High-touch, non-critical surfaces and equipment such as door handles, stretcher side rails, blood pressure cuffs and stethoscopes rank low in the hierarchy of disinfection and sterilization requirements. In fact, there is often disagreement about whether they need to be disinfected at all, or whether soap and water might suffice rather than chemicals. Let's take a look at that controversy and several other surface disinfection misconceptions on our way to busting a few cleaning myths.

Myth #1: Surface disinfection is not necessary. Because they have contact with only intact skin, don't touch mucous membranes or penetrate the skin and present a low risk of transmitting healthcare-associated infections, non-critical surfaces don't require sterilization or high-level disinfection. As mentioned, there is often disagreement about whether they need to be disinfected at all.

While the CDC's "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" acknowledges there is little hard data to prove that surface disinfection actually reduces infections, it does note that phenolics and quaternary ammonium compounds have been shown to reduce microbial load on floors more effectively than detergent does, without extra work or significant cost.

To that end, the guideline supplies the following reasons why we should routinely disinfect environmental surfaces:

• Although floors are non-critical surfaces, they're still regularly contaminated by shoes and equipment wheels.
• When a bucket of detergent and water is used in more than 2 or 3 areas, the risk that the mop will spread bacteria from area to area is increased.
• Both the CDC and OSHA recommend that we clean and disinfect medical equipment surfaces that are contaminated with blood or body fluids.
• Standardizing what products are used to disinfect surfaces in your facility can streamline both your training and your purchasing of product.

As mentioned, there is a paucity of scientific data directly implicating surfaces in the spread of surgical site infections, and questions persist about the efficacy of habitually using germicides on non-critical items. However, given the significant increase in the incidence of multidrug-resistant organisms, infection prevention authorities generally agree that surface disinfection efforts are justified.

Myth #2: Surface disinfection is a low priority. How thorough is your disinfection process? Several studies have shown that after environmental services terminally cleaned a patient room, about half of the surfaces that should have been sanitized weren't. Given the importance of throughput in surgery, it's easy to see how hurried and pressured staff may shortcut the process. But we shouldn't neglect under-surfaces on stretcher side rails, over-bed tables and grab bars (which might just get their tops wiped down). And while we can spot-decontaminate privacy curtains between beds in pre-op and PACU if they get visibly soiled, you should determine how often they're routinely laundered or changed. An effective strategy in heightening awareness and improving the performance of your cleaning staff is a fluorescent targeting method that uses powder or gel and ultraviolet light to demonstrate gaps in the cleaning process.

Strict compliance with manufacturers' product directions is imperative. Take pre-packaged, ready-to-use disinfectant wipes, for example. They're convenient and often cost-effective, but it's not uncommon for users to try to cover too large of a surface with a single wipe. Each manufacturer should recommend how large a surface can be disinfected by a single wipe. Be sure your staff is aware of and complies with these recommendations.

Remember that if a surface or a piece of equipment is visibly soiled, you must first clean it before you can truly disinfect it. It's the same reason hand hygiene guidelines state that if your hands are visibly soiled, you must use soap and water rather than alcohol-based hand rubs.

Ensuring proper surface disinfection requires a multidisciplinary process for ongoing performance improvement. Standardizing your facility's cleaning and disinfection products as much as possible (a step that, admittedly, may prove challenging in a large facility) is beneficial. Ongoing communication with and education of your staff through orientation, frequent in-services, reminder signage in utility areas and areas to be cleaned and consistent performance monitoring are all key strategies to improving compliance.

Myth #3: 10 minutes is needed to sanitize. The contact time required to sanitize a surface has also been an area of debate and scrutiny. The CDC's guideline addresses concerns that the recommended amount of time for a disinfectant to be in contact with a surface may be longer than is realistically achievable. For instance, some products recommend 10 minutes of contact time to achieve low-level disinfection. From a practical standpoint, it takes about 1 to 2 minutes for an item to air dry. So to achieve the recommended 10 minutes of contact time the product must be reapplied at least 5 times. That isn't practical.

There is convincing data to show that in clinical settings 10 minutes is not necessary. William Rutala, PhD, MPH, a professor of infectious diseases at the University of North Carolina School of Medicine in Chapel Hill, is one of the leading authorities on sterilization and disinfection. He reports that many disinfectants reach their maximum microbial kill after 30 to 60 seconds. Fortunately, more and more manufacturers' products now list shorter contact times of 1 to 2 minutes. If possible, purchase products that list these shorter contact times. Teach staff to follow label instructions and let the chemical solution air dry rather than wiping it dry.

Myth #4: Disinfectants cannot become contaminated. You may not be aware or may forget that, if not handled properly, even disinfectants can become contaminated. The longer a mop and bucket of diluted disinfectant are used, for instance, the greater the possibility that the bacteria they intend to kill will instead be spread to other surfaces. That's why you should frequently change mop heads and disinfectant solution. At our facility, we use microfiber mops, meaning a different mop is used for each room, which is an improvement over the previous practice of changing the cotton string mop head after 3 rooms.

The longer a bucket of water-diluted disinfectant stands open, the more likely it is to become contaminated. Disinfectants are often diluted with tap water, which routinely contains many organisms such as pseudomonas. If the solution remains in the bucket for an extended period of time, the organisms multiply and the solution becomes a reservoir of contamination. Many facilities have installed closed disinfectant dispensing systems, in which wall-mounted equipment automatically mixes disinfectant with purified water that's dispensed directly into a bucket, sprayer or other container.

Pre-packaged disinfectant wipes can also become ineffective or even contaminated if not used properly. If the lid of the container is not snapped shut after use, or if an imperfect design causes the lid to pop open, this leaves a portion of the wipe exposed to the air, causing the chemical to evaporate and rendering the wipe ineffective. Keep the lids closed, and dispose of any wipe that has been exposed to air.

Myth #5: Environmental services staff are adequately trained. When reviewing which surfaces are sanitized and which might be overlooked, it's not uncommon to discover that high-tech equipment such as patient monitors and medication pumps have fallen through the cracks. We've found that perioperative staff may assume environmental services will take care of those items, while the environmental staff is hesitant to handle them for fear of accidentally changing dials or settings.

How the disinfection duties are divided up is a critical conversation to have with your entire staff. Work with both perioperative and environmental services employees to decide which staff will take care of which item. Clinical personnel should be assigned to wipe down the equipment that environmental services is not trained to touch. In light of healthcare safety experts' enthusiasm for airline-industry style checklists, this format is an effective way to monitor your staff's performance.

The role of environmental services is critical in terms of patient safety, and their assigned tasks require a sophisticated and scientific skill set. I'm not convinced that we have paid enough attention to how adequately they're trained. It's critical that you include them in your performance improvement initiatives since their role is vital and they have so much to contribute.

A commonsense approach
When I began my career in infection prevention, the role of the environment in transmission of healthcare associated infections was being de-emphasized. Instead, prevention strategies such as hand hygiene and the use of personal protective equipment became the main focus. The pendulum began to swing back to the importance of the environment about 8 or 10 years ago with the rise of vancomycin-resistant Enterococcus. Certainly the increased incidence of other multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Clostridium difficile has dramatically increased the emphasis on sanitizing the patient's environment.

Although there's not a preponderance of evidence proving the link between non-critical surfaces and healthcare associated infections, routine and careful cleaning and disinfection of the patient's surroundings is a commonsense approach to prevention. Even with the lack of hard evidence, wouldn't you rather err on the side of patient safety?