Cleanliness Guidelines for Healthcare Settings

Millions of patients develop healthcare-associated infections (HAIs) each year, resulting in lost lives and livelihoods, as well as financial hardship, for those infected and the facilities in which they occur. Now, during the COVID-19 pandemic, increased cleaning requirements have further strained healthcare facilities that must use Environmental Protection Agency-approved disinfectants to comply with infection prevention and control requirements. And, while environmental cleaning is admittedly not a sexy topic, often overshadowed by new equipment and breakthrough treatments, it is critical to the safety of patients and hospital staff. 

Unfortunately, this obscure topic often remains invisible until deadly outbreaks of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile and others occur. And, once pathogens take hold, they can be hard to overcome. In the right conditions, pathogens can survive on surfaces for months, hiding in cracks and crevices, and they can infect new hospital room occupants following discharge of an infected patient, even after cleaning has been performed. In fact, about one in 31 hospital patients develops at least one HAI. And, infection risks are significantly higher for patients housed in rooms previously occupied by those with an HAI. Unfortunately, environmental surfaces aren’t the sole culprit when it comes to pathogen-spread infections. According to the Centers for Disease Control and Prevention (CDC), on average, healthcare providers clean their hands less than half the time they should.¹ Another problem contributing to pathogen spread? Clean supplies housed in dirty storage.

Clean Versus Dirty 

“I see the same issues repeatedly,” says Peggy Luebbert, MS, CIC, CHSP, CBSPD, an infection preventionist consultant with APIC Consulting Services, a subsidiary of the Association for Professionals in Infection Control and Epidemiology. “More often than not, no matter the type of facility, storage and separating clean from dirty, including instruments and supplies, is the challenge.” Luebbert says, too frequently, building design just doesn’t incorporate enough clean storage: “It’s always a struggle.”

Since COVID-19, the storage problem has worsened, and it was particularly bad early on when limited supply availability prompted stockpiling. As new supplies came in, and with limited storage capacity, deliveries found their way to any available space, including attics, basements, garages and closets not suitable for storing clean supplies before being used. “These are key problems when talking about infections,” explains Luebbert.

Cleaning and clean storage are the two key areas on which Luebbert first focuses when problem-solving, particularly when an infection isn’t caused by a single source such as a germ or healthcare provider. “The interesting thing,” she explains, “is when people bring supplies in, if they had just left them sealed in the cardboard box, it may have been OK to store in a dirty area. But, once the box is opened, whatever is inside must be stored in a clean area with controlled traffic. I’ve seen clean supplies stored near a time clock! No! Don’t do that!” Once a box of clean supplies is opened or stored in a dirty area, its contents must be thrown away. 

You Don’t Know What You Don’t Know: SOPs

Standard operating procedures (SOPs) are comprehensive measures outlining specific requirements at every step of the process, from receipt of materials, to sorting and storage of everything from equipment to supplies, as well as the appropriate standard precautions, including cleaning and disinfecting protocols. 

SOPs are intended to be instructional. Therefore, the literacy level and language of those following them should be taken into consideration, as well as definitions of technical terms and acronyms. Infographics are often necessary to minimize user confusion and maximize compliance with expectations. 

On the environmental cleaning front, detailed SOPs should include: 

• Approved cleaning products and vendors

• The quantities in which cleaning products will be purchased, maintained and stored 

• Location of safety data sheets (in close proximity to the products)

• Proper hand hygiene before and after cleaning tasks

• Approved and required personal protective equipment (PPE) by task

• Instructions for donning and doffing PPE

• Step-by-step instructions for all cleaning processes, including preparations of products, listed in sequential order of use, based on the product’s manufacturer instructions

• Safe disposal of soiled cleaning equipment and supplies 

• How to handle emergencies such as chemical spills, etc. 

Detailed environmental cleaning policies as outlined in SOPs must be adequate, effective, regularly practiced, reviewed and, importantly, revised as needed against new and emerging CDC, U.S. Food and Drug Administration (FDA) and Occupational Safety and Health Administration (OSHA) regulations that govern disinfection interventions. As protocols and products evolve, human factors such as staffing, workflow, supervision and collaboration between support services and clinical staff must evolve with them to ensure best practices.

As part of an SOP, employee monitoring against standards should be clearly articulated, including by whom, at what frequency and how feedback will be communicated. Employee monitoring, as well as surface monitoring, is at the heart of ensuring compliance with standard precautions and the development of staff training.

The robustness of any cleaning and disinfecting program is directly related to the specificity of the applicable information in the SOPs, the thoroughness of training for those who will perform the tasks and the priority placed on environmental cleaning by leadership.

Top-Down Approach

The ultimate responsibility for environmental awareness and best practices lies with facility leadership. Reporting lines and accountability may demonstrate who performs what tasks, but leadership demonstrates the expected standard of care through planning and execution. Funding is always a significant hurdle, too, so from an environmental standpoint, consideration must be given to ensure:

• Adequate staffing (including contingencies)

• Appropriate supplies and equipment

• Facility infrastructure design and maintenance (such as clean storage)

• Training and assessments for all staff according to clearly defined performance expectations

Additionally, ancillary costs such as the printing of training materials and posters, software licensing, support for online training programs and administrative costs of documentation and record keeping in accordance with any regulatory requirements or human resource policies must be taken into consideration. 

