maintain physical distance (greater than three feet) from persons showing signs and symptoms of respiratory illness (CDC, 2016). Areas such as the emergency department with common patient
waiting areas should have tissues and trash containers with ABHR available.
CLEANING AND DISINFECTING ENVIRONMENTAL SURFACES
Environmental contamination is everywhere in healthcare settings, and routine cleaning and disinfecting are required to keep the pathogen count low (Jablonska-Trypuc et al., 2022). The CDC and Infection Control Africa Network (ICAN) (2019) published Best Practices for Environmental Cleaning in Healthcare Facilities: In Resource-Limited Settings . This guidance encourages monitoring staff performance in following best practices and providing feedback when opportunities for improvement are found (CDC, 2010; CDC & ICAN, 2019). The CDC (2019) defines cleaning as the removal of organic material (soil) from objects using soap and water or a detergent (a cleaning agent). Cleaning is recommended before disinfecting to remove any organic material, thus allowing the disinfectant to be more effective. Cleaning is a manual process requiring friction and rubbing action to effectively remove the organic material. Disinfection is the use of thermal or chemical agents to eliminate disease-causing pathogens. Bacterial spores (e.g., C. difficile ) General principles of cleaning There are evidence-based recommendations and general principles of cleaning to follow: (1) perform a visual assessment of cleanliness, (2) clean in a methodical manner and move in a direction from clean to dirty and high to low, (3) immediately clean body fluid spills, and (4) never double-dip cleaning cloths if using portable containers (CDC, 2020). For any equipment used, the manufacturer’s recommendations should always be followed using the correct product and frequency of cleaning. The Spaulding classifications The Spaulding classifications for critical, semi-critical, and noncritical items are used as a guide for the disinfection and sterilization of patient care equipment (CDC, 2019; Rutala & Weber, 2019). These classifications provide a standard approach to cleaning and disinfecting in healthcare and have been used for decades. Critical items are those with a potentially high risk of transmission of microorganisms to the patient (i.e., items that enter a sterile body site, tissue, or vascular system) (CDC, 2019). Examples include surgical instruments, catheters (urinary and cardiac), implants, and probes used for ultrasound. These items are cleaned and sterilized according to the manufacturer’s recommendation. The CDC (2019) defines sterilization as destroying all microorganisms to prevent infection transmission. These critical items are sterilized in a sterile processing department, which is most often located in a hospital setting. Employees in these departments have specialized training in handling instruments as well as cleaning and sterilization processes. Semicritical items come in contact with mucous membranes and/or nonintact skin. Examples of semicritical items are equipment used by respiratory therapists or anesthesiologists and any scopes (e.g., endoscopes, cystoscopes) (CDC, 2019). Semicritical items require high-level disinfection (eliminating all pathogens) using chemical disinfectants. Endoscopes are processed using high-level disinfection; however, there are still outbreaks following use of these devices (McCafferty et al., 2018; Other disinfection methods No-touch methods such as ultraviolet radiation (UV), environmental fogging (i.e., hydrogen peroxide vapor), self- disinfecting surfaces (i.e., copper and silver impregnated), and continuous room decontamination are other disinfecting methods currently being researched. These methods are intended to be used in addition to regular cleaning and disinfecting processes. The CDC (2019) currently does not have
are harder to eliminate and may require a special disinfectant. Disinfection is not sterilization. Sterilization removes all viable pathogens (e.g., for surgical instruments); however, there is a slight risk of some pathogens surviving. The Environmental Protection Agency (EPA) and Federal Drug Administration (FDA) register disinfectants. The EPA has an alphabetical list of disinfectant products with claims against common pathogens (EPA, 2022). Some examples are: List B products are effective against Mycobacterium tuberculosis (TB), list H products are effective against MRSA or VRE, and list K products are effective against C. difficile . We recently learned that list N products are effective against SARS-CoV-2. To protect against occupational exposure to chemicals, it is essential to follow the manufacturer’s recommendations for PPE use while the product is being used. Several disinfectants are used in healthcare; therefore, HCWs should be adequately trained to use any necessary product(s) and follow safety precautions. “contact time” (kill time) (i.e., 1 to 10 minutes) for the product should be followed to ensure adequate removal of pathogens (CDC, 2019). Daily cleaning of high-touch surfaces is essential to keep the pathogen count low and reduce transmission from surfaces. High-touch surfaces include bed rails and frames, lamps, bedside tables (including handles), tray tables, IV poles, and blood-pressure cuffs (CDC, 2020). Rutala & Weber, 2019). Pathogens reported as causing outbreaks from endoscopes (gastroscopes, colonoscopes) are Klebsiella, Pseudomonas, E. coli, and Salmonella . While some reported outbreaks were due to lack of adherence to cleaning procedures, others were due to endoscope defects and design. Adherence to best practices, routine maintenance, and inspection of semicritical items should be regularly reviewed (McCafferty et al., 2018; Rutala & Weber, 2019; Society of Gastroenterology Nurses and Associates, Inc. 2018). Noncritical items come in contact with intact skin (CDC, 2019). Examples include bedpans, blood pressure cuffs, and physical therapy equipment. These items are generally reused on other patients and require regular cleaning and disinfecting with a low- level disinfectant between patients. Evidence-Based Practice! Rutala and Weber (2019) developed an evidence-based bundle to disinfect noncritical environmental surfaces and equipment. The bundle has five components that are simple to follow: (1) create policies and procedures, (2) select appropriate cleaning products, (3) educate all staff who clean and disinfect (environmental services staff and nursing departments), (4) monitor compliance and provide feedback, and (5) implement no-touch room decontamination technology. This bundle approach creates standardization and feedback on adherence and is beneficial when used in healthcare facilities as part of their cleaning and disinfecting program. a recommendation for the use of fogging in healthcare settings and suggests further research is needed. The CDC continues to review the research and update the guidelines as more information is published. Boyce (2016) summarized challenges related to the standard cleaning methods, such as personnel issues, protocols and practices, and inconsistent monitoring. He suggested using
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