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Best Practices for Environmental Cleaning

In All Health Care Settings Objectives:

Provincial Infectious Diseases Advisory Committee 1. To review the FINAL DRAFT PIDAC Best
(PIDAC) Practices for Environmental Cleaning in All
Health Care Settings
2. To receive feedback on the content
Mary Vearncombe, MD, FRCPC
Chair, PIDAC Subcommittee on Infection Prevention and Control
Medical Director, Infection Prevention and Control
Sunnybrook Health Sciences Centre, Toronto

PIDAC Organizational Structure IP&C Subcommittee members


- to provide advice to Chief MOH • Dr. M. Vearncombe, Chair
- www.PIDAC.ca • Donna Baker, LTC, Ottawa
• Mary Lou Card, London
• Dr. Maureen Cividino, Occupational Health, Hamilton
PIDAC • Dr. Allison McGeer, Toronto
Dr. D. Zoutman • Pat Piaskowski, NWOICN
• Dr. Virginia Roth, Ottawa
• Dr. Kathryn Suh, Paediatric IP&C, Ottawa
• Dr. Kevin Katz, North York
Infection
Prevention
Communicable
Surveillance Immunization
• Dr. Irene Armstrong, Public Health, Toronto
Diseases • Liz Van Horne, Liaison, OAHPP
& Control Ms S. Callery Dr. I. Gemmill
Dr. C. Lee
Dr. M. Vearncombe • Dr. D. Zoutman, Kingston
• Dr. Beth Henning, ex-officio, MOHLTC

IP&C Subcommittee: Environmental Cleaning I. Principles of Cleaning and Disinfecting


Environmental Surfaces in a Health Care Environment
• Environmental Services Consultants:
• Andre Hendriks, Lakeridge Health
1. Evidence for Cleaning
• Keith Sopha, Homewood Health Care
2. The Client/Patient/Resident Environment and High Touch
Areas
• Writer:
3. Selection of Finishes and Surfaces in the Health Care
• Shirley McDonald
Setting in Areas Where Care is Delivered
4. Cleaning Agents and Disinfectants
5. New Equipment/Product Purchases

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II. Best Practices for Environmental Cleaning in All
Health Care Settings III. Cleaning and Disinfection Practices for all Health
Care Settings
1. Principles of IP&C Related to Environmental Cleaning
2. Cleaning Best Practices for Client/Patient/Resident Care
Areas 1. Routine Health Care Cleaning Practices
3. Laundry and Bedding 2. Cleaning and Disinfection Practices for Patients/Residents
4. Waste Management and Disposal of Sharps on Additional Precautions
5. Care and Storage of Cleaning Supplies and Utility Rooms 3. Cleaning Spills and Body Substances
6. Additional Considerations
7. Education
8. Assessment of Cleanliness and Quality Control
9. Occupational Health and Safety Issues Related to the
Environment

Appendices
Background
A: Ranking System for Recommendations
B: Risk Stratification Matrix to Determine Frequency of • Healthcare Associated Infections (HAIs) occur as a result
Cleaning of health care interventions in any health care setting
C: Visual Assessment of Cleanliness • HAIs are a patient safety issue and represent a significant
D: Sample Environmental Cleaning Checklists and Audit Tools adverse outcome of the healthcare system
E: Advantages and Disadvantages of Hospital-grade • The environment around the client/patient/resident
Disinfectants and Sporicides Used for Environmental influences the incidence of infection
Cleaning • Cleaning and disinfection reduces the numbers of
F: Cleaning and Disinfection Decision Chart for Non-critical microorganisms in the healthcare environment
Equipment • The goal of cleaning is to keep the environment safe for
G: Recommended Minimum Cleaning and Disinfection Level patients/residents, staff and visitors
and Frequency for Non-critical Client/Patient/Resident Care • Overcrowding, understaffing and pressures to move more
Equipment and Environmental Items patients through the health care system can challenge
completion of environmental cleaning

