Healthcare-associated infections (HAIs) are a major, yet often preventable, threat to patient safety, according to the Centers for Disease Control and Prevention (CDC).1 And the toll that these and other infections impose on the healthcare system is significant.2
HAIs affect five to 10 percent of hospitalized patients in the U.S. each year, resulting in 99,000 deaths and an estimated $20 billion in healthcare costs.3 While significant progress has been made in preventing some types of infection, there is still work to be done.4
Research has shown that when healthcare facilities take steps to prevent HAIs, rates of some targeted HAIs can decrease by more than 70 percent.5 The key to preventing them is understanding how they occur, how they are transmitted and how to break the cycle of transmission.
It’s all about touch
Adults touch their mouths about 10 times an hour and about 170 times a day.6 What about surfaces? Research has shown that people touch an average of 246 surfaces in an hour and 4,100 surfaces a day.7 If you think about a community of 20 elderly patients interacting with a dozen or more care providers over the course of a day, you can imagine how that web can build. For harmful bacteria to spread, all it takes is for someone to touch a contaminated surface and then touch his or her cell phone, check an IV bag, write in a chart, touch the control screen on a computer and type in data.
The pathogens most frequently implicated in environmental transmission are11 :
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Vancomycin-resistant Enterococcus spp. (VRE)
- Clostridium difficile (almost exclusively via spores)
- Acinetobacter sp.
- Pseudomonas aeruginosa
- SARS coronavirus
• Fungi (in immune-compromised wards)
- Aspergillus fumigatus
- Aspergillus flavus
- Candida auris 12
These can survive on dry surfaces for varying lengths of time, ranging from several hours to many months.
A 2015 study in the American Journal of Infection Control found that Staphylococcus aureus could be transferred between devices frequently utilized by healthcare workers, such as cellular phones and pens, and spread to other surfaces as a result.8
The study found that the highest potential for transfer is for metal followed by plastic.9
It concluded that healthcare workers should be educated about refraining from touching surfaces or cellular telephones after or during patient contact, adding that “these observations point to the need to define behaviors that reduce the likelihood of hand- and surface-mediated transmission in both clinical and long-term care facilities.”10
A 2005 study by Dr. Gary Noskin, an infectious disease expert at Northwestern Memorial Hospital in Chicago, suggested that people using multi-user computers should wash their hands after each use. The study also recommended periodic disinfection of computer keyboards and keyboard covers. Noskin and his colleagues studied three bacteria often found in hospitals: vancomycin-resistant Enterococcus faecium (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PSAE). “We found that VRE and MRSA were capable of prolonged survival, with growth of the bacteria evident 24 hours after contamination,” Noskin said, according to a report in Science Daily.13 Noskin and his team also found that “the more contact with contaminated keyboards, the more likely the bacteria transmitted to the hands, from 42 percent to 92 percent of the time for MRSA, 22 percent to 50 percent for VRE, and 9 percent to 18 percent for PSAE,” according to an article in HealthDay.14 Transmission of infectious pathogens and viruses is not limited to patients. One study found that in addition to 62 percent of patients developing a gastrointestinal infection, 46 percent of staff members also became sick. Environmental contamination was found to be the cause of this outbreak.15
Breaking the cycle - what you can do
What are the most effective ways to stop the spread of bacteria and viruses? It all comes down to surface disinfection and hand hygiene. This paper outlines ways to maximize both to greatly reduce the spread of infections and break the cycle of germ transmission in your healthcare facility.
