What Lurks Beneath

The hidden dangers of surface disinfection incompatibility

By Linda Lybert

Anurse wheels a patient out of their room to complete their discharge. Within 10 minutes, the environmental services (EVS) team enters the room with their cart of cleaning and disinfectant products. They have less than 30 minutes to turn it over as another patient is waiting to be admitted.

EVS professionals know which disinfectant products to use based on hospital infection prevention guidelines and the type of microbes they are working to remove from the patient room. At some healthcare facilities, this process is followed by ultraviolet disinfection or electrostatic disinfection.

Once their work is complete, the EVS team visually inspects the room. When there are no visible stains, soils or other issues, the room is deemed to have been effectively terminally cleaned.

But why is this assumption made when microbes can’t be seen?

Visual observation of any environment is not going to find microbes lurking in and on surfaces.

Unfortunately, there are often no clear directions for cleaning and disinfection. And specific surface materials or products are rarely tested to ensure the act of cleaning and disinfection doesn’t cause significant damage.

Case in point is a recent study of a large hospital in the Midwest United States that purchased several hundred noninvasive medical devices. Within two years, they had become visibly damaged due to chemical exposure during the disinfection process. The instructions for use (IFU) called for a quaternary ammonium wipe disinfectant. But because the hospital’s infection control guidelines do not allow quaternary ammonium disinfectants to be used in patient care areas due to patient and healthcare worker risk, a bleach-based disinfectant was utilized instead. Through deep dive analysis, it was determined that the bleached-based disinfectant was not approved by the manufacturer for use on the monitoring devices, leading to their damage.

This is not an isolated incident. Infection prevention guidelines don’t necessarily match manufacturer instructions. Cleaning and disinfection protocols also don’t always address issues with broken, cracked or porous surfaces that could easily be harbouring microorganisms. For instance, privacy curtains are rarely changed unless visibly soiled, yet these porous surfaces can be harbingers of deadly pathogens.

Surfaces are a foundational issue that must be addressed as the industry works to mitigate healthcare-associated infections (HAIs). While healthcare professionals focus on cleaning and disinfecting products and protocols, the fact is the majority of surfaces in a healthcare environment are difficult if not impossible to clean and disinfect.

According to the U.S. Centers for Disease Control and Prevention (CDC), approxi-

medical devices are composed of dozens of surfaces — every single product in this room has separate IFU, as well as disparate cleaning and disinfection recommendations. This means that if there are 25 different surfaces, for example, there will also be 25 distinct recommendations for cleaning and disinfecting.

A 2016 study on the presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit found that even after extensive cleaning and disinfection, microbes remained. Biofilm was visually apparent on the sterile supply bucket, opaque plastic door, venetion blind cord and the sink rubber. Extracellular polymeric substances alone were seen on the curtain. Viable bacteria were grown from three samples, including MRSA from the venetian blind cord and the curtain.

In spite of a growing number of studies like this one, there remains insufficient attention on the surfaces selected and products used within the built environment as a potential fomite for transmitting pathogens. Little is known about the pathways and speed at which surfaces become contaminated and how quickly cross-contamination occurs. Damage to surfaces may occur at a microscopic level from cleaning and disinfection processes, compromising routine decontamination practices while increasing health risks to patients.

One of the biggest issues is the lack of standards and agreed upon definitions. Currently, no benchmarks exist to define ‘clean.’ Even definitions of what is porous versus nonporous cannot be trusted, depending on who is defining it and what state the material is in.

Another issue is wet versus dry surfaces. There is a myth that if a hard surface is dry

mately 1.7 million HAIs occur annually, and visibly clean, it poses no threat. And yet with one in 25 patients acquiring at least one a 2014 study found that microbes, including infection while being treated within a health- bacterial spores, vegetative bacteria, fungi care facility. and viruses, can survive on dry surfaces for

What does this translate to? extended periods. As well, contaminated

Someone dying every five minutes from a environmental surfaces are an increasingly HAI, based on CDC statistics. recognized reservoir in the transmission of

The challenge lies in the confusion and certain healthcare-associated pathogens. complexity of surfaces and how to care for The case is clear for more focus on surface them. A hard non-porous surface can disinfection compatibility, with the shared become damaged by some cleaning and goal of reducing the number of HAIs and disinfecting agents, rendering it porous with related deaths. This requires collaboration reservoirs for microbes to harbour and prolif- among manufacturers, researchers, healtherate, and out of reach of the biocides used to care providers and other experts in the field destroy and remove them. to change how surfaces are designed, man-

At present, there is no focus on bridging ufactured, installed and maintained. the gap between what surfaces are selected Facilities professionals can start by asking for the design of the built environment or hard questions at the design, review and products used for patient care. Add to that evaluation stage of any equipment, matemillions of different IFUs healthcare profes- rial, device or surface to be used in their sionals must review and follow for cleaning facility: Can surfaces be cleaned and disinand disinfecting. Healthcare facilities are often fected following infection prevention guideconfronted with selecting an alternative and, lines and using hospital grade disinfectants in many cases, they use one product to clean without damage? Have the materials and everything. This inevitably leads to damage. products been tested using the five to seven

The process of selecting specific disinfect- categories of healthcare grade disinfectants? ants is complex and involves numerous stake- And has the IFU clarified which disinfectholders and varies by institution. What’s ants should not be used? more, the effectiveness of all disinfectants, Now is the time to push manufacturers to regardless of category, is significantly show research completed on the surfaces impacted by how it is used in a hospital envi- and that the materials have been used in ronment where, unlike a laboratory setting, real-world settings, not just laboratory clean there is often pressure to turn rooms around rooms. quickly. Allowing for sufficient contact time can also be challenging, as well as maintaining ideal temperature and ensuring the right concentration of disinfectant is utilized each and every time.

Take the real-world example of an emerBiomedical_CHF_Winter_2017_FINAL.pdf 1 2017-10-23 4:45 PMgency room in the aftermath of a trauma. In addition to the vast number of surfaces that need to be cleaned and disinfected to make the room safe for another patient — some

Linda Lybert is the founder and executive director of the Healthcare Surfaces Institute. For the past 20 years, she has focused her work on surfaces and their role in acquiring and transmitting pathogens in healthcare facilities. She introduced the Seven Aspects of Surface Selection to bring insight into the surface issue's complexity and how they are active in spreading pathogens that cause deadly infections.

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