Healthcare Hygiene magazine October 2019 | Page 10

case study
By Maha El-Sayed, PhD
Hospital Surface Hygiene: The Opportunity
for Continuous Antimicrobial Protection
C
ontaminated hospital environments play a key role in
the transmission of certain pathogenic microbes related
to healthcare-associated infections (HAIs), 1 and the Centers
for Disease Control and Prevention (CDC) recommends that
hospital rooms be routinely disinfected or cleaned in addition
to other measures. 2 Performing this in the setting of large
hospital facilities is challenging, especially while providing
around-the-clock care. The dynamic flow of people in and
out of hospitals (patients, visitors, and a staff typically three
times as numerous as there are hospital beds) can impede
the goal of sustaining a healthy, healing environment.
Challenge #1: The Continuously Contaminated
Environment
In hospitals, up to 20 percent of healthcare-acquired
pathogens are estimated to come from places outside of the
patients themselves, implicating the environment and other
sources. 3 Furthermore, contamination of the environment or
other patient-care items has been identified as an important
factor in the transmission of methicillin-resistant Staphylococ-
cus aureus (MRSA), vancomycin-resistant enterococci (VRE),
Clostridium difficile (C. diff), Acinetobacter, and norovirus. 4
Despite rigorous cleaning efforts, it has also been shown
that admission to a room previously occupied by a patient
either colonized or infected by MRSA, VRE, Acinetobacter,
or C. difficile is a risk factor for the next patient to develop
an infection or colonization as well. 4
While Infection Prevention has focused on improving
disinfection for high-touch surfaces (like bed rails), newer
research has also implicated portable and shared equipment
as key sources of transmission. 5 Shared objects like wheel-
chairs have been tracked throughout healthcare systems to
better understand their movement and exposure. 5 Beyond
shared equipment, the literature has recently identified
contaminated floors as potential fomites for pathogens like
C. difficile spores and other multidrug-resistant organisms. 6
More pathogen-harboring fomites are identified as research
focuses on finding other places where these organisms can
be found.
Patients themselves also seem to be able to sense the
difference in the environment. In “Environmental Services:
Delivering on the Patient-Centered Promise,” a Press Ganey
whitepaper, the authors find that hospital cleanliness as
perceived by patients is highly correlated with infection
rates. Specifically, a correlation was observed between the
patient perception of cleanliness (as measured by Hospital
Consumer Assessment of Healthcare Providers and Systems
[HCAHPS] scores) and HAIs. For example, hospitals viewed
as the least clean had higher associated rates of MRSA
infections, and conversely, hospitals viewed as the cleanest
had the lowest associated rates of C. difficile infections. 6
Challenge #2: Hurdles to Compliant Environmental
Hygiene
In addition to more surfaces being identified as harboring
10
pathogens, environmental hygiene faces another hurdle – the
huge hurdle of compliantly cleaning and disinfecting these
surfaces in the first place.
In the complex hospital ecosystem, environmental
services (EVS) and nursing departments face a myriad of
challenges, like time pressures and burnout. EVS performs
complicated daily and terminal cleaning processes in all areas
of the hospital while closely coordinating patient flow with
nursing personnel. These key members of the healthcare
team are instrumental in keeping hospitals as clean as
possible, providing excellent patient care, and optimizing
hospital operations.
In cleaning and disinfecting hospital surfaces, EVS workers
focus attentively on improving hospital aesthetics, and their
work product is highly visible. From the patient’s perspective,
this team represents the first of multiple infection prevention
efforts encountered during a care episode. However, EVS
workflow can face administrative management pressures,
such as throughput demands and staffing challenges, on
top of their primary objective of complete compliance with
cleaning protocols. Whatever the stressor or exact cause,
cleaning and disinfection failure modes are a highlighted
topic in infection prevention circles. For example, one study
identified that only 48 percent of environmental surfaces
(14 standardized objects) were cleaned at baseline. After
interventions including the provision of feedback to EVS staff,
the percent of surfaces cleaned increased to 77 percent. 7
Potential for Emerging Continuous Antimi-
crobial Solutions
Studies have shown that contaminated surfaces can
contribute to the transmission of healthcare-associated
pathogens, and that improved cleaning and disinfection
can reduce this transmission. 8 Given the potential risk of
contaminated surfaces, continuous antimicrobial products
and technologies, such as residual activity chemicals and
UV lights, were recently reviewed in an article published by
the American Journal of Infection Control in June 2019. The
article by David J. Weber, “Continuous room decontami-
nation technologies,” explores these technologies because
cleaning still remains inadequate. 1
Alternatives like long-lasting or persistent antimicrobials
or microbiostatics are newer to the fight to keep hospitals
clean by continuously impacting that ability of microbes to
thrive on hospital surfaces. Studies like this one demon-
strate the associated reduction in HAI rates that occur with
use of long-lasting, residual activity products. Infection
Preventionists can help pioneer the call for and use of new
products to help support their EVS colleagues in the daily
battle to keep healthcare environments safer.
Maha El-Sayed, PhD, is chief science officer of Allied BioScience.
References for this article and other information are available at
www.alliedbioscience.com
october 2019 • www.healthcarehygienemagazine.com