1. Environmental Cleaning-more than just good looks! Vicky Willet R.N., CIC Network Coordinator NEOICN

2. 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

3. 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

4. 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! Public Health Ontario

5. 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.

6. 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 PIDAC: Best Practices for Cleaning for Prevention and Control of Infections, May 2012,

7. 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 PIDAC: Best Practices for Cleaning for Prevention and Control of Infections, May 2012,

8. 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

9. 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 Anderson Ross/Digital Vision/Getty Images

10. Long term care… • The residents’ individual bed space and bathroom (or commode) and their mobility devices (wheelchair, walker) Public Health Ontario, 2013

11. 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 Public Health Ontario, 2013

12. 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 To name a few…. Public Health Ontario, 2014

13. High touch surfaces PIDAC: Best Practices for Cleaning for Prevention and Control of Infections, May 2012

14. 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

15. 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…..

16. 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

17. 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.

18. 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

19. 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

20. Disinfectants • Disinfectants rapidly kill or inactivate most infectious agents • Only use to disinfect and not used as a general cleaning agent-unless it is a combined “cleaner-disinfectant” Public Health Ontario 2013

21. Choosing a disinfectant • Consider the following when choosing a product: • 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

22. Using disinfectants wisely • Item or surface must first be free of visible soil (unless using a combined cleaner/disinfectant • Use according to manufacturer instructions: • 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

23. 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)

24. 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/Dilution-Calculator.aspx

25. 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

26. Routine practices • Assume that allclients/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

27. Hand hygiene • Strict attention to hand hygiene • 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 Public Health Ontario, 2013

28. 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/OnlineLearning/InfectiousDiseases/IPACCore/Pages/default.aspx

29. 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

30. Hotel clean PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections. May 2012

31. Hospital clean PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections. May 2012 p.p 40

32. 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/Dilution-Calculator.aspx

33. 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? Public Health Ontario, 2013

34. 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

35. 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

36. 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)

37. Risk matrix to determine how often to clean

38. Determining the cleaning frequency with the risk matrix

39. 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

40. Equipment cleaning Non critical equipment and devices • Includes items that touch intact skin or the environment • If it is in the client/patient/resident environment and shared-requires 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 Public Health Ontario, 2013

41. 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

42. Waste management • Waste should be segregated at the point of generation

43. 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 Public Health Ontario, 2013

44. 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.

45. Types of flood water

46. 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

47. Education • Must have a training program • At orientation and ongoing • Must include: • 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 Public Health Ontario 2013

48. Assessment and quality control Monitoring & auditing • Checklists and documentation • Ensures standards are maintained • Tools available Measures of cleanliness • Direct and Indirect observations • Environmental cultures not generally recommended • May use “environmental marking” • ATP Bioluminescence • Patient/resident satisfaction surveys Public Health Ontario 2013

49. 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/default.aspx • http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/Dilution-Calculator.aspx Resources

50. Questions