Preventing infections with cleaning and hygiene
11 February 2020
Tinaz Ranina, infection prevention marketing lead at Diversey UK & Ireland, examines healthcare associated infections (HAIs), particularly those caused by multidrug-resistant organisms (MDROs), which represent a significant impact on patient morbidity and mortality and increase the financial burden on healthcare systems.
Cleaning and hygiene continue to play a central role in the fight against HAIs. Contaminated environmental surfaces have been shown to be an important source for transmission of HAIs, particularly through touch and subsequent personal contact.
Effective cleaning and disinfection can decrease environmental pathogens, reducing the risk of infections, but hospital environments are complex, which can often result in cleaning that is inadequate. Suppliers continue to develop innovations that offer healthcare cleaning teams wider choice to implement the most effective solution to meet infection prevention targets.
One of the techniques that is growing in popularity is the use of UV-C disinfection as an adjunct technology to complement and enhance the effectiveness of manual disinfection processes, particularly in hospital settings where HAIs are of major concern.
UV-C has long been proven as an effective technology to reduce contamination and the potential for infection. This short-wavelength ultraviolet light kills or inactivates microorganisms by destroying nucleic acids and disrupting their DNA, leaving them unable to perform vital cellular functions. It can disinfect surfaces quickly and effectively.
Deploying UV-C alongside traditional disinfectants reduced HAIs by 33%., according to one recent paper. At least 40 scientific studies measure its biocidal effect on micro-organisms or the impact on HAI rates. There is also much less chance of pathogens developing any form of resistance because UV-C disinfection is a physical rather than chemical process.
UV-C provides additional assurance that frequent-touch and hard-to-clean surfaces have been disinfected. It represents a hands-, chemical- and fume-free way to implement safer disinfection. There are many UV-C devices offered in the market with varying designs. The latest developments make the process simpler to utilise and more practical in real-life settings.
Since UV-C disinfection involves light waves, it is important to ensure light sources are parallel to the surfaces most likely to be contaminated or frequently touched in a patient environment. Several studies have shown that the power and speed of UV-C disinfection can be impacted by distance and angle. The strength of the UV-C light decreases the further away it gets from the light source, following the inverse square law. Because of this, the design of the UV-C device can impact the strength of dose applied to surfaces, impacting the level and speed of disinfection.
Systems delivering UV-C must therefore ensure the maximum amount hits the target surface to give the most powerful disinfection. One way to achieve this is to mount the UV-C sources on arms that can be positioned independently and pointed towards and set as close as possible to the target surfaces. This ensures more of the UV-C produced will hit the surface at right angles and at the minimum distance to give the best disinfection.
Despite the advantages of UV-C, few cost-effective practical systems were until recently available for routine use in healthcare settings . The latest devices now produce powerful UV-C light at the optimum wavelengths to provide fast broad-spectrum disinfection in as little as three minutes. This is more than twice as fast as fogging and almost twice as effective as traditional cleaning and disinfection alone in destroying the pathogens that cause healthcare associated infections.
There are other practical advantages of UV-C technologies. With fogging, for example, areas must be taken out of commission to allow equipment which is often large and cumbersome to be installed. This typically takes far longer than the disinfection time. Afterwards, the equipment must be removed and the area allowed to dry before it can be used. With UV-C, the equipment is simply wheeled in, used and removed within a matter of minutes. That makes it a viable option for disinfection in busy and high throughput settings with little or no impact on room availability. This means the technology can be used throughout a hospital, including patient rooms, operating rooms and bathrooms. Such systems can also be used on patient care equipment, fixtures, keyboards, monitors, and workstations.
While innovative technologies such as UV-C offer new approaches to infection prevention, the healthcare sector continues to evolve its understanding of the relationship between infection rates, surface disinfection and hand hygiene. One of the newest ideas in this area builds on the concept of the five moments of hand hygiene that is widely understood and employed in healthcare settings.