Whether cleanliness regimens are handled by employees, are contracted out or are a hybrid (such as facility employees who are recruited by a staffing company that specializes in environmental cleaning), CDC, FDA and OSHA requirements and other applicable government standards (such as state standards) should be clarified so expectations and standards are clear. 

Leadership must also ensure a watchful eye on facility requirements and needed improvements. As an example, even the most advanced cleaning products will be rendered ineffective in the presence of turbid water in which suspended particles such as dirt can reduce the effectiveness of detergents and disinfectant solutions. Likewise, wastewater considerations must be taken into account to protect healthcare facilities and surrounding communities.

Training, Monitoring and Feedback

Environmental staff should be trained on their job descriptions, SOPs pertaining to their jobs, expectations and performance standards and the mechanisms by which they will be evaluated. In addition to understanding how to perform their jobs, these staff members should perform only those duties for which they have been trained. This means those who have not been trained to clean high-risk areas should not be assigned this duty. 

Staff must also receive information about how to identify the various chemical and pathogen hazards to which staff will be exposed, as well as how to protect themselves with PPE. And, they must understand the logic of not only what they are asked to do but why, explains Luebbert. Otherwise, they may not understand the seriousness of their tasks and training. For instance, she says, staff must have answers to why linty towels are a big deal and why it is important to cover their hair. She also recommends that once a facility retains good staff, it should do everything possible to keep them since one of the biggest breakdowns with cleaning and disinfecting is losing trained staff: “Remember, they could get a job anywhere — a hotel, a casino — places with a lot less body fluid. Keeping good staff comes down to respecting good staff. Support them as they do their jobs. Help them understand why they do what they do and why [the facility doesn’t] cut corners.” A good relationship works both ways, she adds, and “people love their environmental services person. Don’t even think about moving them to another area! I always say, from an infection control perspective, ‘If housekeeping’s not happy, Peggy’s not happy.’”

Once trained, monitoring is a critical component of effective cleaning and disinfecting programs, and staffing levels are a critical component of monitoring. There must be clear and defined lines of accountability, functional reporting and responsibilities for all staff. The supervisor-to-cleaner ratio should allow for routine and regular performance observations, with performance intervals consistently maintained to accurately track and benchmark. If resources allow, CDC guidelines recommend in-patient settings include a monitoring program that covers 10 percent to 15 percent of beds on a weekly basis, and outpatient settings monitor either 10 percent to 15 percent of procedural areas on a weekly basis. Better yet, if resources allow, outpatient settings should monitor 25 percent of procedural areas weekly so the entire facility is monitored monthly.² 

While visual inspections are the simplest method for evaluating cleanliness, quantitative feedback provides confirmation, albeit at additional cost and turnaround time. Aerobic colony counts in which cultures are collected and processed, even if they are not immediate, are one option. Or, more rapid feedback can be obtained via UV light inspections and bioluminescence-based adenosine triphosphate assays. In either case, reputable laboratories should be used to obtain valid and verifiable results.

Third-party observers may be enlisted for independent assessments as well. Key questions Luebbert asks when she arrives at a facility include:

• Why are you doing that?

• What disinfectant are you using?

• How will you dilute it?

• What is its expiration date?

• What is its kill time? 

• What surfaces do housekeeping, environmental services and nursing staff clean?

Also, she advised, “Ask, ‘who cleans the bed? Who cleans under the bed? Who cleans the infusion pump?’ Oftentimes, the answer ends up being ‘everyone thought someone else was cleaning it.’”

Feedback helps to further competency and effectiveness of both staff and the procedures they perform. Whether formal or informal, feedback is the basis for improved training. Much like SOPs, training documentation demonstrates compliance. These records must include dates, content, the trainers’ names and those being trained. An evaluation of the content is also helpful. Refresher trainings and competency assessments should be conducted at least annually, and always before introducing new environmental cleaning supplies or equipment.

Safe Handling Instructions

Laundering of reusable linens in a healthcare setting is highly recommended. From soiled linens (bedding, isolation gowns) to protective clothing worn by environmental workers, universal precautions must be used when receiving, handling and laundering. 

Accrediting organizations such as the Healthcare Laundry Accreditation Council (HLAC) set standards by which both in-house and contracted laundering facilities agree to operate to sanitize reusable linens. Expectations go beyond the use of chemical additives and hot water during the wash cycle and extend to equipment design, adherence to OSHA requirements, personnel training, quality monitoring and more. Unless the textiles have been exposed to an infectious agent that would render them unusable, protocols designed by HLAC and similar organizations are sufficient to protect patients and healthcare staff, as well as those workers who handle laundry. 

Remember, once items have been laundered, sanitized and packaged in sealed wrapping, they must be handled and stored in such a way that maintains their integrity and avoids environmental contamination until they are ready for use.

Cleanliness Ensures a Healthy Environment

Cleanliness in healthcare settings is as important as the care provided to patients. By adhering to federal standards implemented by CDC, FDA and OSHA, as well as private collaboratives such as APIC and HLAC that determine best practice standards, providers, environmental services and cleaning staff can ensure facilities are safe for the most vulnerable populations. Understanding and executing appropriate SOPs, correctly preparing and using approved cleaning and disinfecting solutions, and ample space and safe work areas — all under competent and engaged leadership — can instill confidence and a healthy environment for all.