Background I. Principles of Cleaning and Disinfecting


Environmental Surfaces in a Health Care Environment

• The cleaning practices are for all settings where care is 1. Evidence for Cleaning
provided, across the continuum of health care, with the 2. The Client/Patient/Resident Environment and High Touch
exception of home care Areas
• includes: pre-hospital and emergency care, acute care, 3. Selection of Finishes and Surfaces in the Health Care
LTC, CCC, rehabilitation, outpatient clinics, office Setting in Areas Where Care is Delivered
practice 4. Cleaning Agents and Disinfectants
• The best practices provide criteria for health care settings 5. New Equipment/Product Purchases
for Environmental Services (ES) managers and for
contracted services

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I. 2. The Client/Patient/Resident Environment and
I. 1. Evidence for Cleaning High Touch Areas
• Health care environment has been shown to be a reservoir
for bacteria (e.g. MRSA, VRE, C. difficile, Acinetobacter, • Patients shed microorganisms into the healthcare
Pseudomonas, etc.) viruses (e.g. influenza, RSV, environment
norovirus, rotavirus, etc.) and fungi (e.g. Aspergillus, etc.) • Increased if coughing, sneezing, diarrhea
• Presence of the microorganism in the environment does
not prove contribution to infection • Bacteria and viruses survive on surfaces for days to
• Categories of literature cited to show causality: months
• Studies showing survival or proliferation in the • The area around the patient is touched by the HCW
environment during care
• Studies showing direct means of transfer from
contaminated surfaces to patients/residents • Many surfaces and non-critical patient care equipment
• Studies showing exposure to contaminated surfaces is items have been shown to be contaminated
associated with colonization/infection • Cleaning disrupts the transfer of microorganisms to HCW
• Studies showing that decontamination results in lower hands and other patients
rates of colonization/infection
• “High touch” surfaces require particular attention

I. 3. Selection of Finishes and Surfaces in the Health


Care Setting in Areas Where Care is Delivered I. 3. Selection of Finishes and Surfaces in the Health
• Ease of cleaning must be considered in choice of
Care Setting in Areas Where Care is Delivered
materials/finishes
• Materials/finishes must be compatible with hospital-grade • Regular cleaning program should be in place for all items
cleaners/disinfectants • Replace worn, stained, torn, cracked items
• IP&C and ES involvement in choice of materials/finishes • Do not use cloth furnishings that cannot be cleaned in
• Characteristics of surfaces: patient care areas
• Ease of maintenance/repair • If carpeting is used it must be cleanable and maintained
• Cleanability • Not for use in areas where spills/contamination likely
• Inability to support microbial growth or areas for immunocompromised patients
• Smooth, nonporous • Antimicrobial treated surfaces are not recommended
• Absence of seams

I. 4. Cleaning Agents and Disinfectants I. 5. New Equipment/Product Purchases


• Cleaning: physical removal of foreign material from a
surface/object • Non-critical medical equipment must be capable of being
• Disinfection: process to kill microorganisms (except cleaned/disinfected according to standards
spores) on inanimate surfaces/objects • Must have written, item specific, manufacturer’s
• IP&C and ES should be involved in choice of cleaning instructions
and disinfecting agents • IP&C and ES should be involved in selection of non-
• Products should have a DIN from Health Canada critical medical equipment
• Follow manufacturer’s instructions for dilution and • Do not purchase equipment that cannot be cleaned
contact time • Items provided by outside agencies are subject to the
• Prevent contamination of solution: same standards (e.g. therapeutic beds/mattresses)
• frequently change solution;
• no “double dipping”
• Use PPE as appropriate

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II. Best Practices for Environmental Cleaning in All II. 1. Principles of IP&C Related to Environmental Cleaning
Health Care Settings
1. Principles of IP&C Related to Environmental Cleaning* Routine Practices
2. Cleaning Best Practices for Client/Patient/Resident Care • ES staff must adhere to RP when cleaning
Areas* • Hand Hygiene:
3. Laundry and Bedding • The single most effective measure to prevent spread of
4. Waste Management and Disposal of Sharps HAIs
5. Care and Storage of Cleaning Supplies and Utility Rooms* • ABHR is the preferred method, unless hands visibly
6. Additional Considerations* soiled
7. Education* • Must be practiced:
8. Assessment of Cleanliness and Quality Control* • Before contact with patient/patient environment
9. Occupational Health and Safety Issues Related to the • After potential body substance exposure, even if
Environment* gloves worn
• After contact with patient/patient environment

