Research clearly shows that microbes live on surfaces for days, weeks, or even months after cleaning. As more research is published and more is learned, evidence continues to show that surfaces have an active role in the transmission of microbes and ultimately in the spread of infection.
Surface selection and evaluation are predominately based on the design criteria established before any construction or renovation project. How it looks and where it is located is based on creating a homelike atmosphere and a healing environment. While this is important, the selection of surfaces is complicated. The goal is to select a combination of surfaces that can be effectively cleaned and disinfected, leaving little room for human error. Unfortunately, right now the majority of surfaces being used in healthcare are difficult if not impossible to clean effectively.
It is critical that information be collected to address the ability to clean and disinfect the surfaces being selected. Equally important is making sure the ability to clean and disinfect surfaces follows recommended guidelines and infection prevention requirements. It is too common that facility staff learn that the surface materials chosen cannot be cleaned effectively using disinfection products without serious surface damage. Unseen microbial reservoirs create unnecessary risk to patients, healthcare workers and the general public. It also becomes costly to the facility, as products need to be replaced or repaired.
Look at the whole picture
There is a science around the spread of infection via surfaces that should be considered during the evaluation process. It is not enough to learn every physical characteristic of a given surface and surface material or to become an expert in the latest disinfection agents and protocols. This data must be combined with an understanding of microbiology, the physical environment and insight into human behavior. Taking all seven of the following aspects into consideration might change surface and material selection.
1) Materials and Textiles. Needed products such as chairs, beds, sheets, privacy curtains, and beside tables are selected by looking at sample books or swatches of material, in addition to special feature requirements. This provides only a small glimpse of any given surface. Be aware of textured surface materials, such as brushed stainless steel, pebble texture acrylic wall surfaces, and textiles used for soft surfaces, such as privacy or shower curtains. What will it take to clean these surfaces? How often do they need to be cleaned to reduce bio-burden and prevent cross-contamination?
2) Surface Assemblies. It is critical that during the evaluation process, the assembly of surfaces is understood. Different materials and textiles are often combined into a single product, making the product difficult (or even impossible) to clean/disinfect. It is true that some of this is unavoidable. However, it is entirely possible to reduce the number of products in a room that present difficult or impossible disinfection challenges.
When we look closely at surfaces surrounding the patient, we see similar combinations and connections between different materials. Seams, baton strips and connects between surfaces create microbial reservoirs that can be completely avoided when this problem is understood.
3) Microbiology. A person typically sheds some 37 million bacteria every hour into the surrounding air and onto surfaces touched. Patients are a major source of contamination, and bio-burden is heaviest within three feet of the patient. If the patient is mobile, research has shown the patient bathroom is an area where bio-burden is high. With the knowledge that pathogens survive for days, weeks and months, these areas absolutely need to be able to be effectively cleaned. Unfortunately, there are surfaces with microbial reservoirs that provide safe harbor where disinfectant products cannot reach.
4) Location. Where surfaces are located matters. Different departments within the hospital require more focus on the types of surfaces being used. In a previous blog I outline some items that must be considered in the ED. Faced with a need to turn a room over quickly often means that healthcare workers with a primary responsibility for patient care must also clean, disinfect and turnover the room. It is entirely possible to use surfaces that can be easily and effectively disinfected.
5) Human Behavior. Patients, healthcare workers and visitors interact with surfaces in many ways. Clothing, equipment and hands become contaminated and move pathogens throughout the patient room and the entire facility.
While visiting an acquaintance during a three-day hospital stay, I observed human behavior and the way the patient, staff and visitors interacted with surfaces. The behavior of healthcare workers was fairly common during the patient care process. Most interacted with the same surfaces in the same way and in the same order. Visitors interacted with many of the same surfaces as healthcare workers. However, they also used areas such as the windowsill, bed and chair next to the patient bed, which were often covered with a blanket for the patient to sit on. Visitors also used the patient restroom.
Surfaces typically considered “high touch” would not have been easy to identify, since many people touched all surfaces within three feet of the patient frequently.
It is also interesting to note that EVS cleaned a few surfaces and left others completely untouched.
6) Cleaning and Disinfection. Can surfaces be cleaned and disinfected effectively? The typical response a manufacturer would give is yes, you can use anything to clean all surfaces. Further questioning often begins to reveal a lack of understanding of infection prevention protocol and cleaning and disinfection products.
Surface manufacturers don’t know what they don’t know, particularly when it comes to infection control strategies, processes and products. Multiple products may be used, some of which may cause serious damage to surfaces. Many microbial reservoirs are impossible to see. When a room is tested for effective disinfection, testing will provide one result immediately following disinfection, but will often show that microbial counts have rebounded significantly two hours after cleaning.
7) Manufacturer Warnings. Request and understand the manufacturer warnings. During a recent presentation, members of the audience were surprised to learn that so many products actually have warnings about the use of chemicals contained in commonly used disinfectant products. It is not unusual to find that a manufacturer has tested specific chemicals on their product, but has not tested disinfection products. Test results can vary when an actual disinfectant product is tested, since it may be composed of multiple active and inactive chemicals.
Surface selection is a complicated matter
Surface selection in healthcare is complicated and requires a focused effort. By minimizing microbial reservoirs and selecting surfaces that can be effectively cleaned and disinfected, the foundation of a multimodal solution needed to reduce the spread of HAIs will be found.
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