"Seven aspects of surface selection" featured in Health Facilities Management magazine

In 2016, Linda Lybert was featured in Healthcare Facilities Management Magazine and introduced the Seven Aspects of Surface Selection©, which is the foundation of her Healthcare Surface Consulting organization. She will be doing a series of blogs on each of these Seven Aspects over the next several months.

Read the full article below. For further information please contact us.

This article was originally published in    Healthcare Facilities Management    magazine

This article was originally published in Healthcare Facilities Management magazine

Seven aspects of surface selection

Choosing the right materials to help staff prevent infections

Preventing health care-associated infections (HAIs) is a top concern of all health care organizations. On the front lines of these efforts, environmental services (ES) professionals are availing themselves of the latest science-based training, technology and supplies as they fight multidrug-resistant organisms.

Beyond their traditional role in cleaning and disinfection, however, ES professionals are playing an ever-larger role in determining which surfaces are selected for health care interiors. This not only ensures that these finishes won’t degrade under rigorous cleaning regimens, but they also will be easier to disinfect in the first place.

Foundational issue

Most people think of surfaces as part of the design and construction process rather than part of an infection prevention and control program. When selecting materials, a lot of focus tends to be given to colors and textures. Although these aspects of a surface material are certainly important, there are many other surface properties that are critically important, yet are not thought about or given proper evaluation. After all, the most soothing color and texture is of little value to a surface that cannot be cleaned or disinfected properly.

People interact with surfaces throughout the day without a second thought. If hands are washed regularly, someone with a healthy immune system has a good chance of reducing his or her risk of infection. This is not necessarily true for someone with a compromised immune system.

Ironically, surfaces often are cleaned and disinfected based on visual inspection, even though it is commonly understood that microbes cannot be seen. Research has shown that at the microscopic level, microbe counts can rebound quickly — oftentimes to levels seen prior to cleaning and disinfection. This leaves patients, health care workers and the general public at constant risk of acquiring and spreading infection. In fact, studies have shown that patients are at a 35 to 50 percent risk of contracting an infection such as methicillin-resistant Staphylococcus aureus or Clostridium difficile from the patient who previously occupied the same room, depending on the infection and despite routine and terminal cleaning and disinfection.

The science of surfaces as a fomite (object or material that is capable of carrying infectious organisms and serve in their transmission) is just maturing. Research has shown that microbes can live on “clean and disinfected” surfaces for days, weeks and even months. How is this possible when surfaces are being regularly cleaned and disinfected? Below are seven aspects of surface selection that will help ES professionals to gain an understanding of why facilities must set surface criteria to minimize risk and prevent harm to patients, health care workers and the general public.

Selection of surfaces

Currently, the surface evaluation and selection process is predominantly based on specific design criteria established before any construction or renovation project. The look, feel and location of the surface is based on creating a homelike healing environment. While this is important, the selection of surfaces is complicated and the evaluation process must go far beyond the way it looks and feels. Ultimately, it is important that surfaces can be cleaned and disinfected effectively, leaving little room for human error. Unfortunately, the majority of surfaces being used in health care today are difficult, if not impossible, to clean effectively.

There is a science around the spread of infection via surfaces. It is not enough to learn every physical characteristic of a surface or to become an expert in the latest disinfection agents and protocols. These 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 and setting surface selection criteria within health care facilities will begin to address the critical surfaces issue.

1. Materials and textiles. Health care facilities are full of many different surface materials, textiles and products. Necessary products such as chairs, beds, sheets, privacy curtains and bedside tables are selected by looking at sample books or swatches of material in addition to special features any of these products may offer. While these properties are important, they are only the tip of the iceberg, providing only a glimpse into what is truly needed in any health care setting.

ES professionals should be aware of textured surface materials such as brushed stainless steel, pebble-textured acrylic wall surfaces, fabrics with tight or open weaves, and vinyl and plastic materials that may create additional challenges during the cleaning and disinfection process. This is true with any surface material.

There are many critical questions to be answered regarding each surface material being considered. A few important ones are: What will it take to clean this surface? Can it be cleaned with the products the facility is currently using? Has it been tested to verify that hospital-grade disinfectants can be used without causing damage? How often will it need to be cleaned and disinfected to reduce bioburden and prevent cross-contamination?

