These days, reports of healthcare-acquired infections are alarmingly prevalent, and underscore the need for greater vigilance with adherence to infection prevention protocols. HAIs affect about 1 million patients each year – and are among the top ten leading causes of death in the United States, the Centers for Disease Control and Prevention reports. Treating these infections takes a huge toll on facilities’ bottom lines, as well, with costs reaching upward of $5.7 billion. The ongoing spread of drug-resistant microorganisms is further compounding the problem, with such infections affecting roughly 2 million people each year. While only two percent of staph bacteria were drug-resistant in 1972, that percentage now exceeds 63 percent, the CDC states. What’s more, lab-based reports published by the American Medical Association reveal that infections from methicillin-resistant Staphylococcus aureus alone kill about twice as many people as originally believed.

While dirty hands and contaminated equipment undoubtedly play a large role in the development of HAIs, the same can be said of unclean hospital surfaces. One 2007 Wall Street Journal article pointed to a Boston University study that examined 49 operating rooms at four New England hospitals. More than half of all objects in these facilities that should have been disinfected were missed by cleaning staff.

Even if healthcare workers diligently and adequately wash their hands, it’s important to recognize that they will become almost immediately recontaminated whenever they touch an unclean surface. In fact, one study showed that when a nurse walks into a room occupied by a patient with MRSA and has no patient contact, but touches objects in the room, the nurse’s gloves are contaminated 42 percent of the time upon leaving the room.

"The healthcare industry currently spends more than $30 billion per year treating HAIs and each patient costs an additional $15,750 to treat the infection that was contracted while in the hospital," noted Ken Munson, spokesperson regarding epidemiology and the development of infection control programs at the Specialty Chemical Group at BioTech Medical LLC.

Limited resources may play a major factor in cleaning gaps. "In today’s environment, staff have limited time to turn over rooms. This problem is one of the key causes of inadequately cleaned rooms," said Cathy O’Malley, marketing manager, 3M Building & Commercial Services Division, St. Paul, MN.

Unclean conditions certainly aren’t going unnoticed by patients and staff, either. In 2008, a Consumer Reports survey of 13,540 readers revealed that about 4 percent of patients witnessed cleanliness issues; 28 percent of nurse respondents reported the same.

While dirty hospital environments may be all too common, it’s hardly acceptable. Not only do clean facilities help promote a good first impression with patients and other visitors, a facility that dedicates itself to maximizing cleaning efficacy and curbing HAIs will resonate positively with surveyors and give the healthcare institution a significant marketing boost. The pay-offs could become even greater as reimbursement becomes linked to infection rates and other quality care measures.

Healthcare organizations committed to turning up their cleaning efforts aren’t left to their own devices. These days, vendors are offering a wide array of cleaning products and services aimed at simplifying the task, and, most importantly, maximizing cleaning performance.

When it comes to surface cleaning, microfiber is moving to the forefront. A number of leading vendors – including Medline Industries, 3M, Rubbermaid Medical Solutions, and Kimberly-Clark Professional – are offering microfiber products. Not only can some microfiber products clean 45 percent better than traditional methods (i.e., a traditional mop), while also significantly cutting water and chemical consumption, and worker strain, they also have been shown to do a better job of trapping dirt and surface contaminants.

"Microfiber cloths have become increasingly popular in the last several years due to their ability to lift and trap dirt and moisture better than cotton cloths," confirmed Denise Jolly, category manager, KIMTECH Wipers, Kimberly-Clark Professional. K-C Professional’s WypAll Microfiber Cloths feature Microban antimicrobial protection and remove up to 99 percent of bacteria from non-porous surfaces. "When bacteria come in contact with the cloth, the antimicrobial protection penetrates the cell wall of the bacteria, making it unable to function, grow and reproduce," Jolly continued, adding that the cloths may be used wet, dry or damp, and can hold up to eight times their weight in liquid. [Note: Although the WypAll Microfiber Cloths with Microban Protection are designed to withstand repeated laundering (up to 300 times), Jolly warned against laundering with bleach or high-temperature water.]

