Healthcare Hygiene magazine January 2020 | Page 25

All providers should be interested in and know their unit and
organizational infection rates, cleaning effectiveness, hand hygiene
compliance, etc.”
— Mark E. Rupp, MD
and between patients or eliminated altogether,”
Rupp says. “However, there are a myriad of
potential fomites and, as already noted, some
can pose a more serious threat than others. We
don’t live in a perfect world and resources for
our environmental service personnel and clinical
support staff are limited. Thus, the degree of likely
contamination, what it is likely to be contaminated
with, and who it is going to potentially transmit to
are important considerations. So, in the previous
example of the blood pressure cuff, for the average
patient in an ambulatory clinic – I won’t lose too
much sleep. The same blood pressure cuff used in
a patient with fecal incontinence and widespread
skin contamination who is known to be colonized
with a pan-resistant Acinetobacter who is being
cared for in a clinic that is specialized for solid
organ transplant patients – you bet I’m concerned.
Confounders such as hand hygiene and
the quality of cleaning come into play when
evaluating how fomites contribute to the spread
of pathogenic organisms.
“Hand hygiene is critical,” Rupp confirms. “For
example, cell phones are ubiquitous and are in
every healthcare worker’s pocket. They chime while
a nurse or doctor cares for a patient and often they
are tended to. The phone becomes contaminated
and is rarely cleaned (lots of studies looking at
contamination of all sorts of things – phones,
beepers, neck ties, wrist watches, etc.). It is
important that after the phone is dealt with, the
healthcare worker uses the alcohol gel to disinfect
hands before going back to their patient. Similarly,
if the environmental services team is doing a good
job in daily and terminal cleaning, the burden of
contamination is decreased, making it less likely
that hands or fomites become contaminated and
carry pathogens to the next patient.”
Improved cleaning and disinfection, after
controlling for other interventions, has been found
to reduce the risk of patient infection, according
to studies, and Rupp says that experts can argue
about the relative benefit for any intervention.
“The studies that try to isolate the importance
of hand hygiene, environmental cleaning, fomite
elimination, etc. are difficult to do, are usually
underpowered, and are often fraught with con-
founding,” he adds. “However, taken together,
the data clearly demonstrate that the environment
becomes contaminated and can stay so for long
periods of time, the environment can serve as a
vehicle or reservoir for transmission to hands and
www.healthcarehygienemagazine.com • january 2020
clothing of healthcare personnel and sometimes
directly to patients. Environmental cleaning, when
done properly, effectively diminishes the amount
of contamination and results in decreased transfer
to hands, clothing, and patients. We can discuss all
day and still not know if this results in 5 percent of
nosocomial transmission or 50 percent (probably
somewhere in between).”
Rupp continues, “When we consider cross-col-
onization of patients from the inanimate
environment, should we be using tools such as
molecular epidemiologic techniques to identify
pathogens, should we be measuring the quality
of environmental cleaning and hand hygiene over
time, and should we think about the link between
contaminated surfaces and cross-colonization
events in geographic and temporal dimensions?”
Rupp adds, “Use of molecular epidemiologic
tools – up to whole genomic sequencing – can
be very helpful in understanding the dynamics
of transmission. These tests are often expensive
and time consuming and are probably out of
the question in most instances. However, mea-
surement, reporting, and optimization of hand
hygiene compliance and environmental cleaning
(including fomites) should be routinely done by
all healthcare organizations. Leadership should be
involved. All providers should be interested in and
know their unit and organizational infection rates,
cleaning effectiveness, hand hygiene compliance,
etc. If an organization is doing all this right, they
don’t need to be nearly as concerned that the
“superbug’ of the day is going to find a nesting
spot in their facility and spread wildfire from
person to person.”
The mobility of devices and equipment
around the hospital underscores the need for
more awareness of these items’ potential for
pathogen transmission, and experts emphasize
the importance of raising awareness among
healthcare workers that these objects can be
highly contaminated.
“Devices and equipment roam all over the
facility – that why they are called COWs (comput-
ers on wheels). Education should be conducted
regularly with all healthcare personnel to raise
the awareness of this issue and how to combat it.
Again, emphasize hand hygiene, environmental
cleaning, as well as identification and cleaning
of fomites. It may not be too exciting, but it is
important. In many instances, it is a matter of
going to specific units and identifying every piece
Any patient-care
items used
in healthcare
settings can be
contaminated with
a healthcare-
associated
pathogen and are
a potential fomite,
but outbreaks
via these fomites
can be prevented
or minimized by
adhering to current
recommendations
for cleaning
and disinfection
of devices and
surfaces.
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