2. Surface assemblies. Selecting a surface based on sample swatches doesn’t provide enough insight into what the potential challenges might be. It is critical that during the evaluation process, the assembly of surfaces is understood. Different materials and textiles often are combined into a single product, making the final product difficult or impossible to clean and disinfect. It is true that some of this is unavoidable. However, it is possible to reduce the number of products in a room that present difficult or impossible disinfection challenges.

Cross-contamination can occur easily if levels of bioburden are not continually reduced to safe degrees by cleaning and disinfection. An evaluation of assembled surfaces surrounding the patient will provide insight into the challenges faced when trying to clean and disinfect the many combinations of materials, textures and textiles. Seams, batten strips and connects between surface materials create additional microbial reservoirs that often can be avoided completely when this problem is understood.

3. Microbiology. A person typically sheds some 37 million bacteria every hour into the surrounding air and onto environmental surfaces that are continually being touched. Patients are a major source of contamination, and bioburden is heaviest within three feet of the patient. If the patient is mobile, research has shown that the patient bathroom is also an area where bioburden is high. With the knowledge that pathogens survive for days, weeks and months, these areas absolutely need to be able to be effectively cleaned.

Patient shedding is not the only contamination threat. Toilet spray, also referred to as “toilet plume,” plays a major role in the transmission of infectious diseases. Ironically, patient toilets typically do not have lids, due at least in part to the difficulty in cleaning them. After discarding objects laden with viruses and bacteria into a toilet, the toilet is flushed. As a result, these microbes are released into the air and land on surfaces at a relatively high concentration within a three-foot radius of the toilet. This area typically includes a variety of ceramic tiles and many grout lines.

Other materials assembled in this area include towels, shower curtains and sinks with faucets. As a result, these surfaces become microbial reservoirs that provide safe harbor where disinfectants cannot reach their intended targets.

4. Location. The location of a surface matters. Different departments within a hospital require different surface selection criteria. In such areas as the emergency department (ED) or surgery, health care professionals are faced with the need to turn over rooms quickly. Often, this means that health care workers with a primary responsibility for patient care also must clean, disinfect and turn over a room.

Some of these professionals do not understand that it is critical to clean and disinfect these areas effectively. The criteria for selecting surfaces must take this into consideration. Health care workers often say grabbing a wipe and wiping off the gurney railings is about all that time allows. With this in mind, using surfaces that can be disposed easily or cleaned effectively is critical.

Recently, a facility was confronted with a community-based outbreak of C. difficile that had started to spread within the facility from patients who entered through the ED. Facilities must set surface criteria based on the location, taking into consideration short turnover times and which staff member holds primary responsibility for room turnover. 

5. Human behavior. Patients, health care workers and visitors interact with surfaces in many ways. Clothing, equipment and hands can become contaminated and move pathogens throughout the patient room and the entire facility.

While being an advocate for a patient during a three-day acute care hospital stay, I took the opportunity to observe human behavior around surfaces. The behavior of health care workers was fairly common. “Pumping in” by using the hand sanitizer was routine and a good start. However, the very next action was nearly always to reach into a pocket in their scrubs to retrieve a pen. Most health care workers interacted with surfaces in similar ways and in the same order — computer, mouse, nurse call button, controls on the IV and IV pole, catheter bag, bed and bedding.

Visitors interacted with many of the same surfaces, but they also touched such things as the windowsill, bed and chair next to the patient bed, which was often covered with a blanket for the patient to sit on. Visitors also used the patient bathroom.

Specific surfaces that should be considered “high-touch” would not be easy to identify, because many people frequently touched virtually every surface within three feet of the patient. In fact, ES staff cleaned some surfaces but ignored other frequently touched surfaces during the daily cleaning process.

6. Cleaning and disinfection. This is an aspect that is obviously critical, but is often misunderstood. Everyone knows that it is important to clean and disinfect everything. However, can each surface be cleaned and disinfected effectively in the time frame set for completing that task? The typical response from a manufacturer would be, “Yes, you can use anything to clean all surfaces.” Clearly, this is not the case. Not all surfaces of a bed, for instance, can be effectively cleaned and disinfected the same way. Further questioning often begins to reveal a lack of understanding of infection prevention protocol as well as cleaning and disinfection products that are being used at different times and in different situations.