The HYGEN Microfiber Cleaning System by Rubbermaid Commercial Products, Winchester, VA, has been shown to remove more than 95 percent of organisms, versus as low as 67 percent with a standard string mop (when used with detergent or quaternary cleaners). The HYGEN microfiber is comprised of 100 percent split fibers, while a proprietary zig-zag weave packs 17 percent more microfiber in every mop. The HYGEN system has also been shown to cut chemical consumption by up to 95 percent versus traditional mopping, while cutting water consumption by 90 percent and cleaning floors three times faster than with a traditional string mop, according to Mark Hoyle, team leader for hard surface cleaning, Rubbermaid Commercial Products.

"The split microfiber has the ability to pick up both dead and live viruses and bacteria." Hoyle explained that healthcare professionals need to be aware that even if bacteria or viruses are killed, that doesn’t mean they no longer pose a threat. "Unless that bacteria is removed from the surface, it will become a food source for other bacteria," he said, adding that microfiber’s enhanced ability to grab dirt, debris and contaminants can help minimize those risks.

While clean floors are obviously important, it’s been shown that they aren’t a major vector of infection. Instead, it’s surfaces that are often touched by hands that pose the greatest threat. "A focus on disinfecting areas [that] are frequently touched by the patient, visitors and healthcare workers is paramount in any healthcare setting," stressed Kirsten Thompson, BS, technical service expert for ECOLAB Healthcare, St. Paul, MN. ECOLAB’s environmental services educational program includes the identification of these high-touch surfaces and also provides specific strategies to consistently disinfect them.

Just as it’s inadequate to wash only the palms of hands, the same rule applies for surfaces. Hoyle said that the undersides of tables are often filthy, as are the undersides of bathroom sink vanities, which provide a warm, moist breeding ground for bacteria. Other oft-overlooked surfaces: telephone cords and the bundle of wires that hang under the patients’ bed.

"Cleaning under the bed is imperative," he said, adding that staff should raise the bed to a height that allows them adequate, unobstructed access for proper cleaning.

Because effective cleaning involves much more than aesthetic appeal and the elimination of particles, dust and debris that can be seen with the naked eye, it’s imperative that environmental services professionals dig deeper to fully understand the "Whys" behind the "Hows."

For starters, staff must recognize that the products they wield – regardless of their strength, innovative features or advertising promises – are only beneficial if used as directed. Take disinfectants, for example. It’s not uncommon for people to follow the mantra "if a little is good, a lot must be better," or make the false assumption that a chemical will do its job the very moment it comes in contact with a surface.

Appropriate contact time is essential, stressed Hoyle, adding that some chemicals require a ten-minute dwell time in order to effectively kill pathogens.

Too often, the environmental services staff will spray a disinfectant on the surface and immediately wipe it off, according to Munson. "Since the product was not allowed to stay wet for ten minutes, the likelihood of providing adequate protection or efficacy is remote at best. Other staff will use a bucket of a sanitizing solution and go from room to room cleaning all the surfaces with the same cleaning cloth. Naturally, this merely transfers bacteria from one room to another or one patient to another until the solution is absolutely spent and no longer capable of combating the germs found on the surfaces," he said.

To reduce the challenges associated with dwell times and the potential for disinfectants to lose their effectiveness, BioTech Medical developed SpectraSan 24, a new patented disinfectant that provides 24 hours of residual efficacy.

"Most [conventional] disinfectants dry in less than six minutes; plus, once these products evaporate, they cease being effective," noted Munson. "The next person to touch the surface can immediately re-introduce disease causing pathogens. [Because] SpectraSan 24 continues to kill germs for 24 hours it does not have to be applied as frequently as traditional disinfectants, which provides a cost savings as well as peace of mind." Munson also pointed out that SpectraSan 24 is an EPA-registered disinfectant that has been assigned the EPA’s lowest toxicity rating – Category IV. "It’s [also] safe to use in sensitive areas of the hospital like NICU, Radiology/Imaging, pediatrics, etc. where harsh, toxic products can have an adverse effect on children and expensive medical devices."

