January 14, 2021

During the pandemic, this traditional practice is more important — and more daunting — than ever.

FINE PRINT With so many cleaning agents subject to availability issues during the pandemic, it's crucial for staffers to understand each product's IFU before use.

Surface disinfection has always been a core infection prevention practice, but COVID-19 has intensified the focus on this never-ending battle. We recently gathered intel from some infection control specialists that could be helpful as you continue to adjust to the relentless challenges of the pandemic.

• Observe and audit. Reset to get a sense of what exactly is being cleaned and what isn't, both in terms of effort and frequency, suggests J. Darrel Hicks, BA, Master REH, CHESP, a St. Louis-based infection prevention consultant. He recommends combining in-person observation with measurements of cleanliness using adenosine triphosphate (ATP) or invisible fluorescent markers, which can confirm if a surface has been wiped. From there, you can determine who on your staff might need additional training. Mr. Hicks says you should engage staff and set clear expectations of exactly who is responsible for cleaning specific surfaces.
• Identify blind spots. "Think about all the stainless steel and plastic in operating rooms," says Mr. Hicks, who stresses to not overlook items such as IV pumps, side rails and patient transport equipment. "Make sure there aren't any gaps in what's wiped down, whether it's during between-case room turnovers or end-of-day cleaning," he says.
• Keep track of IFUs. Make sure your staff pays attention to the manufacturer's instructions for use (IFU) for whatever disinfectant they're using at a given time. This is especially crucial during the pandemic due to the varying availability of surface disinfection agents and products. "Constantly remind your team that they need to be aware of what those specs are, and the importance of following them to the letter," says Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of infection prevention at University of Rochester (N.Y.) Medicine and president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC). Dry times should be a particular area of focus. "Posting visual reminders about dry times where disinfectants are used, and updating that information on a real-time basis, is important," says Ms. Pettis. Also be sure to purchase appropriate disinfectants for soft surfaces like privacy curtains and upholstered furniture, she adds.
• Call in the tech cavalry. Surface disinfection is hard manual work, but strategic use of technology such as UV robots and lamps, electrostatic sprayers and air purification systems can supplement those efforts.

"It's one more tool in your toolbelt," says Ms. Pettis. "No matter how well-intentioned staff are, they're in a hurry and under pressure. Technology is a safeguard to add on top of the basics."

Addressing three key factors helped a Colorado hospital mitigate the risks of cross-contamination.

BOLD Duodenoscopes present unique reprocessing challenges, along with the potential for infecting patients.

The presence of antibiotic-resistant bacteria in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) has been noted to such an extent in recent years that the CDC developed an Interim Duodenoscope Surveillance Protocol (IDSP) to culture relevant scopes for residual pathogens.

Karin Underberg, MEd, BSN, RN, CNOR, NPD-BC, former clinical educator for ORs at Children's Hospital Colorado in Aurora, recently shared how her facility adapted the CDC's IDSP to fit its unique capabilities and situation. She discussed three key aspects of the program:

• Inventory management. Children's Colorado developed a comprehensive method to track its duodenoscopes through their reprocessing and quarantining phases. Staff log scope models; dates of cleaning, quarantining and culturing; who performed the culture; date of reprocessing after culture; date of quarantine pending return of culture; date cultures were returned; "acceptable" or "unacceptable" status; and who released the scope from quarantine. "Unacceptables" require scope recleaning, reculturing and a return to quarantine pending results of the second culture. The process provides administrators information about which staff members might need further training. For situations where no scopes are available due to quarantining and reprocessing, the hospital developed a premature release and tracking protocol for emergency use.
• Categorization of pathogens. The hospital distinguishes between "high-concerning" contaminants such as yeast, Staph aureus, enterococci and gram-negative enteric bacilli, and "low-concerning" organisms such as coagulase-negative staphylococci, micrococci and gram-positive rods. Very low numbers of low-concerning organisms are considered "acceptable." "Remember, you're not sterilizing scopes," says Ms. Underwood. "You're high-level disinfecting them, so you can't expect a totally negative culture."
• Staff assistance. Because scope reprocessing involves dozens of steps, Ms. Underwood developed three laminated placards listing all of the required steps, along with how-to pictures, as readily available, in-the-moment visual references for sterile processing staff. Skill validation sessions and educational in-services reinforce their knowledge and comprehension.

