Cleaning and Disinfection in Health care setting.pptx

DEFENCE BETTER THAN TREATMENT- CLEANING & DISINFECTION
CLASSIFICATION OF DISINFECTANTS
CLEANING & DISINFECTION OF ENVIRONMENTAL SURFACES
CLASSIFICATION OF HOSPITAL AREAS INTO RISK CATEGORIES
Environmental Cleaning Supplies and Equipment
Best practices for environmental cleaning products
General environmental cleaning techniques
Risk-assessment for determining environmental cleaning method and frequency

1. DEFENCE BETTER THAN TREATMENT - CLEANING & DISINFECTION Dr. Chakrapani Kammineni , Consultant Microbiologist & HIC Officer, KIMS Hospitals & Medicover Hospitals, Kurnool

2. DEFINITIONS Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces and is accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores , on inanimate objects Sterilization describes a process that destroys or eliminates all forms of microbial life and is carried out in health-care facilities by physical or chemical methods.

3. Cleaning Disinfection Sterilization Which one is most essential? One can clean without Sterilizing/Disinfecting, but one cannot Sterilize/Disinfect without cleaning!

4. Cleaning Cleaning is the first and most essential step before any process of disinfection or sterilization. Cleaning should be done as soon as possible after the items have been used as soiled materials become dried onto the instruments and the removal process becomes more difficult which makes disinfection or sterilization process less effective or ineffective.

5. Cleaning Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes Cleaning alone effectively reduces the number of microorganisms on contaminated equipment by 4-6 log 10 .

6. Cleaning Mechanical cleaning machines -automated equipment may increase productivity , improve cleaning effectiveness , and decrease worker exposure Ultrasonic cleaner Washer sterilizer Washer disinfector Manual - Friction and Fluidics

7. Methods for assessment of cleaning and cleanliness Methods for assessing cleaning practice include: direct performance observations- (checklists ) visual assessment fluorescent markers Methods for assessing the level of cleanliness include: measuring the residual bioburden (i.e., ATP) taking a bacteriological culture of the surface itself by swabbing or use of RODAC or contact agar plates.

8. SPAULDING’S CLASSIFICATION Based on the object’s intended use. CRITICAL - D evices which enter sterile tissue or the vascular system or through which blood flows . Level of Processing : Cleaning followed by S terilisation Eg : Surgical, Cardiac and Urinary catheters, Implants, etc., SEMICRITICAL - D evices that touch mucous membranes or Non-intact skin . Level of Processing : Cleaning followed by HLD . But Sterilisation is preferred Eg : Endoscopes, Respiratory therapy & Anesthesia equipment, cystoscopes tonometers etc

9. SPAULDING’S CLASSIFICATION Based on the object’s intended use. NONCRITICAL - medical devices that touch only intact skin require low-level disinfection. BP cuff, Stethoscope, Thermometer, ECG electrodes, Bed pans etc., In 1991, CDC proposed an additional category designated “ environmental surfaces ” to Spaulding’s original classification to represent surfaces. Eg : bed rails, bedside tables, patient furniture and floors

10. CLASSIFICATION OF DISINFECTANTS

11. Level of disinfectant Spores MTB Non-Env viruses Fungi Env. viruses Veg. bacteria Agents Low level No No No +/- Yes Yes QAC, Alcohol Iodophore , Chlorine , Phenolic detergents Intermediate No Yes Yes Yes Yes Yes High level +/- Yes Yes Yes Yes Yes Aldehyde- FD, GD, OPA, H 2 O 2 , PAA with H 2 O 2 Chemical sterilant Yes Yes Yes Yes Yes Yes > 2.4% glutaraldehyde -based formulations, 0.95% glutaraldehyde with 1.64% phenol/ phenate , 7.5% stabilized H 2 O 2 , 7.35% hydrogen peroxide with 0.23% peracetic acid, 0.2% peracetic acid, and 0.08% peracetic acid with 1.0% H 2 O 2

