The war against healthcare-associated infections (HAIs) can be daunting. First, the enemy is invisible. Second, there's usually pressure to fight — and win — quickly. And third, the war never ends. No matter how thoroughly you rout the opposition today, reinforcements will appear tomorrow, forcing you to engage again. So you can never let up. When it comes to surface disinfection, effective strategies are the key to staying ahead. What's your battle plan, and — just as importantly — how will you recognize and motivate your foot soldiers on the front lines? Here are some practical suggestions.

TOUCH TYPE High-touch surfaces for patients often get the lion's share of attention, but don't ignore high-touch areas for staff, such as keyboards.

1 Remember low-touch surfaces, too. Naturally, you want the people doing the cleaning and disinfecting to focus much of their attention on high-touch surfaces like bed rails, over-bed tables and bathrooms. But they should also make sure they disinfect areas that patients don't contact as much, but your staff do — things like light switches, doorknobs, privacy curtains and keyboards.

HITS AND MISSES It helps to spot check how well your staff is doing with a swab and a luminometer, but use the test to teach, never to punish

2 Test for thoroughness. There are several commercial products designed to make your invisible enemy more visible. You can measure how well staff are doing by swabbing an area after they've finished cleaning and then inserting the swab into a light meter or luminometer. The more areas that were missed or cleaned insufficiently, the higher the level of light units it will register. You can also deposit fluorescent material on random surfaces and then shine a black light on those surfaces to reveal what's been left behind. Just keep in mind that the goal of testing is not to be punitive, but rather to create teachable moments. There are a lot of surfaces and it's easy to miss things. More on this in No. 10 below.

3 Do spot checks. Chances are you don't have the resources to check every room every time. That would take too much time and too much money (typically each swab costs between $3 and $4). Instead, consider conducting spot checks. As part of our citywide C. difficile prevention collaborative, each facility is required to do 25 random spot checks a week. That's enough to pinpoint who's doing a good job and who needs more training.

DRY TIME? Allow adequate drying time and follow all label directions with solutions and wipes.

4 Pay attention to manufacturers' directions. One key to effective surface disinfection is that you use products appropriately. That includes allowing adequate drying time and following all label directions with solutions and wipes. A pet peeve of mine is when the cover on the disinfectant wipes container doesn't stay down tightly and firmly. When it pops up with a wipe sticking out of the top, chances are the wipe's going to dry out. A staff member who then uses that wipe will just be spreading germs around. As with most products, the wipes are great if used correctly, but if not, they may do more harm than good.

CLOSE AT HAND Make sure wipes are readily accessible and that staff follow directions carefully. Otherwise, they can do more harm than good.

5 Make wipes readily accessible. Human-factor engineering is important. Think about ways to mount wipes containers so they're right there when people need them. Consider putting them on wheelchairs, IV poles, stretchers, computers on wheels — anything that gets moved from room to room. If they're not handy, and things are hectic, the staff probably isn't going to go looking for them.

6 Consider taking advantage of newer processes and technologies. There are surface disinfection systems that can be used as adjunct approaches to thorough cleaning — things like UV light and hydrogen peroxide fogging systems. Surfaces can also be coated with passive disinfecting materials like copper and silver. The challenge with these materials is that they can be expensive — with new construction, and especially if you're retrofitting. Still, these new technologies are getting a lot of attention, because they may hold considerable promise.

7 You can't sanitize dirt. This is an extremely important principle. The first step in achieving disinfection or sterilization is always good old-fashioned elbow grease. You need friction to do the job right. Insufficient cleaning is the most common cause of failure. Passive disinfection with ultraviolet light disinfection systems can sterilize surfaces within the line of light delivery that you might have missed, but if the area isn't thoroughly cleaned first, it won't do you any good. One small study (tinyurl.com/ogrlox4) found that adding UV to the standard cleaning process reduced surface contamination in the OR by 81% when compared to manual cleaning alone.

8 Don't forget the importance of bleach. It can be tough on surfaces, but if you're dealing with an increased incidence of C. diff, which CDC has designated as the No. 1 HAI in the United States, experts say bleach is your best weapon. The same is true with norovirus, which is also very difficult to kill in the environment. Otherwise, though, there's no need to use bleach on a routine basis.

One additional note about bleach: Manufacturers stress the importance of removing residue, so it doesn't build up on surfaces. And it turns out that might be more than just an aesthetic issue. Some experts are concerned that residue might facilitate the formation of biofilm, which could shield and protect germs from disinfectants.

9 Protect your staff. Patient safety isn't the only concern. There are documented cases of healthcare workers getting C. diff on the job after working with infected patients. When you're disinfecting, you're dealing with chemicals, so make sure you teach people to use gloves, goggles and other necessary personal protective equipment. You might also consider limiting the use of aerosol sprays in your facility.

10 Motivation is crucial. The people doing the cleaning and sanitizing have a crucial, challenging and sometimes thankless job. So it's tremendously important to ensure that your service staff members feel appreciated, recognized and empowered as part of the team. When their performance isn't perfect, tell them you know that what they're doing is difficult and that you're going to help them improve on the great job they're doing. There should be constant training, monitoring and feedback, so they never lose sight of the ultimate goals — the safety of the patient and their own safety. Make it a collegial atmosphere and make sure you give credit where credit's due. Everybody should be on board. If you have an administrator or a nurse shouting, "I need this room!" that pressure can lead to shortcuts and unsafe situations.

To show appreciation for our environmental service staff's hard work, we've sponsored contests at our facility. We put a poster on the wall, with paper race cars for each person doing the job. Then, when we did spot checks, whoever had the best scores got their cars moved toward the finish line. The ones who crossed the finish line first were given prizes, like movie passes or restaurant gift certificates.

Surface disinfection is extremely serious business, after all, and if small rewards like those help motivate people to do the job well, they're worth every penny.

SHARK SKIN Sharklet is a non-toxic approach to bacterial control, a revolutionary surface technology that inhibits the growth of microorganisms

SHARKS, CICADAS AND DRAGONFLIES
New Strategies Come to the Surface

The future of sterilization and disinfection may have less to do with what you wipe — or spray — on surfaces, and more to do with the surfaces themselves. If so, we'll likely owe a debt of gratitude to sharks, cicadas and dragonflies.

The observation that, unlike virtually every other creature and material that's exposed to water, sharks aren't susceptible to biofouling, led to the discovery that shark skin contains millions of tiny "skin teeth" arranged in diamond patterns. The structure and design work to discourage microorganisms from latching onto them. That revelation has led to the creation of Sharklet, a sheet-plastic product that mimics the structure and can be applied to any number of surfaces, including medical devices. Testing in the healthcare environment is still in the early stages, but one huge potential advantage is that Sharklet's repellant properties aren't chemical, so there's no way for bacteria to develop resistance.

More recently, Australian scientists were amazed to discover that the wings of cicadas and dragonflies contain regularly spaced nanopillars, or spikes, that slice bacteria to shreds as they settle on their surface. The wings feel smooth to the touch, but have been found to be remarkably effective in killing certain targeted bacteria, including Staphylococcus aureus. The scientists say there's no reason synthetic materials with similar effectiveness can't be manufactured.

— Jim Burger