Surface manufacturers don’t know what they don’t know, particularly when it comes to infection control strategies, processes and products. Many different cleaning products are used, some of which can cause serious damage to surfaces. Often, this damage is unseen and creates a microbial reservoir that harbors pathogens that can proliferate, untouched by disinfection products.

7. Manufacturer warnings. Finally, it is extremely important to request and understand manufacturer warnings. Surface materials often come with warnings about using cleaning and disinfection products commonly used in health care facilities. Additionally, ES professionals should make sure surface materials are tested as an assembly. Testing specific materials will give one result, but combined materials that are cleaned and disinfected can produce an entirely different result. Equipment may include many different surfaces that cannot be cleaned and disinfected the same way.

It is not unusual to find that a manufacturer has tested specific chemicals on its product, but has not tested disinfection products. Results can vary when an actual disinfectant product is tested, because it may comprise multiple active and inactive chemicals. Even if cleaning products are not called out in manufacturer warnings, ES professionals should confirm that they are safe to use for each product and surface.

A critical role

Environmental surfaces play a critical role in the transmission of HAIs. By being aware of the seven aspects of surface selection, it becomes clear that health care facilities must set surface criteria to minimize risk and prevent harm to patients, health care workers and the general public.

By using the seven aspects to create surface selection criteria, health care facilities will lay a foundation to achieve a sustainable reduction in the number of HAIs.

Copyright © 2019 Healthcare Surface Consulting LLC

Linda Lybert is president of Healthcare Surface Consulting LLC and co-founder of the Healthcare Surface Summit. She can be contacted at linda@healthcaresurfaceconsulting.com. The Seven Aspects of Surfaces is used by Healthcare Surface Consulting LLC as the core focus of their business.

Linda Lybert Featured in Infection Control Today on the 2018 Healthcare Surfaces Summit


A new article published in Infection Control Today by Matthew Hardwick, PhD; Debra Harris, PhD; Linda Lybert; and Amber Mitchell, DrPH, MPH, CPH, on the 2018 Healthcare Surfaces Summit, “Unprecedented Collaboration to Eliminate Infection and Illness Caused by Contaminated Surfaces in Healthcare Environments.” (Re-printed below)


Unprecedented Collaboration to Eliminate Infection and Illness Caused by Contaminated Surfaces in Healthcare Environments

By Matthew Hardwick, PhD; Debra Harris, PhD; Linda Lybert; and Amber Mitchell, DrPH, MPH, CPH

Originally published September 13, 2018 by Infection Control Today

In a world full of conflict and complexity, we seek solidarity and simplicity. In an age of globalization of travel and medical tourism, we need the delivery of healthcare to make common sense for all who access it. A healthcare facility must be a safe place designed for health and healing. If its surfaces cannot be effectively cleaned, disinfected and/or sterilized, it is not a healing environment.  

A design cannot just be created, initiated and executed by architects, designers, engineers, builders, without input from clinicians, specialists, scientists, manufacturers, advocates, and educators. The problem we continue to see is that manufacturers often develop new products to solve a specific problem without input from healthcare professionals that will be responsible for the care and maintenance of them. In particular, those who are in daily contact with patients and personnel have a different level of understanding and knowledge of infection prevention as it relates to surfaces. Ensuring all key stakeholders are at the table for all discussions provides invaluable insight and knowledge of protocols and process for cleaning and disinfection. 

The Healthcare Surfaces Summit (HSS) is just that -- a collaboration of stakeholders adamant about making healthcare environments and the delivery of healthcare free from harm. 

HSS is a collaboration between infection preventionists, epidemiologists, infectious disease experts, scientists, laboratorians, engineers, occupational health and safety experts, and architects working in healthcare, manufacturing, academic, entrepreneurial, government, standards setting, and non-profit organizations. All are focused on creating measures, metrics, standards, research, outreach and education to reduce preventable infections by interrupting the transmission of surface-related pathogens in healthcare in support of community health.

Readers of Infection Control Today well know that 1 out of 25 patients will acquire an infection while being treated for something else.1 This statistic is unacceptable. We also know that this is not just an issue for patients, but that healthcare personnel also experience increased incidences of illness and infection and are continually at risk.2 Exposure to pathogenic microorganisms that can cause morbidity and mortality in patients and personnel, also carry risk to the public and impact overall global public health.3 This is not just the case in crowded, heavily occupied healthcare facilities.  In fact, it may potentially be more pertinent -- especially with hearty environmental microorganisms like Clostridium difficile -- in regular, everyday settings like moderately occupied acute care hospitals and outpatient clinics.4

Together, HSS is pulling together all science, research, and resources necessary to create meaningful tools and resources for the healthcare industry.  HSS is working to ensure that healthcare surfaces – including items such as countertops, toilets, sinks, patient care items, machines and appliances, textiles, upholstery and medical devices – become less of a culprit for harboring pathogens and contaminants that cause infection and illness in patient and personnel.