12. PROPERTIES OF AN IDEAL DISINFECTANT Broad spectrum-wide antimicrobial spectrum Fast acting-should produce a rapid kill Remains Wet-meet listed kill/contact times with a single application Not affected by the presence of organic matter Nontoxic-not irritating to user Surface compatibility-should not corrode instruments and metallic surfaces Persistence-should have sustained antimicrobial activity Easy to use Acceptable odor Economical-cost should not be prohibitively high Soluble (in water) and stable (in concentrate and use dilution) Cleaner (good cleaning properties) and nonflammable Rutala , Weber. Infect Control Hosp Epidemiol . 2014;35:855-865

13. SELECTION OF DISINFECTANTS There is no ideal disinfectant. The best option should be chosen according to the situation . Maintain a balance between Antimicrobial activity / Required disinfection level, Material Compatibilty Toxicity of the product, Easy to use Cost Always follow the manufacturer’s instructions

14. HIGH LEVEL DISINFECTANTS

15. Chemical Charasteristics Hydrogen Peroxide (7.5%) Peracetic Acid (0.2%) Glutaraldehyde (≥2.0%) OPA (0.55%) High-level disinfectant claim 30 min @ 20°C Not Applicable 20-90 min@ 20-25°C 12 min@20°C, 5 min @ 25°C in AER Sterilization Claim 6 hours @ 20°C 12 min @ 50-56°C 10 hours @ 20-25°C None Activation No No Yes (alkaline glutaraldehyde) No Reuse life 21 days Single use 14-30 days 14 days Shelf life stability 2 years 6 months 2 years 2 years Materials Compatibility Good Good Excellent Excellent Monitor MEC of solution Yes (6%) No Yes (1.5% or higher) Yes (0.3% OPA) Safety Serious eye irritant Serious eye and skin irritant Respiratory irritant Eye irritant, stains skin Cost profile (per cycle) + (manual) ++ (automated) +++++ (automated) + (manual) ++ (automated) ++ (manual)

16. Intermediate to Low level disinfectant

17. Alcohols Broad spectrum – Except Spores Hand rub- ABHR (75-80% v/v) ( WHO recommended) CHG-Alcohol (60% v/v) Small Surfaces like stethoscopes, thermometers, external surfaces of equipments, scissors. Disadvantages: Highly Flammable, Evaporate rapidly , Cannot penetrate Protein rich materials Eg : Bacillol 25 spray, Wettask wipes (25% w/v)

18. Chlorhexidine (CHG) Bactericidal, Mycobactericidal , & Sporicidal but variable effects on Yeast, Protozoa & Viruses. Handrub – 0.5% w/v Hand wash- 4% w/v (scrub) ( C.difficle spores ) Skin preparation- 2% w/v Mouth wash- 0.1-0.2% w/v Antiseptic (e.g. savlon )- Wound (directly apply) - CHG 0.3% v/v , cetrimide , IPA Hospital conc : CHG 7.5% v/v, cetrimide , IPA Prolonged residual activity Disadvantages: pH dependent, reduced by organic matter , slow action, stains cloth

19. Phenolics Disinfectant Phenols - Cresol, Xylenol , Lysol & Ortho-phenyl phenol. 5% phenol- sputum (RNTCP) Toxic & Irritant Active in presence of org. matter Antiseptic Phenols- Chloroxylenol ( Dettol ) More effective on GP organisms

20. Idophors Combination of Iodine & Solubilizing agenst /carrier. Antisepic prep. NOT TO BE USED as Environmental disinfectant. Antiseptics 5% - topical sol and ointment for wound 7.5%- for hand scrub 10% - for surgical skin preparation 1%- Mouth wash Non-antiseptics: hydrotherapy tanks, thermometer, IV stand, Bed rails, etc Disadv : Corrosive to metals, Contamination, Inactivated by Organisc matter & stains

21. Quaternary Ammonium Compounds QUATs/QAC Most commonly used Upto 7 generations Higher generations are Broad spectrum, short contact time, extensive self life, more stable USES: Good Cleaning Agent Disadv : Activity inhibited by organic compounds and detergents. So combined with dodecyl dimethyl ammonium chloride High water hardness & Materials (Cotton, gauze pads) absorb active ingredients – less effective Contamination