Although some may assume that cleaning products are self-explanatory, experts agree that the benefits of detailed user education cannot be overestimated.

"Training is critically important to ensure staff understand what is important and why," noted O’Malley. To assist end users in safe, effective cleaning, 3M provides versatile, robust training and support tools that help ensure that critical cleaning procedures and infection prevention practices are taught, followed and documented. The 3M S.M.A.R.T. Procedure Wizard, for example, uses industry standards to train employees in more than 150 procedures, the 3M S.M.A.R.T. Computer-Based training provides employees with self-paced training in more than 23 customizable modules, and the 3M S.M.A.R.T. Videos offer comprehensive training on common, must-know cleaning and maintenance tasks. Additionally, 3M offers healthcare seminars and onsite inservices to keep key personnel up to speed and well-versed on the latest industry issues, products and techniques.

ECOLAB’s Thompson also reasoned that education for environmental services staff is truly the foundation for successfully implementing and maintaining best practices. "EVS staff must consider themselves part of the patient care team with an important responsibility in reducing the risk of transmission from the environment," she said, adding that great improvements in environmental hygiene can be made with simple training and auditing tools. ECOLAB recently announced an exclusive licensing agreement with Philip Carling, MD, director of infectious diseases and hospital epidemiology at Carney Hospital and Quincy Medical Center, and professor of clinical medicine at the Boston University School of Medicine, for his environmental patent applications. Dr. Carling has shown that combining implementation of training and education programs with continuous monitoring, the thoroughness of cleaning can be dramatically improved. One of Dr. Carling’s patent-pending cleaning compliance monitoring tools is a product that fluoresces under a black light when applied to surfaces, such as bed rails, door knobs and tray tables.

"Monitoring cleaning efficacy is important to understand current performance and to document improvement," added Thompson. "Linked with education, the products and tools used, as well as the methods of application, are an important consideration in providing a clean and disinfected environment."

Thompson explained that proper disinfectant concentration is extremely important, yet often overlooked. While quaternary ammonium disinfectants are frequently used on hospital surfaces, she pointed out that, recently, concern has arisen around the discovery that the active ingredient (quat) has a tendency to become attracted to and absorbed into fabrics. Further, quaternary ammonium chlorides are cationic – or positively-charged – surfactants, and they are attracted to fabric surfaces which are anionic, or negatively-charged, she said. "This results in a portion of the quats becoming unavailable to adequately kill the microorganisms that may be present."

While quat absorption occurs in both cotton terry cloth and microfiber cloths, the microfiber versions have been shown to be superior to cotton terry cloth with regard to quat absorption, cleaning and disinfection efficacy, and the prevention of organism transfer to clean surfaces, according to
Thompson. Still, she noted that when using a quaternary disinfectant, quat absorption should be considered with an application that requires the use of textile tools, such as cleaning cloths or mops.

Even microfiber products require some explanation to promote cleaning efficacy, however.

"Training and inservicing is key to the success of microfiber. It is a very big change going from a traditional loop mop with a bucket and wringer to a flat mopping system," said Tamara Dick, director of marketing, EVS+ Division, Medline Industries Inc., Mundelein, IL. "You have to make sure the staff that is using the microfiber understands how the product works and how it should be used."

With microfiber, staff should be aware that the products are designed to do a better job of hard surface cleaning with minimal use of chemicals.

"The guiding principle is always to remove germs, if possible, rather than kill them, and then, when necessary, use the least amount of the mildest chemical that will do the job," noted J. Darrell Hicks, director of environmental services for St. Luke’s Hospital, Chesterfield, MO. His preferred cleaning method is with a split fiber microfiber. When soil is removed, so are pathogens in their spore or vegetative state, he said.