II. 1. Principles of IP&C Related to Environmental Cleaning


II. 1. Principles of IP&C Related to Environmental Cleaning
Cleaning and disinfection practices
• Each health care setting should have policies and
“Hotel Clean”
procedures
• A measure of cleanliness based on visual appearance that
• Cleaning is a continuous process
includes dust/dirt removal, waste disposal and cleaning of
• Cleaning responsibilities and scope should be clearly
windows and surfaces. The basic cleaning that takes
defined; ensure no items are missed
place in all areas of the health care setting.
• Frequency of cleaning dependent on risk classification of
the surface or item

Components of “Hotel Clean” II. 1. Principles of IP&C Related to Environmental Cleaning


• Floors and baseboards are free of stains, visible dust,
spills and streaks “Hospital Clean”
• Walls, ceilings and doors are free of visible dust, gross • A measure of cleanliness routinely maintained in patient
soil, streaks, spider webs and handprints care areas of the health care setting.
• All horizontal surfaces are free of visible dust or streaks
(includes furniture, window ledges, overhead lights, • Hospital clean is hotel clean with the addition of
phones, picture frames, carpets etc.) disinfection, increased frequency of cleaning, auditing
• Bathroom fixtures including toilets, sinks, tubs and and other infection control measures in patient care areas.
showers are free of streaks, soil, stains and soap scum • Priority for cleaning should be given to patient care
• Mirrors and windows are free of dust and streaks
• Dispensers are free of dust, soiling and residue and areas, rather than administrative or public areas.
replaced/replenished when empty
• Appliances are free of dust, soiling and stains
• Waste is disposed of appropriately
• Items that are broken, torn, cracked or malfunctioning are
replaced

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Components of “Hospital Clean”

HOTEL CLEAN II. 1. Principles of IP&C Related to Environmental Cleaning


+
• High-touch surfaces in client/patient/resident care areas are
cleaned and disinfected with a hospital-grade disinfectant Outbreaks
• Non-critical medical equipment is cleaned and disinfected • There may be requirements for additional or enhanced
between clients/patients/residents cleaning during an outbreak to contain the spread of the
• Wear appropriate PPE during cleaning for outbreak microorganism.
clients/patients/residents on Additional Precautions • Allow for surge capacity
+ • additional staff, supplies, equipment
CLEANING PRACTICES ARE MONITORED AND AUDITED • Include ES on the outbreak management team
WITH FEEDBACK AND EDUCATION

NOTE: Frequency of Hospital Clean is determined according to


the Risk Stratification Matrix in Appendix B

II. 2. Cleaning Best Practices for Client/Patient/Resident


II. 1. Principles of IP&C Related to Environmental Cleaning
Care Areas
Personal Protective Equipment (PPE) All health care settings should provide adequate resources for ES:
• PPE is used: • One individual with overall responsibility
• to protect staff from microorganisms and chemicals
• to prevent transmission of microorganisms from one patient to another • Written policies and procedures, including defined
• Gloves: responsibility and accountability for specific items and areas
• Worn if there is a risk of hand contact with body substances, chemicals • Adequate human resources
• Remove gloves immediately after the task for which they are worn and • Priority given to patient care areas
discard • Outbreak response capacity that does not compromise regular
• Clean hands after removing gloves
• Use of gloves does not replace need for hand hygiene patient care area cleaning
• Remove gloves and perform hand hygiene on leaving each patient • Education of cleaning staff
room/bed space; do not walk from room-to-room or to other areas • Monitoring of cleanliness
wearing gloves • Supervision by trained, knowledgeable staff
• Do not wash or re-use disposable gloves • Ongoing review of procedures
• Select type of glove appropriate to task
• Prolonged wearing of gloves increases risk of irritant contact dermatitis • Same standards apply whether ES is provided in-house or
contracted out