22. Chlorine & Hypochlorite Sodium hypochlorite (household bleach, 5.25%-6.15%) Calcium hypochlorite (bleaching powder) Sodium dichloroisocyanurate ( NaDCC )

23. Uses- Chlorine & Hypochlorite Indications Available chlorine ( ppm ) Blood spills (large spill) 5000 Blood spills (small spill) 500 Laboratory discard jars 2500 General env. disinfection 1000 Disinfection of clean instruments 500 Infant feeding bottles and teats 125 Food preparation areas and catering equipment 125 Eradication of Legionella from the water supply system, depending on exposure time 5-50 Hydrotherapy pools Routine 1.5-3 If contaminated 6-10 Routine water treatment 1.5-1

24. Preparation of Chlorine Household Bleach Solution Dilution Preparation Chlorine (ppm) Neat (5.25-6.15 %) None 50,000 0.5% of NaOCl 1:10 1 volume of neat +9 volumes of cold tap clean water 5000 0.05% of NaOCl 1:100 1 volume of neat + 99 volumes of cold tap clean water 500 1% of NaOCl 1:5 1 volume of neat + 4 volumes of cold tap clean water 10,000 0.1% of NaOCl 1:50 1 volume of neat + 49 volumes of cold tap clean water 1000

25. Broad spectrum, Fast acting Less expensive Does NOT leave toxic residues Unaffected by water hardness Corrosive at high conc. Inactivation by organic matter Bleach the fabrics, carpets Irritant to skin and mucosa- PPE to be worn Activity reduced: cationic detergent, soaps, UV (sun ray), biofilm Carcinogenic when mixed with Formaldehyde Preparation: daily, stored opaque container Stability: Tend to loose 40-50% ppm over month (closed container) Advantages Disadvantages

26. DISINFECTION OF SEMICRITICAL ITEMS

27. DISINFECTION OF Flexible Endoscopes Because of the types of body cavities they enter, flexible endoscopes acquire high levels of microbial contamination during each use. Bioburden found on flexible GI endoscopes after use - 10 5 CFU/ mL to 10 10 CFU/ mL : Highest levels in the suction channels Using HIV contaminated endoscopes, investigators have shown that cleaning completely eliminates the microbial contamination on the scopes Soaking in 2% glutaraldehyde for 20 minutes is effective only when the device first is properly cleaned

28. Stages of reprocessing for flexible endoscopes: Bedside procedure (pre-clean) - To remove readily detachable organic matter. Leak test : To ensure the integrity of the endoscope. Manual cleaning: Brushing of accessible channels and flushing of all channels to remove organic matter. Rinsing: To remove detergent residues that may affect the performance of the disinfectant Drying: To expel excess fluid that may dilute the disinfectant Disinfection: To eradicate potentially pathogenic microorganisms. Rinsing: To remove disinfectant residues that could cause a harmful effect to the patient Drying: To expel excess fluid before use on the patient or storage

29. Monitor MEC of solution Glutaraldehyde test strips are used in determining whether the concentration of glutaraldehyde (GTA), the active ingredient in the solution, is above or below the established minimum effective concentration (MEC) Test strips are also available for Ortho- Phthalaldehyde

30. CLEANING & DISINFECTION OF ENVIRONMENTAL SURFACES

31. Environmental Contamination Leads to HAIs Increasing evidence to support the contribution of the environment to disease transmission EIP - MRSA, VRE , C . difficile & Acinetobacter baumannii Surfaces are contaminated- ~25% EIP survive days, weeks, months Contact with surfaces results in hand contamination ; contaminated hands transmit EIP to patients Disinfection (daily) reduces HAIs Weber, Kanamori , Rutala . Curr Op Infect Dis .2016.

32. Admission to Room Previously Occupied by Patient C/I with Epidemiologically Important Pathogen Results in the newly admitted patient having an increased risk of acquiring that pathogen by 39-353% For example, increased risk for C. difficile is 235% (11.0% vs 4.6%) Weber, Kanamori , Rutala . Curr Op Infect Dis .2016.