To best identify where we need to go, it is important to identify where we have been and what the science tells us.  As a result, the HSS has commissioned an extremely robust literature review and meta-analysis. The purpose of the literature review is to develop collaborative strategies to design, specify, maintain and use surface materials that contribute to a solution to reduce the risk of healthcare associated infections (HAI). Often, research focuses on the cleaning process, but not the material being cleaned. Similarly, studies focus on transmission via healthcare practitioner and hand washing strategies without controlling for contact with surfaces prior to patient interaction. 

Understanding the contributing factors to the selection, maintenance, and use of environmental surfaces in healthcare facilities is the foundation to identifying successful processes and innovating new solutions to mitigate infection and illness. This study utilizes a peer-reviewed assessment method and ranking system for published journal articles and will conduct meta-analysis to evaluate the evidence and identify gaps where additional research is needed. By systematically reviewing the literature and investigating practice processes, collaborators across interested disciplines can work together to define best practices, develop guidelines and standards, and provide educational opportunities to increase compliance and reduce infections and illness.

We know that to tackle an issue so complex and wide-reaching, that there needs to be focused efforts in several different and distinct arenas.  As part of HSS, there has been ongoing, focused work among and between four initiative workgroups with the following missions:

- Research: Evidence-based efforts to demonstrate the connections between HAI transmission and healthcare surfaces and provide best practices guidance to accelerate the adoption of new innovations and interventions for surface decontamination.
Standards and Utilization: Evaluate and implement objective measurement tools for disrupting pathogen transmission. Review products and technology for decontaminating surfaces 

- Surface Disinfection and Compatibility: Develop testing guidelines for surface disinfection incompatibility by evaluating disinfection process, products and protocol to understand the relationship between surface damage and microbial acquisition and transmission.

- Education: Create and disseminate tools, resources, educational material, and other critical information for providers, patients, and the public to reduce transmission of surface related pathogens.  A range of materials including infographics, presentations, checklists, training parameters, and educational curricula will be developed to target individuals at all levels of awareness to improve their knowledge, skills, and ability to act as agents of change.  

Historically, infection prevention research focuses largely on handwashing and antibiotic stewardship. There is also a vast body of research that indicates the primary role of healthcare surfaces in the transmission of pathogens. Much of the current surface research examines the bacterial-reducing efficacy of specific interventions, but it fails to provide any evaluation of the surface materials used to construct healthcare facilities and how they can or cannot support microbial growth and movement. Additionally, surface materials used for healthcare products such as furniture, medical equipment and medical devices are typically made of multiple surface materials that cannot all be cleaned, disinfected or sterilized in the same way or with the same disinfectant products. When these surfaces are damaged during the cleaning process, the question remains: How is microbial growth and ultimately the acquisition and transmission of microbes affected? 

While this oversight may seem inconsequential, several disinfectants are known to compromise both hard and soft healthcare surfaces. The HSS Research Initiative is performing research to identify incompatibilities between current disinfectants, both physical and chemical, and existing healthcare surfaces. To this end, we are currently studying the impact of disinfectants and various wiping techniques on bacterial reduction on a variety of healthcare surfaces. This data will inform development of modernized cleaning techniques, incompatibility issues between disinfectants and surfaces, and highlight the need for more collaboration between the research community and disinfectant manufacturers, as well as healthcare environment designers. While the work of the HSS Research Initiative is largely independent, much of our work will be a collaborative effort with industry groups. After all, reduction of HAIs is a global need and requires the input of all stakeholders.