II. 2. Cleaning Best Practices for Client/Patient/Resident II. 2. Cleaning Best Practices for Client/Patient/Resident
Care Areas Care Areas
Staffing levels should take in to account:
• Building factors:
• age, design, size, climate, season, outside soil, type of floors/walls, Frequency of Routine Cleaning depends on:
presence of carpet/upholstered furniture, area of patient care vs
administrative/public • frequency of contact: high touch vs low touch surfaces
• Occupancy factors: • type of activity in the area
• rate and volume of cases, patient acuity, cleaning methodology, • vulnerability of the patients in the area
facility ARO rates, number of isolation rooms, outbreaks, etc. • probability of body substance contamination in the area
• Equipment factors:
• type of cleaning equipment available, placement of custodial closets
• Training: • Each area should be evaluated to determine the
• training for new staff and auditing activities influence supervisory appropriate routine cleaning
staff levels, staff experience • Appendix B: Risk Stratification Matrix to Determine
• Legislative requirements: Frequency of Cleaning
• supervisory responsibilities under OHSA

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II. 2. Cleaning Best Practices for Client/Patient/Resident II. 2. Cleaning Best Practices for Client/Patient/Resident
Care Areas Care Areas
High Touch Surfaces
• Frequent contact with hands Vulnerability of the client/patient/resident population
• higher likelihood to be a source for transmission • More susceptible to infection
• Require more frequent cleaning • Medical condition or lack of immunity
• at least daily or more frequently if higher • e.g. oncology, transplant, newborns, burns, etc.
contamination • Less susceptible to infection
• e.g. doorknobs, telephone, call bell, bedrails, keyboards, • All other patients
monitors, etc.
Low Touch Surfaces
• Minimal contact with hands
• Require scheduled cleaning and when visibly soiled
• e.g. floors, walls, window sills, etc.

II. 2. Cleaning Best Practices for Client/Patient/Resident II. 2. Cleaning Best Practices for Client/Patient/Resident
Care Areas Care Areas
Probability of contamination of items/surfaces
• Heavy contamination
• Exposed to large amounts of blood, body fluids, Non-critical patient care equipment
secretions, excretions • Equipment that contacts only the intact skin of the
• e.g. delivery suite, OR, haemodialysis unit, burn unit, etc. client/patient/resident or the environment
• Moderate contamination • Requires cleaning and disinfection between uses for each
• Contaminated with blood or other body fluids as part of patient
routine activity • Selection of equipment should include cleaning and
• e.g. patient room, patient bathroom disinfection considerations
• Light contamination • Written policies and procedures for each item defining
• Surfaces not exposed to blood or other body fluids frequency, level and responsibility for cleaning
• e.g. lounges, libraries, offices

II. 5. Care and Storage of Cleaning Supplies and Utility II. 6. Additional Considerations
Rooms
Construction and Containment
• Use automated dispensing systems • “Construction Clean”: cleaning performed by
• No “topping up” construction workers to remove gross soil, dust,
• Toilet brushes remain in patient bathroom dirt, materials, hazards in the construction zone
• Clean and dry cleaning equipment between uses • Responsibility usually delineated by hoarding
• Sufficient, dedicated housekeeping closets; appropriately • inside: construction workers
sized and designed
• outside: health care setting’s staff
• Separation of clean and soiled items on carts
• Separation of clean and soiled utility rooms • Clear definiton of responsibility in contract
• Absence of personal items and food from housekeeping • Clear transport route for materials, clean and used
carts, closets, utility rooms

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II. 6. Additional Considerations II. 7. Education
Evolving Technologies • Environmental cleaning should be supervised and
performed by knowledgeable, trained staff
• Microfibers • Training program should include documentation of
• Air disinfection/Fogging training and proficiency verification
• Hydrogen peroxide vapour • IP&C component should include:
• Ozone gas • Routine Practices
• Super-oxidized water • Hand hygiene
• Ultraviolet Irradiation • Signage for Additional Precautions
• Use of PPE
• Steam Vapour • Prevention of blood and body fluid exposure,
• Antimicrobial-impregnated supplies and including sharps injury prevention
equipment • ES managers/supervisors should be trained and certified