"We never had any trouble with infections from duodenoscopes, most likely because we were constantly refining our cleaning processes based on the latest data and guidelines, as well as our own experiences," says Ms. Underwood.

Infection preventionists in hospitals are introducing new solutions to help prevent cross-contamination and improve patient safety during the worldwide pandemic.

Credit: Ansell STAT-BLOC^™ Antimicrobial Linen

As infection prevention professionals work on the front line during the COVID-19 pandemic, infection control priorities have heightened the need for effective procedures in patient safety and protection, including surface cleaning and use of disposable products whenever possible. Operating room tables, mattresses, stretchers and other similar surfaces can allow penetration and absorption of pathogenic organisms, blood and body fluids and a variety of other contaminants through undetected holes or tears which can be trapped and resurface during future use.¹

This poses cross contamination and infection risk for subsequent patients. Infection control professionals and healthcare providers across the globe are constantly looking for ways to reduce the risk of cross contamination in surgery and patient care settings. The most common method to prevent the risk for cross contamination is by using a disposable product. The Centers for Disease Control (CDC) recommends the use of disposable patient care equipment in acute care settings.²

When considering the use and cleaning of operating room tables, mattresses, stretchers and gurneys used for patient transport, disposable sheets and covers provide a valid option. Impervious, disposable products provide additional protection by preventing strike-through contamination to the surface below. An expanded level of protection can also be provided by the addition of an antimicrobial layer bonded to the material, if available.

If all three characteristics are combined, these features isolate the patient from potentially contaminated surfaces while actively inhibiting bacterial and viral organisms which gives an upper hand in protection. For this reason, testing was done on the only antimicrobial disposable table sheet available on the market today to determine if it could also provide barrier protection from SARSCoV-2.

Testing was performed on STAT-BLOC^™ disposable, antimicrobial, quilted, absorbent table sheets to evaluate virucidal activity compared to an untreated, disposable table sheet material when challenged with exposure to the Human Coronavirus strain 229E (ATCC #VR-740). This study was performed in order to establish its effectiveness against the family of lipid enveloped Coronaviruses, which includes the SARS-CoV-2, the cause of COVID-19.

Testing Results

Testing was conducted based on the International Organization for Standardization (ISO) method ISO 18184:2019(E), Textiles - Determination of antiviral activity of textile products, and was performed in accordance with Good Laboratory Practices, as specified in 21 CFR Part 58. Results showed that STAT-BLOC™ antimicrobial table sheets reduced potential infectivity of Coronavirus 229E by an average of 2.000 log10 (99.00%), which is categorized as good antiviral effect in accordance with ISO181843 (See Figure 1).

The coronaviruses virus family consists of 7 large RNA lipid enveloped viruses. The viral envelope of the coronavirus is the major target of surface-active biocidal formulation. Destruction of the lipid envelope which protects the fragile RNA material leads to virus inactivation and its inability to infect a susceptible host. The viral envelope structure and composition is very conserved within a family of viruses due to the cellular origin of envelopes. Biocidal formulations effective against one strain of an enveloped virus representing the virus family are effective against the whole family of viruses.

Conclusion

Knowing that the STAT-BLOC^™ antimicrobial table sheet can help reduce transmission of COVID-19 should provide confidence in reducing risk within the facility during these trying times. The 2.0 log reduction demonstrated by STAT-BLOC^™ antimicrobial table sheets is a prudent and logical next step to further improve the patient experience and their safety.