There is a great deal of fragmentation within oversight and standards setting groups for healthcare surfaces that can impact the transmission of infections and illness in healthcare facilities. This is especially true as it pertains to protocols for surface testing, materials compatibility, cleanability, contamination rates, durability, testing methods, and outcome and intervention measures. For years, consensus, specification, performance, and testing standards organizations like AAMI, ASTM, ISO and others have built and published parameters to designers, manufacturers, and oversight organizations for commercialization of products – medical devices, personal protective equipment, textiles, chemicals, and their subsequent components.  These groups set standards for all sorts of processes, procedures, and products including diagnostic testing, materials compatibility, safety, shelf life, packaging, sterility, quality measures, biocompatibility, and electrical, physical, and flammability parameters. However, there are no standards set for the selection on surface materials used to manufacturer these products. 

In addition, regulatory, licensing, and accreditation institutions like the Joint Commission and State Departments of Health and Public Health, OSHA, EPA, FDA, and many more incorporate consensus standards into their regulations, standards, and guidance.  It is then that professional and trade associations and member organizations -- the alphabet soup of AHA (American Hospital Association), ANA (American Nurses Association), AMA (American Medical Association), APIC (Association for Professionals in Infection Control and Epidemiology), ACHA (American College of Healthcare Architects), ASM (American Society of Microbiology), ASCLS (American Society for Clinical Laboratory Science), ABSA (The Association of Biosafety and Biosecurity), IAFF (International Association of Fire Fighters), SHEA (Society for Healthcare Epidemiology of America), AdvaMed, PhRMA, and so many more - craft “evidence-based” standards and best practices for adoption among their members and clients.  These standards are often only available to paying members in good standing or to the public for a fee. Open, free access to timely, accurate, and succinct information is simply not happening. A widely adopted standard does not currently exist. 

The HSS and its stakeholder members are dedicated to joining forces to make this a common practice. They are creating an evidence-based consensus standard to serve as a foundation to manufacturers, architects, engineers, and construction trades in healthcare to balance the specifications needed for healthcare surfaces that are safe and safely able to be cleaned, disinfected, and/or sterilized. The HSS workgroups will collectively provide information to achieve this goal.  It will be determined at a future time, what standards-setting organization would provide the best platform for publication and dissemination of such a standard.

Many areas of work that need to be completed and the need for collaboration have been identified. The challenge is bringing people together for discussion and testing and developing a clear understanding of what systems can be put together that provide sustainable solutions. Ultimately, the end goal we all share is reducing risk and mitigating the spread of pathogens that cause infections and illness. A new project for HSS is the development of an incubator. Much like a business incubator that helps new and startup companies develop services, HSS will utilize this concept to develop a testing site.

Working through the Initiative Groups, we will look at all aspects of the problem and test solutions as a system. Manufacturers will have the opportunity to interact with many healthcare professionals to understand what they do and how they operate. They may also gain input from them on innovative new ideas and solutions. 

1. CDC. HAI Data and Statistics. https://www.cdc.gov/hai/surveillance/index.html
2. van Vugt, JLA, Coelen RJS, van Dam DW, et al. Surgical Infections. April 2015.
3. Mitchell A, Spencer M, Edmiston C Jr. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. J Hosp Infect. 2015 Aug;90(4):285-92.
4. Mahshid Abir, MD, MSc, Jason Goldstick, PhD, Rosalie Malsberger, MS, et al. The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection. Journal of Hospital Medicine. Web June 27, 2018.

A Critical Step Missed During Design!

OR 2.jpg

Recently, I read a great article in the Wall Street Journal's May 29th issue, titled “The Operating Room of the Future.” The article highlighted the expanded operating room with more technology (such as imaging equipment) that allows for minimally invasive treatments – or when necessary, more invasive surgeries – without the need to move the patient and team to a different OR. The additional technology allows physicians to tap into big data during and after procedures to get guidance and analysis in real time. I'm sure everyone agrees that these current trends of minimally invasive outpatient surgeries, faster recovery times and fewer complications are benefits to both patients and the medical teams treating them. I'm even more certain that healthcare facilities are very supportive of increasing the number of patients that take advantage of this technology and new way of treatment. 

No silver bullets.

I want to urge all members of the design team to add more healthcare professionals to the discussion BEFORE construction begins. There is more to evaluate. Operating rooms are critical areas that turnover quickly from one case to the next. Typically, those responsible for doing this work to get the time down to around 9 or 10 minutes. Pathogens can’t be seen and a quick turnover between patients leaves potential risk for the next. To ensure this can be disinfected and prepared effectively and efficiently requires evaluation. BEFORE construction begins. Manufacturer partners, environmental services, infection preventionists, and facilities professionals must evaluate the time it takes to effectively clean, disinfect and when necessary sterilize equipment before the next patient.

