When it comes to the COVID-19 pandemic that refuses to ebb, the general populace may be all too eager to switch off the red-alert button with hopes of returning to “normal.” But no matter how dangerous or irritating the pandemic-that-simply-won’t-go-away is and all of the heightened and onerous protective measures issued by clinical and governmental authorities, second-guessing or underestimating actual progress can be dangerous. Presumptuous at best.
Some may be willing to compromise, relax and lower the red-alert shields to orange or even yellow as hospitalization, infection and vaccination numbers fluctuate, but not at the expense of effective room decontamination. After all, bacterial and viral microbes don’t follow human desire, expectations or scheduling. If they’re not eradicated through effective cleaning, decontamination, disinfection and/or sterilization they just wait around to infect humans.
People may succumb to “pandemic fatigue” or embrace “mask rebellion” because they just want to get back to their lives as they knew them in 2019. Who doesn’t? But in healthcare, there’s no such thing as “infection prevention fatigue” as the fight remains continuous – not just continual – to the point that healthcare professionals must never let down their guard.
The new baseline
If anything, the COVID-19 pandemic increased the development, emphasis and scrutiny of room decontamination through more stringent infection prevention measures and protocols.
Unfortunately, as COVID-19 infection and hospitalization statistics began to decrease, states and organizations seemed more motivated to open and relax precautionary rules before the emergence and resurgence of the Delta variant back in July.
Still, many infection prevention experts acknowledge that the increased precautions for COVID-19 not only were educational and necessary but also must remain – at least those that do not require further efficacy research once temporary emergency use authorizations expire.
“Environmental measures instituted at the beginning of the pandemic have evolved as we learned more about the importance of aerosols being the primary means of transmission of COVID-19,” she said. “For example, in rooms where patients have had procedures that generate aerosols (e.g., intubation, bronchoscopy), or when caring for patients with suspected or known COVID-19 the Centers for Disease Control and Prevention (CDC) recommends increasing ventilation. However, healthcare facilities have ventilation systems with limits on number of air exchanges and filtration capabilities that generally cannot meet CDC ventilation recommendations. One technology that CDC recommends facilities consider using as an adjunct if a facility cannot meet the increased ventilation standards is upper room ultraviolet germicidal irradiation (UVGI). The Vidashield UV24 system is an upper room UVGI that has demonstrated statistically significant reductions in air and surface contamination from fallout of not just aerosolized viruses but also all forms of bacteria and fungi.”
Hoffman serves as a clinical instructor in the Division of Infectious Diseases at the University of North Carolina’s School of Medicine in Chapel Hill and is the immediate past president of the Association for Professionals in Infection Control and Epidemiology (APIC).
One specific technology that has emerged more as a necessity than a novelty is “no-touch” ultraviolet radiation for air and surface decontamination.
Stibich encourages healthcare facilities to evaluate carefully the various disinfection options, recommending that they ask manufacturers to provide peer-reviewed and published studies validating the efficacy of a specific device or system. “If the technology hasn’t been proven effective in multiple peer-reviewed studies, then it hasn’t met the bar of an evidence-based solution,” he added.
“Whole room disinfection after every patient discharge, or transfer, from a room should be required as standard operating protocols,” Cunningham insisted. “Too often, terminal disinfection of a room is only done when the patient is known to have a transmittable virus or germ. Regardless, if a patient had MRSA, VRE or COVID-19, every single room should be fully disinfected every time before a new patient is admitted because we know pathogen transfer from room to room is a constant battle and cause of new infections. You must lower the entire bioburden of the hospital to have a meaningful impact on hospital acquired infection rates.”
Community, improved practices
Stibich also lauds the camaraderie and ingenuity among providers in crisis mode.
“We saw incredible collaboration and innovation from our hospital customers during the pandemic,” he indicated. “We were proud to be able to act as a resource for our customers.” He recalls sharing solutions created by New York facilities during the early surge of the pandemic to help prepare hospitals in other parts of the U.S. and the world, particularly in Italy when they faced a surge. Some shared best practices and strategies for patient care and for maximizing utilization of their LightStrike disinfection robots.