Rubbermaid provides detailed, task-specific guidelines and comprehensive training materials for ongoing training support and assurance that the HYGEN system is being used properly and to its fullest potential. Aside from dedicated field support that will conduct site surveys and provide seminars and training classes, and post-implementation support, Rubbermaid also offers procedural, step-by-step training videos, comprehensive product use manuals, e-learning tools, and the Rubbermaid HYGEN microsite that features detailed product information, electronic versions of support materials, and an online calculation tool to help facilities build the proper cleaning system for their needs.

BioTech Medical’s recommendation for safe, effective product use is simple. "Read the product label for directions, application methods, efficacy claims, and warnings – if it’s not on the product label, it doesn’t matter what the sales rep or environmental manager says. It’s not true. Since the EPA is the only government agency that approves and registers all commercial and consumer disinfectants, the proof is right on the label," stressed Munson.

Biotech Medical also provides in-service instruction and support to healthcare partners and develops customized cleaning and disinfectant protocols and procedures to maximize the effectiveness of facilities’ sanitation programs, and educate staff on the best ways to enhance patient outcomes, reduce HAI’s and improve the quality of life of people within the facility. "Naturally, this cannot all be accomplished with a single product, regardless of its intrinsic benefits; however, we focus on training in prevention and common sense ways to protect the patient, the staff and the community," Munson added.

Vendors are becoming increasingly aware that cleaning efficacy is also dependent upon ease of use. More than ever, their solutions are designed to help environmental services professionals take the guesswork out of the cleaning process, while also preventing the dangerous and all-too-common occurrence of cross-contamination.

Products that offer enhanced chemical management, for example, are available, as are color-coded systems that provide at-a-glance assurance that the right products are being used in the right application and in the right environment.

The Twist ‘n Fill system from 3M, for example, provides accurately diluted chemicals and consistent cleaning performance. "Accurate dilution is critically important with disinfectants to ensure compliance with EFP efficacy claims," stressed O’Malley. To assist with environmental sustainability efforts, 3M also offers products that reduce the amount of chemicals required. Scotch-Brite Surface Prep Pads allow facilities to prepare floors for floor finish without the use of chemicals. Also, the 3M Clean-Trace ATP System helps address the problem of HAIs by detecting the presence of organic contamination and providing immediate feedback on how well cleaning procedures have been followed.

"This objective approach takes the guesswork out of cleaning and provides the ability to assess and monitor cleaning effectiveness over time," O’Malley explained.

K-C Professional offers a closed-bucket system with 90 presaturated wipers (Kimtech Prep Wipers for Disinfectants and Sanitizers, which are designed for compatibility with chemicals used in surface disinfection) that are extracted as needed.

"The enclosed WetTask Refillable Wiping System also helps avoid the contamination of the wipers and the cleaning solution because it eliminates any opportunity to re-dip wipers into an open bucket," assured Jolly.

The same approach is being applied to microfiber products, with the goal to avoid carrying or spreading pathogens from one area or surface to another. One mistake some cleaning professionals make is reusing the same saturated cleaning mitt, mop or cloth on many different surfaces.

"When you use microfiber [or any other cleaning cloth, mop or wipe], you should only be using one mop and one cloth per room to reduce cross-contamination," noted Dick, of Medline.

Rubbermaid’s solution with the HYGEN system is to offer a complete color-coded system (not just for the microfiber mops and cloths, but also the buckets and containers). Red is designed only for cleaning beds, for example, (a major area for C. difficile transmittal, so it’s important to isolate it, stressed Hoyle), yellow is for toilets (porcelain and chrome), and green is general purpose cleaning of all other hard surfaces. Hoyle pointed out that because bleach is the only EPA-approved method for killing C. difficile, the HYGEN microfiber mops and cloths were designed to withstand laundering with bleach (the cloths can last for 500 washings without bleach, and up to 200 launderings with bleach). Also part of the HYGEN system are four color-coded "charging" buckets that rest on top of the cart. Prior to cleaning, the appropriate amount of cleaner is placed in the buckets and the color-matched cloths are then placed inside. The cloths absorb all the liquid, which prevents re-dipping and inadvertent cross-contamination. The same method is used for the microfiber mop heads.