Pathogens can’t be seen and harbor on handles, on cords, in cracks, creaves, and damaged surface areas. In many cases, the disinfectants used in this environment can damage equipment. Within the article, there are only two minimal references to infection prevention – the terrazzo floor and a photo caption stating, “…it aims to be more versatile, reduce infection risks, and improve the surgical team’s views and workflow.”  How is it going to reduce infection risk? A terrazzo floor is not a silver bullet solution, and there is so much more to infection prevention.

According to a recent report from the Center for Disease Control (CDC), Surgical Site Infections (SSI) were the most common healthcare-associated infections (HAI), representing 31% of all HAIs among hospitalized patients.  This means someone from Infection Prevention needs to be at this table. Now. Before it’s too late.

Cleaning is only step one.

Cleaning, disinfecting and sterilizing surfaces within the operating room environment are absolutely critical. Invasive procedures leave patients at higher risk of infection. This should not be taken lightly! Look at and think about the many different surface materials, textiles, and assemblies in this environment. Medical devices, carts, cords, supply carts, X-ray equipment, lights, walls, floors, countertops just to name a few. Looking at this environment with the requirement for cleaning/ disinfecting and sterilizing BEFORE finalizing the design and during the mock-up evaluation phase is critical so you have a clear picture of what will be required to provide a sterile environment for the next case.  So, before construction begins, the below question needs to be forefront in everyone’s mind:

Can this OR, with all of this technology, be cleaned, disinfected and sterilized (microbes killed and removed) quickly in the 10–20 minutes allotted between cases?

Manufacturers can provide answers to these questions:

  • What disinfectant products are required? (Not all surface materials and products can be cleaned and disinfected in the same way with the same products.)
  • What are the manufacturer warnings for disinfectant products?
  • Are they all compatible with the combined surface materials used on any one product?
  • Was a surface disinfection compatibility testing performed in conjunction with the specific disinfectant products currently being used in the facility? Can the product be required?

Infection Prevention experts must evaluate and make recommendations for:

  • Changes to products, processes, or protocols may be required to provide a safe, sterile environment for the next patient based on this new technology and configuration.
  • Testing protocols to validate infection prevention effectiveness that includes a microscopic evaluation of surface integrity.
  • Specific roles for each team member to support effective infection prevention.
  • Comprehensive plans to ensure the safety of every single person in that OR.

Everyone has the goal to mitigate HAI’s and ultimately save lives. A proactive approach not only includes the development of technology and the design of the OR space. It also must include an understanding of what infection prevention process, products, and protocol will be required.  The only way to do that is to bring in the teams to test and validate before construction, and again before the OR opens to patients.

Required Manufacturer Testing

A step in the right direction

The recent requirement imposed by the FDA for scope manufacturers to test their products is a step in the right direction and hopefully, testing requirements won’t be limited to just scopes. The next step is to develop clear testing requirements, which will provide indisputable evidence that products can be cleaned, disinfected and sterilized properly, and that manufacturers can provide recommendations that coincide with infection prevention requirements and strategies.


There are several ways manufacturers may test their products:

  • In-house, often using some recognized testing protocol such as ISO and ANSI
  • Professional associations representing product manufacturers often provide testing
  • Third party independent laboratories

All options provide data and information about specific products. However, third party independent laboratory testing is unbiased. All products or materials in any given category are tested using the same protocol, providing an “apples to apples” comparison.  Often testing data is available online in the same format as other manufacturer results.

Testing Standards and Requirements

Testing standards and requirements need to be developed and put in place that take into consideration current infection control requirements and recommendations. Conflicts occur when manufacturer recommendations don’t coincide and those responsible for cleaning, disinfection, and sterilization step outside required and existing protocol. Potential risk and liability exist for everyone. If manufacturer recommendations are not followed warranties may be voided, leaving healthcare facilities vulnerable.

There is obviously a microbiology component of testing. Data may show that a specific product can be effectively cleaned or sterilized using a given process, but does this process effectively destroy or eliminate microbes and the potential for cross contamination? When establishing testing protocol this data must be collected as well.