Studies suggest that somewhere between 20 and 40 per cent of HAIs arise when a healthcare worker passes on pathogens from one patient to the next. Pathogens can also be deposited on frequent touch surfaces and survive for extended periods, sometimes months, allowing them to be touched and passed on to other patients. There is a higher risk of acquiring certain pathogens if a room was previously occupied by a colonised or infected patient. All of this helps explain why effective hand hygiene and surface disinfection are important when aiming to prevent infections.
However, there is a growing realisation that even with high levels of compliance, the tried and tested methodologies could be improved. Rigorous daily cleaning of all surfaces, but especially those that are likely to be touched by patients or staff, is essential. But in many settings, some of those surfaces are more likely than others to be touched by multiple people throughout the day. Under those circumstances the idea of a once-a-day disinfection could be inadequate and put patients and staff at increased risk. In reality, studies show that with various people coming into a patient’s room during a normal day, a bed rail could be touched around 250 times by nurses, medical staff, clinical and non-clinical staff, and visitors.
The latest thinking is to adopt a more targeted approach. All areas are cleaned and disinfected daily, as before, but additional attention and focus is paid to frequent touch and high-risk surfaces. In practice, this means items such as bed rails, table-tops and light switches are cleaned much more often. Going further, studies suggest that additional disinfection at the point of care (where three elements come together: patient, healthcare worker and care or treatment involving contact with the patient or their surroundings) will help reduce infection rates.
This can be distilled into five critical points:
- Before placing a food/drink on an over-bed table
- After any procedure involving faeces or respiratory secretions within the patient bed space
- Before/after any aseptic practice (wounds, lines, etc)
- After patient bathing (within bed space)
- After any object used by/on a patient touches the floor.
The idea is in effect to disinfect on demand and clean hands and disinfect surfaces before and after each of these critical moments. Put another way, it is everyone’s job to disinfect, but it is not everyone’s job to disinfect everything every time. However, to be effective these processes must be simple and accessible so that they can be completed whenever needed. They must also be acceptable to healthcare workers and visitors, for example the products used should be non-hazardous and non-irritating. Finally, processes must be fast because anything that adds time or becomes a burden is less likely to be done.
With hand hygiene and surface disinfection critical to these new as well as traditional approaches it follows that there will be innovations in these areas too.
The best healthcare sites globally have reduced their infection rates to around 5% through diligence and a rigorous application of best practice. In the UK the average infection rate is nearer to ten per cent.
The World Health Organization promotes hand hygiene through a number of high-profile initiatives. Its annual Clean Your Hands Day, for example, was established in 2005 and has been a global success. This and related WHO programmes are based around the concept of a multimodal hand hygiene improvement strategy. This incorporates five components or building blocks including system change, training, evaluation, awareness and an institutional safety climate that lead to long-term and sustainable improvements. This framework is complemented by the WHO’s focus on the five moments of hand hygiene – the critical times when healthcare professionals should wash their hands: before touching a patient; before a procedure; after body fluid exposure; after touching a patient; after touching patient surroundings.
These recommendations can mean a lot of washing during a normal day. This is not only time-consuming but conventional soaps can strip natural oils which protect the skin, leading to an increased risk of damage through conditions such as dermatitis. Under these circumstances it is sensible to use an alcohol-based hand sanitiser that kills pathogens faster than soap without removing protective oils.
Whatever products are chosen, they must be available and ready to use whenever required. Dispensers should be situated conveniently to encourage regular and proper use. At the same time, they should ideally contain enough product to prolong the interval between refills and therefore minimise the risk of outages and reduce necessary restocking burdens.
Another way to encourage compliance is to monitor usage. While it is rarely desirable to monitor individuals, it is helpful to know how often a particular dispenser has been used and how much product has been consumed. Knowing how many times a dispenser has been used and comparing this with the number of patient contacts by the clinical and nursing team should give a reasonable indication of whether they are complying with agreed standards. If not, additional awareness and training can be provided and the subsequent change in usage patterns assessed.