33. CLASSIFICATION OF HOSPITAL AREAS INTO RISK CATEGORIES Different functional areas represent different degrees of risk and, therefore, require different cleaning frequencies, and levels of monitoring and evaluation. High risk areas Moderate risk areas Low risk areas.

34. Environmental Cleaning Supplies and Equipment Cleaning products- liquid soap, enzymatic cleaners, and detergents. For most environmental cleaning procedures, select neutral detergents (pH between 6 and 8) Disinfectants- Low-level disinfection (QAC) Intermediate-level disinfection – Alcohols (60-80%), Chlorine releasing agents, Improved hydrogen peroxide

35. Best practices for environmental cleaning products Develop and maintain a master list of facility-approved environmental cleaning products. Minimize the number of different environmental cleaning products in use at the facility. Store environmental cleaning products in a manner that: eliminates contamination risk and degradation minimizes contact with personnel (e.g., inhalation, skin contact) Prepare cleaning and disinfectant solutions according to manufacturer’s instructions

36. Surface cleaning supplies Portable containers for environmental cleaning products (or solutions) should be clean, dry, appropriately-sized, labelled , and dated. Narrownecked bottles are preferred over buckets to prevent the "double-dipping" of cleaning cloths, which can contaminate solutions. Squeeze bottles are preferred over spray bottles for applying cleaning or disinfectant solutions directly to cleaning cloths prior to application to a surface.

37. Surface cleaning supplies- one color for cleaning 2 nd color for disinfecting. Color -coding also prevents cross-contamination between areas, like from toilets to patient areas, or isolation areas to general patient areas. For example, red cloths could be used specifically for toilet areas, blue for general patient areas, and yellow for isolation areas . Colour coded mops

38. charged fibers , ↑higher adherence dirt/ mcgs Inhibited by pH Microfiber mop Cotton mop

39. They has the ability to carry and safely manage all the essential cleaning supplies and equipment and increased occupational safety for cleaning staff. Thoroughly clean them at the end of each day or shift Cleaning carts and trolleys

40. Two-bucket system (routine cleaning) Three-bucket system (disinfection) 1.Cleaning solution 2.Rinse water 1.Cleaning solution 2.Rinse water 3.Disinfectant solution

41. Disinfectant or Detergent-Disinfectant Wipes Ready-to-use wipes that are saturated with an appro . disinfectant or detergent-disinfectant product can be used as an alternative to cotton or microfiber cleaning cloths. Take care to evaluate the appropriateness of the product, considering the recommended properties. Ensure that they are stored appropriately, Wipes should be discarded if they are no longer saturated.

42. For cleaning & disinfection of environmental surfaces and noncritical patient care equipment: Do not use brooms and dry mops fumigators (and fumigation) and disinfectant fogging Antiseptics (e.g., chlorhexidine , iodophors ). Phenolics (due to high toxicity)

43. General environmental cleaning techniques

44. 1.Conduct Visual Preliminary Site Assessment: Check for additional (isolation) precautions signs Follow precautions as indicated Remove clutter before cleaning

45. 2. Proceed From Cleaner To Dirtier To avoid spreading dirt and microorganisms. During terminal cleaning, clean low touch before high-touch surfaces. Clean patient areas before patient toilets. Within a specified patient room, shared equipment and common surfaces , then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally with surfaces and items directly touched by the patient inside the patient zone

46. 3. Proceed From High To Low (Top To Bottom) To prevent dirt and microorganisms from dripping or falling down and contaminating already cleaned areas. Practical examples of this strategy include: • Cleaning bed rails before bed legs Cleaning environmental surfaces prior to cleaning floors Cleaning floors last to allow collection of dirt and microorganisms that may have fallen

47. 4. Proceed in a Methodical, Systematic Manner To avoid missing areas —for example, left to right or clockwise

48. 5. Others Never shake mop Do not double-dip the mop 120 sq feet area to be mopped before re-dipping Mop head to be turned @5-6 strokes Rinse the mop with water before re-dipping Mop head-change when heavily soiled /at the end of the day. Cleaning solution- @ 240 sq feet , or when heavilty soiled