Product testing often is done on individual components or parts rather than on complete assemblies. Characteristics and the ability to effectively clean, disinfect and sterilize changes once components are put together as a final assembly. It is important to have a clear understanding of how the assembly needs to be cleaned before the product enters the market.

Human Behavior

Product testing will provide data that shows if and how a product can be effectively disinfected/sterilized to destroy harmful microbes. What is not tested is human behavior. This is a great subject for a future blog, but felt it important to mention. Despite testing, we still must recognize that human behavior impacts the success or failure of the disinfection/sterilization process.

Don’t know what they don’t know

Silos play a key role in the current problem. Over the years, I have come to learn that manufacturers don’t know what they don’t know about infection prevention and control. Within the healthcare facility there are many different specialized silos that often conflict on the subject of infection prevention. If and when manufacturers or anyone for that matter, seek to learn something they receive many opinions.

The ultimate goal is to mitigate the spread of infection, save lives and provide a safe environment. Reaching this goal will also help reduce the financial loss healthcare facilities experience. I am pretty sure most people will agree this can’t be achieved by focusing on only one aspect of the problem.

Establishing testing standards and requirements will require communication, education and a clear understanding about the data that is necessary from all perspectives.


We certainly can’t stop by simply establishing standards and protocol. We need to establish who is going to enforce product testing and who will hold accountability and responsibility to verify all data has been collected.

There is so much more to do, but a big step in the right direction has been taken. Let’s make sure steps continue to be taken to reduce the spread of infection and risk to patients, healthcare workers and the general public.

Antimicrobial Surfaces are NOT “Self-Cleaning”


During a community tour of a new critical access hospital, I was shocked to see carpet leading from the main entry of the hospital, up the stairs and throughout the entire patient care area. Hallways and nursing station areas all carpeted. This was not continuous carpet, it was carpet tiles with visible seams and edges. Perfect sites for microbes to harbor. I am thrilled to say that the patient rooms were not carpeted!

When I asked about the ability to effectively clean the carpet, the exchange went like this:

“It is antimicrobial.”

“Oh, okay. What exactly does that mean?”

“It is continually disinfecting.”

The answer was given in such a way that everyone believed, with every step we took, the microbes from our shoes were being destroyed instantly.

No such thing

Recent conversations with healthcare professionals have also caused me to stop to catch my breath. The belief that surfaces are “self-cleaning” can lure people into a false sense of security. ATTENTION: There is no such thing as a self-cleaning surface!

Every surface in every healthcare facility must be thoroughly cleaned and disinfected regularly!

Today there are many different antimicrobial products on the market. All work in different ways. Some need water, some need light, some need to be free of any kind of coating, some need to be reapplied on a regular basis. Understanding how the antimicrobial surface works and how it can be cleaned and disinfected is extremely important.

Is there a chance that a surface may be overlooked or the due diligence necessary to effectively clean the surface will not be followed because staff members believe antimicrobial surfaces are “self-cleaning?” Will we see an increase in the number of infections as a result of this misunderstanding? Remember, the goal is to mitigate the spread of infection.

After asking a series of questions in countless interviews with manufacturers of antimicrobial products, not one representative has ever claimed that a surface was capable of cleaning itself continuously, even though that was the initial impression given when the conversation started. Asking the right questions is key, since misunderstandings happen quickly.

Digging deeper

My first question is always “What do you mean by antimicrobial?” Here are just a few of the responses I have heard:

  • We use pine and linseed oil in our manufacturing process. Both of these products have natural antimicrobial properties
  • The surface slows down the bacteria
  • The antimicrobial properties of this product provide a backup to regular cleaning and disinfection procedures, so you don’t need to clean it as often
  • The savings come from not having to clean this material as often
  • Since our product is non-porous, it is naturally anti-bacterial. (Hmm, anti-bacterial or antimicrobial?) Bacteria can’t survive on the surface.

Another important question that is often not asked has to do with quantifying efficacy. Has this antimicrobial product reduced the number of infections within a healthcare facility? By how much? The majority of antimicrobial surfaces show a 99.999% reduction of microbes over time in a testing laboratory. But does this reduction in a controlled laboratory environment translate into a measurable reduction in a real world active healthcare environment?

I believe there are good products on the market that can be an effective part of a multimodal solution. However, I am concerned that some people believe that “self-cleaning” surfaces actually exist. This will likely lead to reduced attention on required cleaning and disinfection protocols, setting facilities up for failure.