Healthcare Hygiene magazine January 2020 | Page 26

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
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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