II. 8. Assessment of Cleanliness and Quality Control II. 9. Occupational Health and Safety Issues
• ES staff should be offered appropriate immunization for
• Direct and indirect observation: health care settings:
• Visual assessment • annual influenza, MMR, varicella, tetanus, hepatitis B,
• Observation of performance acellular pertussis
• contracts with supplying agencies should include the
• Patient/resident satisfaction surveys above for contracted staff
• Residual Bioburden: • PPE use for infectious and chemical hazards
• Environmental culture • System for preventing and managing staff exposures
• “Healthy workplace” policy
• ATP Bioluminescence • Chemical safety
• Environmental marking • Cleaning chemicals may be irritants and/or sensitizers
• Fluorescence under UV light • Respiratory or skin exposure
• Do not apply cleaning chemicals using aerosol packs
or trigger sprays
• Choose equipment following ergonomic principles

III. Cleaning and Disinfection Practices for all Health III. 1. Routine Health Care Cleaning Practices
Care Settings • Goal of cleaning is to keep the environment safe for
clients/patients/residents, staff and visitors
• Sample procedures are provided for:
• general cleaning practices
1. Routine Health Care Cleaning Practices • daily routine cleaning of patient/resident rooms
2. Cleaning and Disinfection Practices for Patients/Residents • terminal/discharge cleaning of patient/resident rooms
on Additional Precautions • routine bathroom cleaning
• floor cleaning
3. Cleaning Spills and Body Substances • carpet care
• ice machines
• playrooms/toys
• ambulances
• operating rooms
• reprocessing areas
• medical laboratories
• haemodialysis units
• neonatal ICUs and isolettes
• biological spills

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III. 2. Cleaning and Disinfection Practices for Appendices
Patients/Residents on Additional Precautions A: Ranking System for Recommendations
• PPE to be worn as per signage outside the room B: Risk Stratification Matrix to Determine Frequency of
• Contact Precautions: sample daily and terminal cleaning Cleaning
procedures are provided for: C: Visual Assessment of Cleanliness
• VRE D: Sample Environmental Cleaning Checklists and Audit Tools
• C. difficile E: Advantages and Disadvantages of Hospital-grade
• Norovirus Disinfectants and Sporicides Used for Environmental
• ( for MRSA – routine terminal/discharge cleaning) Cleaning
• Droplet Precautions: F: Cleaning and Disinfection Decision Chart for Non-critical
• routine daily and terminal cleaning Equipment
• attention to “high touch” surfaces
• Airborne Precautions: G: Recommended Minimum Cleaning and Disinfection Level
• routine daily and terminal cleaning and Frequency for Non-critical Client/Patient/Resident Care
• allow sufficient time, dependent on air changes per Equipment and Environmental Items
hour, for air to clear

Appendix B: Risk Stratification Matrix to Determine


Frequency of Cleaning
Total Risk Risk Type Minimum Cleaning Frequency
• For each type of client/patient/resident care area Score
Step 1: categorize factors:
• Probability of contamination 7 High risk Clean after each case/event/ procedure
• heavy = 3; moderate = 2; light = 1 and at least twice per day
• Vulnerability of the population Clean additionally as required
• more susceptible = 1; less susceptible = 0 4-6 Moderate Risk Clean at least once daily
• Potential for exposure Clean additionally as required (e.g.,
• high touch = 3; low touch = 1 gross soiling)
Step 2: add to get score: maximum 7; minimum 2 2-3 Low Risk Clean according to fixed schedule
Step 3: determine cleaning frequency based on risk Clean additionally as required (e.g.,
gross soiling)
stratification matrix
• examples provided

PIDAC Best Practices for Environmental Cleaning


Status of Document and Next steps: In All Health Care Settings
• Stakeholder feedback reviewed and incorporated,
as appropriate, by PIDAC IP&C Subcommittee • Questions?
• Reviewed by PIDAC main committee and given • Feedback!
final approval
• Suggestions on practical strategies to get to
• CMOH final approval pending, before posting
• Educational rollout: front line?
• CanClean, “Red, White and Green”, OHA • train-the-trainer?
HealthAchieve 2009 • partner with RICN Coordinators?
• PIDAC/OHA videoconference • other?