In areas where environmental cleaning may be challenging, where rapid turnover of patient care areas is common, it makes sense to isolate the patient from potential surface exposures while also providing a material that targets the lipid envelopes of epidemiologically highly contagious viral pathogens. STAT-BLOC^™ antimicrobial table sheets have been demonstrated to provide the three key features that healthcare facilities should demand of their surface protection products. They are disposable, impervious and antimicrobial. This unique combination provides a solution with the potential to reduce patient exposure risk.

UV-C is being used to attack pathogens within HVAC systems.

Ultraviolet C (UV-C) light has proven effective at neutralizing viruses and bacteria, including COVID-19. In surgical settings, UV-C has commonly been deployed in a surface disinfection role through or with portable robots or direct fixed lamps that require the entire OR to be evacuated for a period of time. "Indirect" UV-C lamps that can stay on all the time are used to disinfect "upper air" in the room while safely directed away from personnel.

None of these options, however, address the larger issue of how the air in the OR, and frankly anywhere in your facility, gets there in the first place. As a result, an increasing number of surgical facilities are integrating UV-C infection prevention technology directly into HVAC systems.

"Some systems have combined UV-C technology with HEPA filtration to create a reduction in both viable and non-viable particulates," says Charles Edmiston, Jr., PhD, CIC, FIDSA, FSHEA, FAPIC, a professor of surgery and director of the surgical microbiology research laboratory for the Medical College of Wisconsin in Milwaukee.

Using such systems, UV-C can directly irradiate HVAC cooling coils and dripping pans to prevent formation of colonies of bacteria, virus, fungi and mold. Likewise, surgical facilities are placing in-duct UVC air cleaners to make sure the air coming out of vents is safe. Another supplemental technology, germicidal UV door barriers, can prevent pathogens entering the sterile environment from outside of the OR.

When evaluating air purification technologies for your facility, Dr. Edmiston recommends a deep dive into your needs, wants and budget. "Work with vendors to develop a cost-benefit analysis, documenting the yearly cost savings associated with preventing surgical site infections in selective operating rooms or for selective surgical services associated with the use of the proposed air filtration/purification technology," he says.

If that question made you panic, here's some advice.

The lead aprons, skirts and vests worn by your staff and patients to protect themselves from radiation exposure can harbor pathogens, but in many facilities they aren't cleaned as often or as well as they should be. Often, in a busy facility, cleaning is forgotten or delayed.

Angela Ellis, MSN, RN, CNOR, perioperative clinical specialist at H. Lee Moffitt Cancer Center in Tampa, Fla., shares these tips on keeping leaded layers clean and safe:

• Establish a baseline. Ms. Ellis recommends using fluorescent markers to test your staff's cleaning compliance. "A month later, use a black light to see if the markers are still there," she says. "If they are, staff weren't properly cleaning the garments." She switches the locations of the invisible marks so even if staff is aware that markers are being used, they never know exactly where they'll be.
• Establish accountability. Do your staffers know how to clean these garments, and who is responsible for doing it? Ask them, and if the answers aren't satisfactory, take action. When Ms. Ellis surveyed staff, she found the biggest barriers to compliance were short turnover times, staffing levels, availability of flat surfaces to lay the garments on for cleaning and an "It's not my job!" mentality. "Bottom line, there was no accountability for cleaning the garments," says Ms. Ellis. If you're in this situation, she suggests education and hands-on demonstrations about proper cleaning protocols.
• Wipe down every surface. "Thoroughly clean each garment with peroxide wipes on the front, back and along all side seams between every use," says Ms. Ellis. Follow the dry time recommended in the wipe's instruction for use. Ms. Ellis notes that you'll need a large flat surface to clean the garments.
• Store them properly. At Ms. Ellis' hospital, staff had commonly flung radiation garments over storage racks instead of hanging them neatly. "Folding these garments can result in breaches of integrity over time, increasing the risk of radiation exposure," she explains.

Ultimately, codification of this often-overlooked aspect of infection control encourages awareness and compliance. "This might not be top-of-mind for most staff members, but we hope our protocol can raise the profile of this important but often overlooked aspect of infection prevention," says Ms. Ellis.