to engage staff delivering food trays to patients or residents to help them clean their hands and disinfect the surfaces near the patient, such as the overbed table, prior to the placement of food trays.
Determine a team approach to cleaning, including more frequent cleaning of environmental surfaces during the day as needed.
● Define roles and responsibilities using tools and checklists
● Clearly communicate and train staff on their roles during implementation
● Provide ongoing communication vehicles to continually reinforce
● Measure outcomes, communicate feedback, and stay focused toward success
Patients and visitors can also play a key role in helping to keep the environment safe. It is critical to educate them on the need to properly clean their hands — including when and how. They are just as likely to move germs around the environment as the healthcare team.
Most family members of patients want to help, so take the opportunity to let them. In fact, encourage them to be part of the solution. Helping them understand that excessive clutter in the room makes cleaning and disinfection more difficult may encourage them to help reduce the clutter. And, if you have disinfectant wipes that are safe for use, you can also invite them to wipe high-touch environmental surfaces, such as bed rails, overbed tables and other items near the patient, such as phones or controls. Use signage and educational materials to help educate on how and when disinfecting surfaces may be valuable. These steps may play a key role in helping to reduce the risk of transmission, and may even help with satisfaction scores, as an added demonstration of your facility's commitment to cleanliness and infection prevention.
Measure what matters. This one may be the simplest idea, yet the hardest to implement. If hand hygiene compliance is important, measure it. If high-touch surface cleaning compliance is important, measure it. Studies have demonstrated that staff will respond to constructive feedback and increase compliance when consistent measurement data is provided. Feedback and a continual focus on improvement are critical to drive improvements in compliance.
Added assurance. The healthcare environment is very complex with the combination of sick patients, busy staff, a high level of patient care activity and the ongoing stream of visitors. Because of this, even in the best situations, there is risk.
Several studies have demonstrated the persistent contamination of environmental surfaces despite the use of traditional cleaning and disinfection methods. This has led to widespread acceptance that there is a need to address traditional cleaning processes as well as the need to assess the use of secondary disinfectant technologies.
Based on this, many facilities are now looking at no-touch disinfection systems, such as ultraviolet-C devices, to augment their manual cleaning processes. These systems have demonstrated the ability to be highly effective against vegetative pathogens and spores. It should be noted that these adjunct technologies are not a substitute for manual cleaning and disinfection, but instead are being used in addition. The use of the combined systems — manual cleaning plus no-touch disinfection — has been shown to reduce the environmental bio-burden, reduce HAIs and help to address the inadequacies and inconsistencies in manual cleaning processes and implementation.
Every Moment Counts
Preventing infections requires a multi-modal approach, engagement of numerous stakeholders and the commitment to provide a safe and satisfying environment of care.
References
1. Duckro AN, et al. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med. 2005 Feb 14; 165(3):302–307.
2. Weinstein RA. Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med 1991; 9 (suppl 3B): S179-S184.
3. Otter, “Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings”. American Journal of Infection Control, 2013; 41: S6-S11.
4. Havill NL. Havill HL, Mangione E, Eumigan D, Boyce JM. Cleanliness of portable medical equipment disinfected by nursing staff. Am J Infect Control 2011;39:602-4.
5. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ, “A quantitative approach to defining high touch surfaces in hospitals”, Infect Cont and Hosp Epidemiol, 2010; 31 (8): 850-853.
6. Lei et al. “Exploring surface cleaning strategies in hospital to prevent contact transmission of methicillin-resistant Staphylococcus aureus”, BMC Infectious Diseases (2017) 17:85 DOI 10.1186/s12879-016-2120-z