ONCE IS NOT ENOUGH High-touch items should be wiped down several times a day, and make sure adequate kill time is provided.

Are your high-touch surfaces clean? I mean thoroughly disinfected? Even though we assume that our ORs will be sterile, surfaces are rarely cleaned, especially between cases. The likely culprits are turnover pressures and inadequately trained environmental services staff. Is your team making these 13 common surface cleaning mistakes?

Not leaving surfaces as wet as they should be for as long as they should be. Most disinfectants used to have 10-minute kill times — and really, nobody could afford that kind of time unless they were doing terminal cleaning. Now, most products have 2- or 3-minute kill times. Everyone feels the pressure to turn rooms over quickly, but 2 or 3 minutes shouldn't be that big of a deal.

Failing to clean high-touch items. Bed rails, light switches, toilet handles, faucets, IV poles — these could all benefit from being wiped down about 6 times a day. They're all big transmission points, especially for Clostridium difficile patients.

Glossing over items that get moved from patient to patient. Too often people just give a cursory wipe when they're dealing with a large vital signs monitor or an Accu-Chek machine. But even healthy patients have organisms on their skin, and they may have resistant organisms that shouldn't be passed around. The next patient might be more immune-compromised and more susceptible.

Using one small cloth on a large surface. When staff do this, they can end up just moving bacteria around. Use as many wipes as are needed.

Failing to clean computers. Tell staff to use wet wipes on the keyboard and mouse every time a new nurse comes on duty. That way you know they're getting cleaned several times a day.

Not using covers on keyboards. Keyboards may not be as responsive as you'd like with covers. But manufacturers are making progress. Recently, we've seen the introduction of sealed keyboards that are easier to clean and less likely to be ruined by moisture.

Forgetting that cleaning is a 2-step process. You can't skip ahead. Disinfection can't take place until you remove all organic materials and soil.

Leaving wipe containers open. When the lid isn't tightly closed, wipes dry out. That leads to less effective disinfection.

Missing nooks and crannies. Ventilation goes a long way, but you still have to clean thoroughly. You don't want dust in the corners or on the lights.

Not keeping up with training. The science is always evolving and newer products involve different instructions. Most of us have transitioned to microfiber mops and cloths in recent years, and those require different processes than we used with cotton. Hold in-services on the proper ways to use cleaning tools and products.

Not monitoring. We use fluorescent markers and black lights periodically to help staff see whether they're cleaning surfaces adequately. Adenosine triphosphate (ATP) testing is another effective tool.

Using vinegar instead of honey. If people aren't doing an adequate job, encouragement usually works better than scolding. Make sure environmental staff feel valued, and make sure they understand how important their jobs are.

Not having champions. You can't be everywhere, so you have to have friends everywhere — people who have a vested interest in seeing that things are done properly, who do the right things for the right reasons and who hold others accountable. Our champions meet once a month to talk about issues and to share new information.

SCRAPING THE SURFACE
The Thin Science of Surface Disinfection

What we don't know about surface disinfection as it relates to healthcare-associated infections may exceed what we do know. After reviewing 80 studies published between 1998 and 2014 (osmag.net/j8cNTR), that's the somewhat disconcerting conclusion my colleagues and I reached.

Most studies have focused on before-and-after research. For example, how much bacteria remains on a surface before and after cleaning with bleach or ammonium compounds? But measuring surface bacteria isn't a patient-centered outcome. The reality is that when it comes to HAIs, we know much more about the significance of hand hygiene and the wise use of antibiotics than we do about surface disinfection.

We can say with some certainty that visual observation is a comparatively poor way to assess surface cleaning. Studies consistently show that the absence of visible contamination, even to trained personnel, doesn't mean a surface is free of bacteria or pathogens. Fluorescent markers or ATP bioluminescence methods are much more reliable.

We can also say that some newer cleaning modalities look very promising as adjuncts — automated devices that use UV light or hydrogen peroxide vapor, for example. But there, too, stakeholders need more evidence, because the devices are very expensive.

The importance of environmental services is also clear. EVS people need to understand where they fit into the healthcare hierarchy. They're not just "housekeepers" or "cleaners" — they need to know that they play a vital role in keeping patients safe from infection.

— Jennifer Han, MD, MSCE

Dr. Han ([email protected]) is an assistant professor of medicine and epidemiology in infectious diseases and an associate healthcare epidemiologist of the Hospital at the University of Pennsylvania in Philadelphia.