Surface disinfection is another critical aspect of infection prevention and it is vital to choose the right products. Healthcare cleaning professionals have traditionally selected disinfectants with chlorine as the active ingredient (usually as bleaches) for cleaning hard surfaces.
While widely used, the drawbacks of these formulations in terms of effectiveness and safety are well known. Alternative formulations with Accelerated Hydrogen Peroxide (AHP) as the active ingredient offer numerous advantages with few limitations and their use is growing in popularity.
The key requirement from any disinfectant in healthcare settings is efficacy - to prevent the introduction of potentially harmful pathogens and infections. These can range from hospital associated infections such as MRSA and C. diff to infections common in any setting, such as influenza and Norovirus. Effective surface disinfection is especially important in healthcare because patients are likely to be frail and vulnerable.
It is important to select disinfectants capable of killing pathogens of concern. Problem pathogens, such as norovirus and C. diff., might not be killed by conventional disinfectants. Contact times must be realistically short so that any pathogens are killed before the surface dries.
Disinfectants containing AHP are highly effective against a wide range of viruses, spores, yeasts, and fungi found in healthcare, including C. diff, MRSA, Norovirus, E. coli, and Pseudomonas aeruginosa. This broad-spectrum efficacy has been tested to the latest EN standards and submitted into the Biocidal Products Regulations (BPR) - a standard which all actives and disinfectants need to pass. AHP simplifies processes because just one product is needed - using numerous alternative products to provide the same level of performance adds unwanted complexity.
Products containing AHP can be supplied in ready-to-use and ultra-concentrate formats. They can be used at different dilution rates for various applications from daily cleaning to terminal disinfection to offer the right combination of efficacy and economy. Depending on the specific formulation, these products are effective against viruses, spores (including C. diff), yeasts and fungi in one minute or less, meeting demand for highly effective products with shorter contact or dwell times.
Traditional products containing chlorine are generally not as effective on spores and require significantly longer contact times. Products containing AHP have been tested and shown to kill viruses such as Norovirus in up to 30 seconds and the most persistent spores such as C. diff in one minute. Products containing AHP offer additional benefits that simplify day-to-day cleaning operations. With more cleaning taking place while patients are present, processes must be completed safely and efficiently, so as not to create an unpleasant environment or put patients at risk.
AHP degrades to oxygen and water alone shortly after use which helps make formulations containing it safer to use. Chlorine-based products are suspected of aggravating asthma and other respiratory problems, and forming chlorine compounds in the atmosphere. Another consideration is that some products containing AHP have no safety classification whereas chlorine-based products usually carry a hazard symbol.
Breaking down to water and oxygen alone means products with AHP leave little or no residue on surfaces, helping to promote the appearance of the area being cleaned. They can be used safely on a wider range of surfaces, including wool and other fabrics, with reduced risk of damage. Chlorine based products on the other hand will corrode or degrade many surfaces with regular or prolonged use. Nor can they be used as part of a microfibre system because they damage the material, severely restricting their disinfection potency.
The variety of disinfectants has grown in recent years, as manufacturers have developed solutions for specific daily and problem-solving tasks. It is therefore important to match the product to the specific application. This optimises cleaning performance and reduces inefficiencies, poor results, and the need for repeat cleaning. Reputable manufacturers will provide advice on the most suitable products from their ranges to use in every situation. They should also be able to supply the documentation and evidence with independent test data to support product claims.
Hospitals and other healthcare facilities have a wider range of infection prevention tools at their disposal than ever before. The choice available means that there is greater flexibility to specify the right combination to meet infection prevention compliance and reduction targets in the quickest, simplest and most effective way that integrates with the facility’s other processes. The choices can be complex but leading cleaning and hygiene suppliers with experience in healthcare will be able to work with clinical, nursing and housekeeping teams to devise and implement robust infection prevention policies.