Implementing Stringent Cleaning and Disinfecting Policies in the Healthcare Setting

AFTER DEALING WITH the COVID-19 pandemic for more than two years, many establishments are loosening precautionary restrictions. In healthcare facilities, these revised measures include allowing family and friends to accompany patients to care visits and hospital stays, thus increasing the possible spread of the SARS-CoV-2 virus. As a consequence, it is increasingly important for management to implement stringent cleanliness policies to curb the spread of infection.

How the SARS-CoV-2 Virus Spreads

COVID-19, a respiratory infection caused by the SARS-CoV-2 virus, is transmitted mainly through exposure to respiratory droplets. This spread typically occurs through close physical contact within closed settings such as healthcare facilities, but it is also possible for the virus to be transmitted via surface contamination.¹

According to the World Health Organization (WHO), environmental surfaces are more likely to be contaminated in healthcare settings where medical care is performed. Environmental surfaces include furniture and other fixed items inside and outside of patient rooms and bathrooms such as tables, chairs, walls, light switches, computer peripherals, electronic equipment, sinks and toilets, as well as the surfaces of noncritical medical equipment such as blood pressure cuffs, stethoscopes, wheelchairs and incubators.²

The SARS-CoV-2 virus, according to WHO, “is an enveloped virus with a fragile outer lipid envelope that makes it more susceptible to disinfectants compared to nonenveloped viruses such as rotavirus, norovirus and poliovirus.” In studies that have evaluated the persistence of the COVID-19 virus on different surfaces, one found that the COVID-19 virus remained viable up to one day on cloth and wood, up to two days on glass, four days on stainless steel and plastic, and up to seven days on the outer layer of a medical mask. Another study found the COVID-19 virus survived four hours on copper, 24 hours on cardboard and up to 72 hours on plastic and stainless steel. In addition, WHO found, “the COVID- 19 virus also survives in a wide range of pH values and ambient temperatures, but is susceptible to heat and standard disinfection methods.” Yet, while WHO cautions that these studies “were conducted under laboratory conditions in absence of cleaning and disinfection practices and should be interpreted with caution in the real-world environment,”² it would seem prudent in light of the ever-persistent and constantly mutating virus that sanitizing and disinfecting cleaning protocols should be strictly followed.

Cleaning Protocols

Chavaun LeBlanc, manager of environmental health and safety at MD Anderson Cancer Center in Houston, Texas, reports she frequently hears questions about cleaning high-touch objects to reduce the spread of COVID-19, including “What’s the difference between cleaning and disinfecting?” Cleaning, she explains is removing all visible traces of dust or dirt such as laundering a shirt or wiping a shelf with a cloth. Disinfecting is killing the germs that may be living on the surfaces by using heat, light and chemicals. The distinction, says LeBlanc, is that “dirt-free does not equal germ-free.”³

In healthcare environments, it is imperative that disinfecting measures be put in place, which is in addition to cleaning and sanitizing. The difference between sanitizing and disinfecting is sanitizing kills bacteria on surfaces using chemicals, whereas disinfecting kills viruses and bacteria on surfaces using chemicals. According to the U.S. Environmental Protection Agency (EPA), surface disinfectant products are subject to more rigorous EPA testing requirements and must clear a higher bar for effectiveness than surface sanitizing products.⁴

Currently, five main EPA-registered chemicals that hospitals use for disinfectants include quaternary ammonium, hypochlorite, accelerated hydrogen peroxide, phenolics and peracetic acid. And, choosing which chemical to use can often be a complicated process.⁵

Quaternary ammonium compounds are used broadly in routine cleaning, and the Centers for Disease Control and Prevention considers them to be a low-level disinfectant effective against most bacteria, enveloped viruses and some fungi. They are best used on noncritical surfaces such as floors, bed rails, tray tables, blood pressure cuffs, walls and partitions.

Hypochlorite is the most commonly used chlorine disinfectant. Sodium hypochlorite is commercially available as household bleach, and can be used in hospitals for bathrooms, food prep zones and blood spills. However, all areas must be precleaned to remove organic matter before disinfection.

Accelerated hydrogen peroxide, a more recent breakthrough in hospital disinfectants, is a blend of safe, active cleaning agents with hydrogen peroxide. It is safe for the cleaning staff and the environment with the lowest EPA toxicity category. These one-step cleaners disinfect in the presence of organic matter and blood, and they kill bacteria, viruses, mycobacteria, pathogenic fungi and blood-borne pathogens.

Phenolics, which have been around for a long time, are best for disinfection of nonporous surfaces and noncritical devices.

Peracetic acid preparations, which are rapid-acting disinfectants, are bactericidal, fungicidal, virucidal, mycobactericidal and sporicidal. Hospitals often use these in automated machines to sterilize medical instruments and to disinfect hemodialyzers.

Of course, it’s always preferable to choose products that contain less-hazardous ingredients if possible. For instance, sodium hypochlorite (bleach) and quaternary ammonium compounds can cause asthma, so they should be used with caution in certain areas. Further, when using these products, they should be left wet on the surface or air dried for the correct dwell or contact time to ensure they kill resistant germs.⁶

Best Practices

Employing the best strategies to disinfect surfaces in the healthcare environment is crucial. Following these steps achieves maximum results:⁶

1) Create a plan. A set of written standard operating procedures for cleaning and criteria for when to sanitize or disinfect should be developed.

2) Routinely clean all frequently touched surfaces. Particular attention should be paid to high-touch surfaces and items such as light switches, bed rails, door handles, intravenous pumps, tables, water/beverage pitchers, trays and mobile cart rails. Clearly, this is critical in areas where there are suspected or confirmed COVID-19 patients (Table).

3) Provide information and training. Workers must be informed about the hazards of the cleaning chemicals used in accordance with OSHA’s Hazard Communication Standard, and they should wear appropriate protective equipment such as gloves. In addition, cleaning should follow accepted best practices that include cleaning from high to low, toward the doorway, and with dry cleaning tasks performed prior to wet cleaning tasks.

4) Evaluate. Last, continually reassess the plan, and seek feedback from people using the products and from those in spaces where they are used.

Proper Implementation Is Essential

As the COVID-19 pandemic persists, properly implementing effective and responsible cleaning and disinfecting practices is essential to protect the wellness of both healthcare staff and patients.