Healthcare Hygiene magazine October 2019 | Page 28

Applying the Hierarchy of Controls to the
Seven Aspects of Surface Selection ™
By Linda Lybert and Amber Mitchell, DrPH, MPH, CPH
T
he Healthcare Surfaces Institute has recently adopted a
combination of the Hierarchy of Controls and the Seven
Aspects of Surface Selection™ as a quick guide for patient
and healthcare worker safety as it relates to surface selection.
Healthcare surfaces have long been established as fomites
— objects or materials to carry microorganisms that can cause
infection and illness. Research has shown that microbes can
live on “clean and disinfected” surfaces for days, weeks and
even months. How is this possible when surfaces in healthcare
settings are regularly cleaned and disinfected?
Surfaces are complicated. Discussion around the impact
surfaces have in infection prevention and control creates
confusion and misunderstanding. Some believe environmental
or high-touch surfaces like sinks, counters, bedrails, door
handles, light switches and patient equipment are the main
contributing factor for the acquisition and spread of patho-
gens, but these surfaces only make up about 25 percent of
surfaces in patient and procedure rooms.
Limiting focus on these surfaces and/or these thought
processes leaves about 75 percent of the surfaces that exist
in the healthcare environment unaddressed. These include
upholstery on furniture, walls, floors, linen, fixtures, and
more. They also include surfaces made up of multiple surface
materials that interact with patient and personnel, including
medical devices, surgical equipment, and instruments. In
addition, soft surfaces such as scrubs, hospital gowns, and
bedding always move between various areas of the hospital
and can serve as fomites.
Seven Aspects of Surface Selection™
To reduce the role that healthcare surfaces play in
the acquisition and transmission of pathogens, the Sev-
en Aspects of Surfaces Selection TM must be evaluated.
Considerations include:
➊ Surface Materials and Textiles: There are many
different surface materials and textiles used within healthcare
facilities both in the built environment and products used
during patient care.
➋ Assemblies: Multiple surface materials on any one
product must be evaluated individually and as an assembly
for use and cleanability. Examples; beds and other medical
devices, furniture.
➌ Location of the Surfaces: High-contamination
and high-turnover areas require durable surfaces that can
withstand frequent disinfection. Example; OR, ED.
➍ Cleaning, Disinfection/Sterilization: Infection
prevention protocol, process and products that will be used
must be considered and an evaluation completed before
products and surfaces are purchased and put into service.
➎ Human Behavior: Humans continually interact with
surfaces and move throughout the healthcare facility. While
28
hand hygiene is critical, clothing and other products also
move throughout the facility. Many questions exist around
human behavior and transmission of microbes that cause
deadly infections.
➏ Microbiology: There are surface materials that sup-
port the proliferation of microbes despite routine cleaning.
Manufacturers lack standardized testing for microbes that
allow purchasers to compare products equitably.
➐ Manufacturer Warnings and Instructions for Use
(IFUs): Disinfectant compatibility testing for surfaces is rarely,
if ever, conducted. It is concerning when manufacturers
list all disinfectants as compatible without testing data
and validation that they are in fact compatible, creating
risk of damage and the potential for a voided warranty
for healthcare facilities. It is also important that healthcare
professionals request manufacturing warnings. In this
document, you will find warnings that include chemicals
used in disinfectants and detergents.
Note: Many products have multiple surface materials that
cannot all be cleaned, disinfected and sterilized the same
way. When they are damage occurs creating reservoirs for
microbes to harbor out of the reach of biocides.
By incorporating the Seven Aspects of Surface Selection™
into the Hierarchy of Controls, an innovative method begins
to emerge for addressing surfaces more comprehensively.
The process more closely integrates infection prevention
and occupational health and allows healthcare institutions,
manufacturers, and experts the ability to address controls
for surfaces in a more methodical process with the focus
first on making the biggest impact.
However, currently, there are no consistent surface testing
standards or requirements. This can leave those accountable
and responsible for infection prevention and patient care at
risk. This is due in part to a general lack of understanding
and knowledge about the impact surface materials and
composition can have on the ability to successfully clean,
disinfect, and/or sterilize them.
Hierarchy of Controls
Controlling exposures to occupational hazards is the
fundamental method of protecting workers. While this
concept is typically used in occupational health and industrial
hygiene disciplines, we can use the hierarchy to apply the
same concepts to protect patients and their caregivers from
healthcare surface-derived hazards as well. Traditionally, a
hierarchy of controls has been used as a means of determining
how to implement feasible and effective control solutions in
a manner that provides first, the greatest level of protection.
The idea behind this hierarchy is that the control methods
at the top of the graphic (below) are more effective and
protective than those at the bottom. Following this hierarchy
october 2019 • www.healthcarehygienemagazine.com