Healthcare Hygiene magazine November 2019 | Page 8

perspectives
By Matthew Hardwick, PhD
Education and Training of Frontline
Infection Preventionists
O
ne of the most fundamental operations in any medical
facility is cleaning. However, cleaning hospitals has
followed the same basic principles as cleaning hotel rooms
— clean visible soil. While there are cleaning protocols
in place at nearly all medical facilities, the predominant
feature of these protocols is routine cleaning with a focus
on visible soil. It should surprise no one that pathogens do
not always reside in visible soil. Indeed, many of the fluids
and semi-solids that transmit pathogens are not readily
visible to the naked eye (think sputum or fingerprint oils).
Nevertheless, many cleaning protocols do not take invisible
soil into account during both routine and specialized cleaning
protocols. Everyone in healthcare is responsible for this lack
of awareness. While environmental services (EVS) personnel,
nurses and technicians are primarily responsible for keeping
medical facilities and equipment clean, they are only as good
as they are trained to be.
From the CDC to AHE to APIC, all agree that EVS personnel
require extensive training to play their pivotal role in keeping
healthcare environments free of pathogens. Indeed, each
has dedicated significant resources to developing training
programs for EVS workers. AHE has a suite of training pro-
grams aimed at frontline EVS workers, ranging from surgical
suite cleaning to EVS management and leadership. Through
funding from the CDC, APIC has developed training modules
that run the gamut of cleaning from the basic principles, per-
sonal protective equipment, chemical safety, and techniques
for cleaning and disinfection. In addition to these resources,
vendors have developed their own extensive training for EVS
workers. Such training is perhaps more individualized and
often encompasses multiple days for training sessions and
accompanied by annual refreshers for each worker.
Key tools require training:
• Fluorescent markers – This tool was developed in order
to provide “before” and “after” feedback for EVS workers.
In short, an invisible fluorescent gel is applied to pre-deter-
mined surfaces prior to EVS cleaning. Following cleaning, a
manager uses a black light to determine if the gel has been
removed from all the spots. In this way, the manager can
determine adherence to cleaning protocols. It should be
noted, however, that this method does not determine the
efficacy of removing pathogens from environment.
• Adenosine triphosphate (ATP) swabs – One way to
determine if a surface is free of pathogens is to detect
organic ATP (derived from biological organisms like bacte-
ria, fungi and human cells) left on surfaces. ATP detection
is performed only following cleaning, reducing the time
needed for monitoring. In theory, this method will not only
determine an EVS workers adherence to established cleaning
protocols, it will also evaluate the protocol for pathogen
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removal. There is one big problem with this method,
however. First, we do not know the half-life of biologically
derived ATP, meaning that cells maybe dead (killed by auxiliary
techniques such as UV and vapor) and still leave active ATP
behind. In our laboratory, we have detected ATP signals in
the absence of viable bacterial loads, more than 48 hours
after exposure to UV light.
The development of fluorescent marker and ATP swab
methodologies are a boon to the education and monitoring
of EVS workers. However, given the limitations of both the
current cleaning methodologies and these monitoring devices,
we still have a long way to go before we have adequate tools
to empower EVS workers.
While EVS personnel receive considerable training,
nurses and technicians may only receive cursory training, if
any at all, on how to clean medical equipment and how to
use disinfectants. APIC’s training does include sections for
healthcare professionals including a section on “roles and
responsibilities” geared toward who cleans what in health-
care environments. Despite APIC’s efforts, there is clearly a
gap in training for nurses and technicians. This education
and training gap is critical, since these individuals are largely
responsible for cleaning critical patient-care equipment such
as blood pressure monitors and dialysis machines. Without
understanding which disinfectant to use and the appropriate
dwell times, as well as how to use wipers in order to reduce
cross-contamination, we cannot begin to hope that healthcare
surfaces will be cleaned properly.
In last month’s Healthcare Hygiene magazine, Linda Ly-
bert and Caroline Etland described a comprehensive literature
review commissioned by the Healthcare Surfaces Institute. As
a part of this review, studies on current healthcare training
and education were examined. Despite the availability of
numerous training programs and studies to show that only 48
percent of healthcare surfaces are cleaned appropriately, no
research studies were found to determine if these programs
are effective. Rather, only a handful of research studies were
focused on monitoring cleaning practices. This lack of scientific
research into the effectiveness of EVS training is surprising
and, frankly, appalling.
Given the rapidly evolving world of infection prevention, it is
critical that all healthcare professionals – EVS workers, nurses,
technicians – receive the education and training they need to
fill their roles as frontline infection preventionists.
Matthew Hardwick, PhD, is president/CEO of ResInnova
Laboratories and is the president of the board of directors of
the Healthcare Surfaces Institute. He is a thought leader in the
field of infection prevention in the healthcare environment of
care and is an expert in antimicrobial surface technologies.
november 2019 • www.healthcarehygienemagazine.com