49. After Cleaning Do not overstock rooms Tools used for cleaning and disinfecting should be cleaned and dried between uses . Launder mop heads daily & should be dried thoroughly before re-use Clean sanitation cart and carts used to transport biomedical waste daily

50. NO TOUCH” APPROACHES TO ROOM DECONTAMINATION( UV/HP) should be used for terminal room disinfection (e.g., after discharge of patients on TBP ). Ultraviolet C Hydrogen Peroxide Vapor

51. FACTORS INFLUENCING THE CLEANING FREQUENCY AND LEVEL OF DISINFECTION Potential for Contamination with Pathogens Heavy Contamination: Surfaces and/or equipment are exposed to copious amounts of blood or other body fluids. Moderate Contamination : Surfaces and/or equipment are does not routinely (but may) become contaminated with blood or other body fluids and the contaminated substances are contained or removed (e.g., wet sheets). Light Contamination: Lightly or not contaminated.

52. FACTORS INFLUENCING THE CLEANING FREQUENCY AND LEVEL OF DISINFECTION Degree and Frequency of Hand Contact High Touch Surfaces - that have frequent contact with hands. eg : doorknobs, telephones, bedrails, light switches, computer keyboards, monitoring equipment, haemodialysis machines, wall areas around the toilet. Transmission of microbes is more likely. Such surfaces require more frequent cleaning. Low Touch Surfaces - that have minimal contact with hands.

53. FACTORS INFLUENCING THE CLEANING FREQUENCY AND LEVEL OF DISINFECTION Vulnerability of Persons Present in the Area More Susceptible to infection Susceptible clients/patients/residents are those who are most susceptible to infection due to their medical condition or lack of immunity. These include those who are immunocompromised (oncology, transplant and chemotherapy units), neonates (level 2 and 3 nurseries) and those who have severe burns (i.e., requiring care in a burn unit). Less Susceptible: all other individuals

54. High-Touch Surfaces bed rails bed frames moveable lamps Tray table bedside Table handles IV poles blood-pressure cuff

55. Risk-assessment for determining environmental cleaning method and frequency

56. Step 1: Categorize the risk factors that determine the need for environmental cleaning Probability of Contamination with Pathogens Heavy Contamination (score = 3) Moderate Contamination (score = 2) Light Contamination (score = 1) Vulnerability of Population to Infection More Susceptible (score = 1) Less Susceptible (score = 0) Potential for Exposure High-touch surfaces (score = 3) Low-touch surfaces (score = 1)

57. Step 2: Determine the Total Risk Stratification Score Probability of contamination with pathogens More susceptible population (score = 1 ) Less susceptible population (score = 0) Heavy ( score = 3) 7 (3+3+1) 6 (3+3+0) Moderate ( score = 2) 6 (3+2+1) 5 (3+2+0) Light ( score = 1) 5 (3+1+1) 4 (3+1+0) Risk Stratification Scores for High-Touch Surfaces (Score for Potential for Exposure = 3 )

58. Step 2: Determine the Total Risk Stratification Score Probability of contamination with pathogens More susceptible population (score = 1 ) Less susceptible population (score = 0) Heavy ( score = 3) 5 (1+3+1) 4 (1+3+0) Moderate ( score = 2) 4 (1+2+1) 3 (1+2+0) Light ( score = 1) 3 (1+1+1) 2 (1+1+0) Risk Stratification Scores for Low-Touch Surfaces (Score for Potential for Exposure = 1 )

59. STEP 3: Determine the cleaning frequency based on the risk stratification matrix: Total Risk Score Risk Type Minimum Cleaning Frequency 7 High Risk Clean after each case/event/procedure and Clean additionally as required 4-6 Moderate Risk Clean at least once daily Clean additionally as required (e.g., gross soiling) 2-3 Low Risk Clean according to a fixed schedule Clean additionally as required (e.g., gross soiling)

60. Patient Care Area Examples Location Probability of Contamination Potential for Exposure Vulnerability of Population Total Score Minimum Cleaning Frequency Burn unit 2-3 3 1 6-7 Clean after each case/event/procedure, at least twice daily and clean additionally as required General inpatient 1-2 3 4-5 Clean at least once daily and clean additionally as required

61. General outpatient area (Adult) P robability of contamination and/or the vulnerability of the patients to infection is low.

