Healthcare Hygiene magazine January 2020

Environmental cleaning, when done properly, effectively diminishes the amount of contamination and results in decreased transfer to hands, clothing, and patients. — Mark E. Rupp, MD of patient-care equipment and establishing who cleans it, how do they clean, how do they know it is clean, etc.” Rupp says that some of the tools that can be used to help identify problems is UV-tagged marking gels and ATP detection. “These tools allow one to establish more clearly that surfaces are contaminated or are not being cleaned appropriately,” he says. “Sometimes, little demonstration projects can be fun and elucidating,” Rupp adds. “Culturing keyboards and posting pictures on a unit of what the culture plates look like; posting pictures of visibly soiled equipment items, and posting data regarding cleanliness of high-touch objects on a ward, are all ways to increase awareness and get a bit of the ‘ick-factor’ working in your favor.” Some fomites’ role in the transmission of disease is still being debated. Shoe sole and floor contamination is another consideration in the environmental hygiene challenge for healthcare institutions. Research seems to indicate what common sense already tells us -- that items which contact the floor are contaminated and could serve as vectors. In the now-antiquated Guidelines for Environmental Infection Control in Health-Care Facilities (2003), the CDC asserted, “Extraordinary cleaning and decontamination of floors in healthcare settings is unwarranted. Studies have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning and has minimal or no impact on the occurrence of healthcare-associated infections. Additionally, newly cleaned floors become rapidly re-contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. Nevertheless, healthcare institutions or contracted cleaning companies may choose to use an EPA-registered detergent/disinfectant for cleaning low-touch surfaces (floors) in patient-care areas because of the difficulty that personnel may have in determining if a spill contains blood or body fluids (requiring a detergent/disinfectant for clean-up) or when a multidrug-resistant organism is likely to be in the environment.” The recommendation from the dated CDC guidance is to “keep housekeeping surfaces (floors, walls and tabletops) visibly clean on a regular basis and clean up spills promptly.” Additionally, the CDC indicated, “After the last surgical procedure of the day or night, wet vacuum or mop operating room floors with a single-use mop and an EPA-registered hospital disinfectant.” These guidelines have not been updated by HICPAC since their issuance. More recently, Koganti, et. al. (2016) observed, “… hospital floors are often heavily contaminated but are not 26 considered an important source for pathogen dissemination because they are rarely touched. However, floors are fre- quently contacted by objects that are subsequently touched by hands (e.g., shoes, socks, slippers). In addition, it is not uncommon for high-touch objects such as call buttons and blood pressure cuffs to be in contact with the floor . ” The authors posited that floors may be an “underappreciated reservoir for pathogen transmission.” Deshpande, et al. (2017) made a strong argument for a new focus on floors with their survey of five hospitals. They found that floors in patient rooms were frequently contaminated with pathogens and high-touch objects such as blood pressure cuffs and call buttons were often in contact with the floor. Contact with objects on floors frequently resulted in transfer of pathogens to hands. In this study, researchers cultured 318 floor sites from 159 patient rooms, including C. difficile infection (CDI) isolation rooms and non-CDI rooms. Researchers also cultured hands (gloved and bare) as well as other high-touch surfaces. The researchers found that floors in patient rooms were often contaminated with MRSA, VRE and C. difficile. Of 100 occupied rooms surveyed, 41 percent had one or more high-touch objects in contact with the floor. These included personal items, medical devices, and supplies. MRSA, VRE and C. difficile were recovered from bare and gloved hands that handled the items. As Rashid and VonVille, et al. (2016) observe, “From the floor, it is plausible that air currents, human movements over the floor and other factors that aerosolize or provide an airborne opportunity for the organism may occur, thus causing human infections via inhalation, horizontal or cross-contamination from other persons, clothing or equipment that the organism resettles upon. It is furthermore plausible that due to the existence of these microbiological pathogens on shoe soles that the rapid spread of these organisms in the healthcare environment can be directly related to the organisms on floors getting picked up and carried by shoe soles and retransferred to floors in other areas by human movement. This potential transmission dynamic requires validation. Shoes become contaminated from a dirty floor and parallel methods to decontaminate flooring is also required. Perhaps most surprising finding from this study was the relative lack of consistent efficacy to decon- taminate shoe bottoms using either chemical or nonchemical strategies. Although, most strategies had variable success, the complexity of maintaining sterility of the disinfectant strategy appeared to be the most complex and difficult to optimize component of the decontamination strategy.” Kraay, et al. (2018) emphasize that “Fomite-mediated transmission can be an important pathway causing significant disease transmission… The importance of these pathways relative to other transmission pathways such as direct person-person or airborne will depend on the characteristics of the particular pathogen and the venue in which transmission occurs.” In their study, the researchers developed and analyzed a compartmental model that accounts for fomite transmission by including pathogen transfer between hands and surfaces. They focused on january 2020 • www.healthcarehygienemagazine.com

Healthcare Hygiene magazine January 2020 | Page 26