One of the biggest causes of morbidity and mortality in modern healthcare is infection.
And many of those infections are acquired in hospital or residential care, hence the term “healthcare acquired infection” or HAI.
Multiple factors influence HAI rates. The best-known is hand hygiene. Other factors include isolating infected patients, implementing antimicrobial stewardship (which means monitoring antibiotic usage) and environmental cleaning and disinfection. Cleaners remain the last line of defence against HAIs. Because of the pressures placed on cleaning staff, it is becoming more and more important to work smarter, not harder.
Antimicrobials or antibiotics kill pathogens in the bloodstream through a delicate “lock and key” mechanism. If the pathogen evolves and changes, it can make it impossible for the antibiotic to attach to the pathogen. The key won’t fit in the lock. We call this “antimicrobial resistance”.
Disinfectants are far less elegant. They are more like a sledgehammer to a watermelon. This means there is minimal risk that bacteria will become immune to disinfectants the way they have to antibiotics. A good disinfectant is the most effective tool in the cleaner’s toolkit. Unfortunately, there is no perfect disinfectant. No silver bullet. Some disinfectants are very strong but they damage surfaces; others have a high safety profile but have poor efficacy against healthcare pathogens.
There is no evidence that antimicrobial resistance correlates with the effectiveness of disinfectants. This is due to fundamental differences in the mechanism of killing of micro-organisms by these agents (antibiotics vs. disinfectants). Most disinfectants are effective against vegetative bacteria regardless of the antimicrobial resistance profile. It is only when faced with spore-forming bacteria such as C. difficile that a higher-level disinfectant with sporicidal properties should be considered.
In her 2015 study published in the American Journal of Infection Control, Michelle Alfa demonstrated that best practice disinfection requires the right product, the right process, and proof of cleaning compliance.
Once the right disinfectant for your environment has been selected, the right procedures need to be standardised. There is a growing body of evidence that the biggest pathogen loads are found on high-touch surfaces next to the patient. Thus it makes sense for cleaners to target the point of care. If cleaning time is limited, it makes no sense to disinfect ledges and window panes when the pathogens are concentrated on bedside tables, remote controls and bedrails. One study showed that the bedrail in an average surgical unit was touched 256 times per day by different people. Yet it was disinfected only once. That leaves a lot of scope for cross-contamination.
Best Practice: When should patient surfaces be disinfected?
To adapt the vernacular of the World Health Organisation, there are 6 Moments of Surface Disinfection, and they all relate to the point of care:
- Before placing a food tray on a bedside table
- After any procedure involving blood, vomit, urine or faeces
- After any wound dressing procedure
- After a bed bath
- After assistance with productive cough
- Any time surfaces are visibly soiled
Should floors be disinfected?
Normal shoes are heavily contaminated and will deposit germs on the cleanest of floors. Recent studies have shown that air currents pull germs from the floor into the air, where they are carried in currents behind people as they walk. The germs are then deposited on high-touch surfaces elsewhere within 24 hours. Similarly, patient stockings and shoe covers pick up floor germs and deposit them in their bedding. A weekly deep cleanse by a floor scrubber may be more effective than a daily wipe with a disinfectant-soaked mop. Whether or not you choose a disinfectant for your floor, the common denominator remains effective disinfection at the point of care.
Proof of compliance is becoming popular as hospitals seek validation that cleaning is being done. There are various models available, including protein swabbing and fluorescent ink with UV light.
Most hospitals focus their efforts only on terminal cleaning of patient rooms with less emphasis on daily cleaning. This must change in order to achieve better patient outcomes. More emphasis should be placed on daily cleaning of high-touch surfaces at the point of care, with a safe and effective disinfectant, and a program to ensure surfaces are being cleaned effectively.