62. TBP/Isolation wards Area Description Frequency Products Technique Additional Guidance / Description of Cleaning Airborne precautions Daily and as needed Clean (neutral detergent and water) High-touch surfaces, handwashing sinks and floors; work towards patient zone Clean low-touch surfaces on a scheduled basis (e.g., weekly). Primary focus is adherence to required ppe and additional entry/exit procedures. Droplet and/or contact precautions Twice daily and as needed Clean and disinfect High-touch surfaces and floors, focus on all surfaces within the patient zone, noncritical patient care equipment; any surface visibly soiled with blood or body fluids Cleaning staff must wear required PPE, clean and disinfect low- touch surfaces on a scheduled basis (e.g., weekly); Dispose of or reprocess cleaning supplies and equipment immediately after cleaning

63. I C U

64. Emergency department

65. Labour room

66. Other special areas Hemodialysis units Burn unit Special isolation units house highly immunocompromised patients Pediatric wards General procedure rooms

67. DISINFECTION POLICY IN SPECIAL SITUATIONS HBV, HIV, TB-contaminated devices/ surfaces Critical/semi-critical items: Disinfect in same way (HLD) Non- critical items: use HLD Hemodialysis unit Non-critical items- NaOCl (500ppm) Critical items- NaOCl (1000ppm) or H2O2 Inactivation of C. difficile : NaOCl (5000 ppm ), 2% GD, Hand wash

68. DISINFECTION POLICY IN SPECIAL SITUATIONS Processing Patient-Care Equipment Contaminated with Antibiotic-Resistant Bacteria (e.g., VRE, MRSA, MDR-TB), or Emerging Pathogens (e.g., H. pylori, E.coli O157:H7, C. difficile , SARS Coronavirus , COVID-19), or Bioterrorist Agents: Use standard sterilization and disinfection procedures for patient-care because they are adequate to sterilize or disinfect instruments with the exception of prions .

69. Fumigation – YES / NO OT with- Heat Ventilation Air Conditioning (HVAC) system. AHU HEPA filters Laminar air flow and UV radiations Maintenance of the HVAC & AHU done at least once a year . HEPA filters are changed at regular intervals. Results of weekly air count monitoring using settle plates/air sampler are within acceptable limits. Surface cleaning protocols are implemented correctly Adequate time is given for OT cleaning.

70. Fogging of wards/rooms: Wards and rooms need not be fogged on a routine basis. Fogging of wards and rooms should be done in the following situations: After an isolation ward/room is emptied at the end of an outbreak After an infected patient is discharged from a room (in absence of an outbreak) When an outbreak of infection occurs in a ward.

71. TESTING OF DISINFECTANTS Phenol coefficient (Rideal Walker) test Chick Martin test- Capacity (Kelsey-Sykes) test- In-use (Kelsey and Maurer) test -

72. Acknowledgements Dr. Apurba S Sastry Dr. B.Sreekanth Reddy Dr. Swathi Prakasham

73. References Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. CDC Guideline for disinfection and sterilization in healthcare facilities , 2008. C. Glen Mayhall . Hospital Epidemiology and Infection Control, 4 th Edition Lippincott Williams & Wilkins 2012; 1180-1229 The APSIC guidelines for Disinfection And Sterilisation of instruments in Health Care facilities, 2017. World Health Organization and Pan American Health Organization, 2016. Decontamination and reprocessing of medical devices for health-care facilities. [Online] Available from https://www.who.int/infection-prevention/publications/decontamination/en/ [Accessed February,2020] Apurba S Sastry , Essentials of Hospital Infection Control, 1 st Edition Jaypee Brothers Medical Publishers,2019. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings, November 2019 Rutala WA, Weber DJ. An overview of disinfection and sterilization. In: Rutala WA, ed. Disinfection, sterilization and antisepsis: principles, practices, current issues, new research, and new technologies . Washington, DC: Association for Professionals in Infection Control and Epidemiology, 2010:18–83.

74. [email protected]