“For example, several of our customers moved a robot from their OR to the Emergency Department (ED) so they could disinfect rooms and areas where COVID-19 patients were seen and treated,” Stibich said. “Keeping a robot in the ED is a trend that has continued, especially as the number of COVID cases in the U.S. is now on the rise. With highly virulent variants emerging, it’s important to remain vigilant and maintain the enhanced disinfection protocols.”
“[Before] the pandemic, healthcare facilities primarily utilized acute room decontamination in rooms where a highly contagious infection (e.g., C. diff) had been identified or in high-traffic and high-risk environments (e.g., operating rooms),” he observed. “Since COVID-19, healthcare facilities have elevated their standards for disinfection by utilizing whole room disinfection systems to kill pathogens in a greater number of areas across facilities. For instance, the Halo Disinfection System, which combines the H2O2-based HaloMist (EPA Reg. No. 84526-6) disinfectant with the HaloFogger dry fogger, was trusted by hospitals worldwide for its flexibility and efficacy in eliminating SARS-CoV-2 pathogens, the virus that causes COVID-19.
“As healthcare facilities look to the future, they should ensure the disinfection products they utilize are registered by the EPA and approved to use against some of the most challenging pathogens to kill,” St. Clair continued. “EPA List K, products with sporicidal kill claims against C. difficile, and EPA List N, products that meet criteria for use against SARS-CoV-2, are two EPA resources to consider when looking for an approved solution.”
“During the pandemic, more hospitals deployed UV-C room disinfection more broadly than previously,” he noted, “not just for outbreaks or terminal disinfection of isolation rooms, but for everyday use in and beyond critical areas. Proven UV-C devices with independently verified pathogen inactivation claims via third-party laboratory testing and peer-reviewed published studies, enhance environmental hygiene as a complement to manual cleaners and disinfectants. Additionally, the broader focus on the entire environmental – both surface and air protection – has led to widespread implementation of proven UV-C air disinfection technologies to help prevent airborne pathogen transmission.”
These efforts shouldn’t come as a surprise, according to Halden Shane, DPM, Chairman & CEO, TOMI Environmental Solutions Inc.
“The pandemic showcased how pathogens can easily spread and take hold, highlighting the need for an increased level of disinfection and decontamination to maintain a healthy environment and reduce cross contamination,” Shane noted. “Adding an advanced disinfection to your current facility cleaning protocols is paramount to ensure pathogens no longer exist in any area and provide a peace of mind to patients, staff and visitors.”
“This involved increasing usage of traditional chemical disinfectants such as bleach, quaternary ammonium, quaternary ammonium/alcohols, hydrogen peroxide, etc.,” she noted. “But it became quite clear early on that traditional cleaning and disinfection may not be enough. Therefore, many facilities opted to adopt improved disinfection strategies that involved ‘no touch’ technologies.
“Technologies such as ultraviolet germicidal irradiation, electrostatic sprayers or foggers with hydrogen peroxide or other germicides, and continuous active disinfectants (CAD) act as adjuvants to current cleaning and disinfection practices,” Rea continued. “No-touch technologies fill the void that often occurs with manual cleaning and disinfection, but they do not replace the need for manual cleaning and disinfection. Evidence shows that manual cleaning and disinfection is a deficiency throughout healthcare, which can lead to transmission of pathogens to others.”¹, ²
Remain vigilant
Rea advises healthcare organizations to continually evaluate their current environmental cleaning and disinfection practices.
“Some facilities may have adopted some of these new cleaning and disinfection strategies during the initial chaos of the pandemic that may now not be appropriate for use,” she said. “The Environmental Protection Agency (EPA) granted some technologies temporary emergency use authorizations, and these allowances may no longer be valid due to inability to prove efficacy or other factors.” ³
But she compliments healthcare organizations for adopting favorable infection prevention habits during the pandemic.
“They became accustomed to performing more frequent hand hygiene, which is instrumental in decreasing transmission of potential pathogens,” Rea said. “Healthcare staff also became more proactive in wearing appropriate personal protective equipment (PPE). An emphasis on proper PPE use based on the potential exposure risk is an important aspect of infection prevention, which is also known as standard precautions. Now we will likely see more staff routinely wearing masks and eye protection whenever they have a patient with respiratory symptoms.”
