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Environmental Cleaning-more than just good looks!

Environmental Cleaning-more than just good looks!. Vicky Willet R.N., CIC Network Coordinator NEOICN. Objectives. To review the PIDAC document for environmental cleaning Describe the components of cleaning Describe routine cleaning in health care

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Environmental Cleaning-more than just good looks!

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  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

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