The Science Supports Whole-Room Disinfection

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Automated cleaning systems are providing extra assurance for infection prevention efforts.


MISSED A SPOT Even the most dedicated manual surface disinfection efforts can sometimes neglect small crevices and buttons that harbor pathogens — places that whole-room systems can disinfect.  |  Pamela Bevelhymer

Manual surface cleaning isn’t completely effective. Your staff can’t eliminate every pathogen, no matter how much elbow grease they apply and diligence they display. If you accept this truth, it becomes apparent that effective surface disinfection requires a standardized, multimodal approach. The good news is that whole-room disinfection technologies such as ultraviolet (UV) light robots and hydrogen peroxide misting systems provide an added level of assurance that infection risks are reduced.

Whole-room disinfection technologies have demonstrated significant reductions with a broad array of pathogens, including highly resistant Clostridium difficile spores. The study my colleagues and I published last year in the Critical Care Explorations journal supports the use of automated cleaning systems. We found that the use of whole-room atomized disinfection with terminal cleaning protocols lowered manual labor times, improved disinfection outcomes and eliminated the transfer of bacterial pathogens to uncontaminated surfaces in healthcare environments.

Limiting factors

Healthcare facilities develop their own cleaning protocols based on CDC guidelines. But what’s printed in the guidelines — what you should be doing — is often not what’s being done in practice. As staff members become more distant from their original training, many tend to become lax about employing proper cleaning practices.

The intensive terminal cleaning protocol in our study involved not just medical equipment and surfaces, but also walls, floors and curtains. We estimated it would take about 90 minutes to clean the way the protocol described. The average manual cleaning time we observed turned out to be one-fifth of that.

There’s a wealth of information in the literature about how manual cleaning isn’t as effective as it’s designed to be. That’s partially due to human error, but also because in many facilities there’s not enough time to follow protocols as written. As a result, we see a lot of “practical” behavior related to the pressure of getting rooms turned over as quickly as possible.

The errors we saw in the ICU room we monitored in our study were many and varied. One common misstep was not cleaning underneath items, and not fully cleaning some frequently touched areas. When cleaning bed handrails, for example, we observed staff not cleaning around the entire surface of the rail, but instead just wiping over the top of it. Staff wiped down difficult-to-clean surfaces such as remote control buttons and crevices, but did not observe the contact times noted in the disinfectant’s instructions for use. Door handles, IV poles, tubes and wires that nurses touch frequently were often neglected, as well as soft surfaces such as curtains, fabric chairs and linens, which require different disinfectants than hard surfaces.

In our study and others, we’ve also observed staff cleaning a contaminated surface and then accidentally contaminating another surface by simply pushing the contaminants around. Consider how clean your cleaning tools are after they’re used for a period of time. For example, how often do you need to change a mop head? Are you disinfecting it thoroughly between uses? Bacteria can grow on cleaning tools over time.

Another issue is how much concentration of the disinfectant is on a wipe, its dry time and the maximum surface area it can clean before the disinfectant has been dissipated or diluted. If you’re opening and closing a container of disinfecting wipes, the wipes dry out over time. The last wipe is going to be a lot drier than the first one. Unfortunately, the only guidance you usually have to reference from wipe manufacturers is contact time or how long the surface should remain wet. 

Of course, training, educating and refreshing staff on surface disinfection protocols and compliance is a must. Remember, for the most part, people don’t consciously decide to clean a room in a suboptimal manner. They have a list of to-do items during turnovers and know someone is waiting outside to bring another patient into the room. They might not be tracking the contact times of the disinfectant on surfaces.

You can monitor compliance easily with a black light or even a common household liquid detergent like Tide that fluoresces. Take a Q-tip and secretly dot the detergent around the room. Let staff clean the room and return to see if they hit those areas. If your staff knows you’re performing those assessments periodically, it’s in the back of their mind that today might be the day they are evaluated. However, human behaviors often revert to bad habits, and after a while people forget they’re being watched.

Whole-room assistance

ADDED ASSURANCE Diligent manual disinfection remains as vitally important as ever, but whole-room disinfection systems provide an extra level of defense against healthcare acquired infections.

The benefit of whole-room disinfecting systems is that you can mitigate many manual cleaning mistakes and concerns from the surface disinfection equation. UV robots require line-of-sight to surfaces so the light can disinfect them. Even if the robot is repositioned in the room after a round of cleaning, that repositioning consumes time while leaving the room off-limits to patients and clinicians for an even longer time. Manual cleaning, then, should place increased focus on areas and objects that won’t be in the UV light’s line of sight.

In addition, no matter if you use a UV robot or a misting system in conjunction with manual disinfection, or even built-in UV lights that run at a safe level while providers and patients are in the room, be aware of the chemistries of both manual wipes and automated whole-room systems. Either one might not target every type of pathogen. The most thorough approach is to treat all surfaces during manual cleaning and use the whole-room system as a backup.

When using a whole-room system, it’s vital that staff first remove visible debris such as blood, mucus and other bodily fluids that settle on surfaces. If staff doesn’t remove that debris, the whole-room disinfection system won’t work very well in those areas. These automated cleaning systems cannot remove organic matter, which serves as a barrier to the chemistry attacking the pathogens within it.

For example, SARS-CoV-2 is easy to kill; it essentially dies on its own with or without the need for technology to treat the surfaces. A resilient organism like C. diff, however, requires appropriate manual and automated cleaning protocols that are much more direct with much higher efficacy.

The bottom line is that the more you clean manually and the more you can use whole-room disinfection systems, the safer your facility will be. Remember, even if you bring pathogen levels close to zero, their concentrations build up over time the longer a surface isn’t thoroughly cleaned. Cleaning regularly and diligently reduces the overall risk of adverse health outcomes.

By adding a whole-room disinfection system to your infection prevention arsenal and using it properly and regularly, you provide extra assurance that the risk to your patients and staff of contracting a healthcare-associated infection will be reduced. OSM 

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