Infection Prevention & Green Cleaning
Infection prevention and control in health care is of primary importance. Healthcare-associated infections (HAI) direct costs are between $35.7–45 billion annually and result in almost 100,000 deaths in the US[i]. HAIs also hold implications for reimbursement, as CMS now requires that the occurrence of three HAI related Healthcare acquired Conditions (HACs) may result in lower reimbursement rates in Medicare patients without other complication. This rule continues as part of its annual Inpatient Prospective Payment System (IPPS) rule which took effect on October 1, 2008[ii]. Although there may not always be a direct relationship, it is well understood that the environment does contribute to the occurrence of HAIs. Further, CMS now includes reimbursement based on scoring for patient satisfaction surveys known as HCAHPS. A major component in the survey is “cleanliness of the environment”
Health care facilities throughout the country have successfully implemented green cleaning programs while maintaining the efficacy of their infection prevention and control efforts. While infection risks are of paramount importance in healthcare settings, many cleaning products and processes – whether conventional or “green” – have little or no direct impact on infection.. Facilities can immediately engage in green cleaning by first addressing resource-intensive practices and toxic or irritating chemicals that can clearly be replaced by preferable alternatives without impacting infection transmission. Some examples:
- Replacing floor strippers and finishes that contain heavy metals and asthmagens
- Substituting low-VOC (volatile organic compound) glass cleaners
- Using 100% recycled content bathroom paper products
- Employing carcinogen-free carpet cleaners
- Introducing high-filtration vacuum cleaners
- Using UV Light Disinfection rather than chemicals in select areas[v]
None of these products or practices significantly impact infection transmission or infection prevention and all can improve worker safety and reduce environmental impacts.
It is important to understand the basic framework for infection control as it relates to cleaning hard surfaces and inanimate objects, such as floors, walls, rolling stock medical equipment (wheelchairs, IV poles, blood pressure devices, monitors, etc.) and high touch surfaces. A primary tenet of infection prevention requires that surfaces be cleaned before they are disinfected, as disinfection does not remove dirt, but instead is focused on destroying or irreversibly inactivating infectious fungi and bacteria (but not necessarily their spores.) Healthcare organizations require the use of disinfectants in instances where there is high risk of infectious potential or in cases where patients could directly transmit pathogens. These disinfectants must achieve a certain level of effectiveness in killing or inactivating certain blood borne/body fluid pathogens including, human HIV-1 virus, Hepatitis B, Hepatitis C viruses, as well as norovirus, Methicillin sensitive or resistant Staphylococcus aureus (MSSA or MRSA) and Vancomycin Resistant Enterococcus faecalis or faecium (VRE). Most of these are easily killed with standard low-level disinfectants. A major challenge today is increasing occurrence or outbreaks of C difficile, since it forms spores that stay in the environment and take a higher level of disinfectants. All disinfectants used in a healthcare setting must be registered with EPA.
Disinfection Practices and Products
All disinfectants are intentionally toxic to microorganisms and currently, none can be accurately qualified as “environmentally preferable” by any major third party certification systems. To date, any claims of environmental preferability by disinfectant manufacturers are inappropriate and may even violate EPA and FTC regulations. Current certification programs for green cleaning products and equipment do not cover EPA-registered disinfectants, but research is underway to examine whether there are certain product attributes that might make some disinfectants both effective AND have less of an impact on worker or patient health and the environment.
Best practices, however, can ensure that disinfection is highly effective without involving unnecessary exposure for workers, staff, and patients. Healthcare organizations should conduct an infection control risk assessment (ICRA) in collaboration with their Infection Control Committee to determine which areas within the hospital require routine cleaning versus those areas that require both cleaning AND disinfection. This assessment may result in classification of:
- Areas without infectious risk
- Areas with possible infectious risk
- Areas with special infectious risk
- Areas with patients who could transmit pathogens
Additionally it may be possible to remove a burden of soil that mitigates the need for higher level disinfectants. Use of microfiber and evaluation method from the CDC may be useful to examine[iii]. This toolkit describes the assessment and process for a performance improvement program for cleaning and disinfection. A broader treatment of this may be found in an article by Carling[iv] and is available as free access. For more information on area classification see the Daschner et al., 2004 articlein The American Journal of Infection Control. A newer body of research is also looking at innovative ways to track the effectiveness of cleaning processes. Learn more at Premier’s Safety Share Newsletter: Cleaning of Patient Rooms, a Persistent Challenge,Prompts Innovative Methods to Evaluate Effectiveness, September 2008.
Hospitals must also use the appropriate product for target microorganisms, use products at the appropriate concentration and for the proper residence time. See the recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)’s 2003 Guidelines for Environmental Infection Control in Health Care Facilities(pp. 71-88) and 2008 Guidelines for Disinfection and Sterilization in Healthcare Facilities.
Note: Infection prevention and control is also integral to the cleaning and sterilization or disinfection of medical equipment, which is covered by GGHC Chemical Management Credit 1.3 and 1.4, and on the Sterilization & High Level Disinfection pages. Infection control related to hand hygiene is covered by GGHC Chemical Management Credit 1.2. Sanitizing of food-contact surfaces, also related to Infection Control, is covered by GGHC Food Services Credits 8.1 and 8.2: Chemical Management in Food Services.
[i] Scott D. CDC/DHQP Direct cost of Healthcare-associated Infections in U.S. Hospitals and the Benefits of Prevention. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf or Burden of HAI website.http://www.cdc.gov/HAI/burden.html
[ii] Premier Safety Share. CMS expands the list to 10 hospital-acquired conditions for reduced payment. September 2008.
[iii] Options for Evaluating Environmental Cleaning. Available at: http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html
[iv] Carling P, Bartley J.Evaluatinghygienic cleaning in healthcare settings: What you do not know can harm your patients. Available at: http://www.premierinc.com/safety/about/recent-publications.jsp
[v] Infection Control Today “New Study Shows Xenex's Room Disinfection System Reduces Environmental Contamination” 6/6/2013.