“The pandemic put a spotlight on effective hygiene practices for the general public – and even more so for those in healthcare – with hand hygiene and surface cleaning at the forefront because we know clean hands and surfaces can help prevent infection spread and save lives,” Chung noted. “Hand hygiene and surface cleaning are intricately linked due to the number of surfaces people touch within healthcare facilities.
“Research shows the general public wants more emphasis on cleanliness,” she continued, citing several projects conducted by Essity. “A recent survey from Essity found 7 out of 10 people say they will have higher expectations on the hygiene standards of healthcare facilities after COVID-19.4 Similarly, 90 percent of respondents in a second Essity survey said increased sanitizing and cleaning in these spaces is important.”5
Chung targets access to products as a fundamental determiner – and deterrent.
“In healthcare facilities these actions can be optimized by making sure appropriate products and educational materials are within reach for users,” she said. “It’s imperative that handwashing stations are fully stocked with soap, paper towels and sanitizers. The placement of dispensers is equally important. Studies show that optimizing dispenser placement can increase usage by more than 50% and has a greater impact on usage than increasing the number of available dispensers.6 To make this tangible for healthcare facilities, Tork offers free, evidence-based online guides to inform optimal dispenser placement.
Chung also expects surface cleaning standards by environmental serves professionals likely to remain higher as a result of the pandemic.
“To optimize cleaning efforts, environmental services professionals should use products that are designed to prevent germ spread, such as Tork Microfiber Cleaning Cloths,” she advised. “The cloths’ tiny, snare-like fibers can wipe away 99.9% of pathogens, including C. diff, helping prevent the spread of healthcare-associated infections. The cloths are also reusable for up to 300 washes and come in a variety of colors. Assigning colors to certain teams is a great way to avoid cross-contamination in a healthcare setting.”
Chung recommends healthcare organizations reach out to Essity for a variety of Tork-branded interactive training guides and tools.
Stepping up
“Many healthcare facilities increased the detail of daily and terminal cleaning as a result of the ongoing COVID-19 pandemic,” Garrett indicated. “These efforts decreased the risk for cross contamination and subsequent transmission of infection between inanimate environmental surfaces and healthcare providers and patients. In addition to total room decontamination, an increased frequency of daily disinfection practices with ready-to-use wipes and sprays has also been observed across many healthcare settings. This enhanced focus will minimize bioburden, increase the effectiveness of cleaning and disinfecting, and reduce the overall risk of healthcare-associated infections (HAIs).”
Garrett, MSN, MPH, MBA, FNP-BC, IP-BC, PLNC, CFER, AS-BC, VA-BC, BC-MSLcert, NREMT, MSL-BC, DICO-C, TR-C, CPPS, CPHQ, FACDONA, FAAPM, FNAP, also serves as Adjunct Assistant Professor of Medicine, Faculty, Center for Education and Training in Infection Prevention (CETIP), Division of Infectious Diseases, Department of Medicine, University of Louisville School of Medicine.
Newer processes and technologies offer promise as well, according to Garrett.
“Moreover, the use of adjunct technologies such as electrostatic devices paired with EPA-registered disinfectant solutions have tremendous promise in the fight against HAIs and can also improve the overall efficiency of room disinfection in both inpatient and outpatient settings,” he noted. “For example, electrostatic devices use proven technology to deliver solutions to the front, back and sides of surfaces, providing comprehensive and uniform surface coverage of even the hardest-to-reach areas. Finally, continued regular automated screening of healthcare personnel and healthcare facility visitors is another prudent approach to mitigating infectious diseases that may be carried in a facility by infected healthcare personnel.”
“From our extensive database of hospital and healthcare customers we have seen a marked increase in operating and procedure room disinfection and decontamination using our advanced no-touch UVC disinfection systems compared to pre-COVID usage,” Trapani told HPN. “Traditional portable UVC systems can take from 20 minutes to several hours to disinfect an OR. That is too much time to have a room out of service. As a result, early this year we launched a new permanently installed ‘fixed system,’ the RD-Fx, that can eradicate SARS-CoV-2 in about 45 seconds, and C.diff in about 2 minutes. This system is well within the allowable room down time limits such that it may be used between each case thereby significantly reducing environmental pathogen load and their resulting transmission.”