To ensure proper surface disinfection, it’s essential to understand the distinctions between different methods and their effectiveness. Antimicrobial agents are disinfectants that kill or slow the spread of microorganisms including bacteria, viruses, protozoans and fungi. Antimicrobial pesticides are used on surfaces or nonliving things and include wipes for kitchens, bathrooms and hospitals. These are regulated by the EPA. Drugs and antiseptics, such as hand-sanitizing wipes, are used on living things. These are regulated by the U.S. Food and Drug Administration (FDA).19
The Environmental Protection Agency (EPA) defines a hospital disinfectant as one that can eliminate: Staphylococcus aureus, Salmonella enterica, Pseudomonas aeruginosa and viruses within a maximum contact time of 10 minutes and no more than a 1 in 60 failure rate.20
Use of disinfectants
When working with your teams, it’s important to remind them about the CDC guidelines for the use of disinfectants for environmental surfaces:21
- Select EPA-registered hospital disinfectants
- Use in accordance with label instructions
- Clean and disinfect high-touch areas
- Avoid methods that produce mist or disperse dust
- Clean mop heads and cloths after use and allow to dry before reuse
Factors that impact performance:
• Time of exposure (contact time)
• Organic matter
The success of environmental surface disinfection is affected by cleaning procedures, use of appropriate tools, the volume and concentration of disinfectant applied to surfaces, disinfectant interaction with wipes, towels and mops and, most of all, remembering to do it.22
One major concern in healthcare facilities is Clostridium difficile bacteria. Reducing environmental sources of C. difficile spores (which are resistant to alcohol and many disinfectants) are likely to reduce C. difficile colonization in hospitalized patients, which might in turn reduce rates of Clostridium difficile-associated diarrhea (CDAD), according to a 2010 article on the efficacy of cleaning products for C. difficile.23
The article concluded that “use of chlorine-releasing, hypochloritebased cleaners or hydrogen peroxide in rooms exposed to C. difficile spores can reduce the number of spores within the environment with some evidence to suggest it also can reduce the risk of recurrence and spread of CDAD,” adding that “evidence is strongest for products with higher concentrations of disinfecting agents.” 24
How to disinfect surfaces When disinfecting a surface in a healthcare environment, the first step is to read the label. This will ensure that you select the right tool for the job. It also will help you identify the active ingredients, dilution instructions, recommended methods of application and contact time. The next step is to apply the disinfectant, making sure it covers the entire area and that it stays on for the required length of time. It is better to allow the surface to air dry vs. wiping it dry.25 When it comes to wiping, there are several options to choose from:
• Paper Towels - Wood Pulp
• Non-Woven Wipes
- Polymer-based Towels
- Mixed Fiber Wipes - Wood Pulp & Polymer
• Woven Towels – Cotton
Choosing the right disinfectant for the job Quaternary ammonium chloride surfactants (QACs), or quats, have been the primary means of disinfecting environmental surfaces in healthcare facilities for several decades.
QACs offer a number of benefits:• Broad-spectrum germicidal efficacy against vegetative bacteria, fungi and numerous viruses
• Relatively low toxicity at use levels
• Good compatibility with most environmental surfaces
• Long shelf life
• Low odor
• Economical: good value vs. other disinfectants26
However, when using QACs, it’s essential to make sure you use the right wiping material—one that is compatible with these disinfectants. Research has shown that the wiping material you use can
dramatically affect the amount of disinfecting agent that actually reaches the surface being cleaned. The reason is that Quaternary Ammonium Compounds (QACs) are attracted to and absorbed into fabrics, such as towels. A 2013 study in the American Journal of Infection Control found that cotton towels may reduce the effectiveness or even inactivate the ability of QACs to disinfect surfaces.27 The study found that laundered cotton towels soak up and hold disinfectant so that it doesn’t reach the surface at the recommended concentration level. As a result, cotton towels were found to reduce the disinfection strength of QAC-based disinfectants by up to 85 percent.28 You can see the degree to which cotton has been found to decrease QAC effectiveness in the chart below.29
A 2014 study found that reusable cotton towels may be a reservoir for live bacteria,30 via the soak buckets containing the QAC disinfectants, including Pseudomonas luteola, Pantoea sp., Klebsiella oxytoca, Klebsiella pneumoniae, Serratia plymuthica, Pasteurella pneumotropica, Aeromonas hydrophilica, Micrococcus luteus, Bacillus sp., Aspergillus niger, Fusarium sp., and Cladosporium sp.31
In addition, hospital laundering practices were found to be insufficient for removing microbial contaminants and may even add contaminants to the towels. These findings demonstrate that the type of wiping material used to disinfect surfaces can potentially interfere with the action of common hospital-grade disinfectants and increase the risk for transmission of pathogens in the hospital.32
Therefore, to optimize infection control practices it’s essential to choose the right type of wipe– one that is compatible with quaternary amine disinfectants—along with the right cleaning delivery system. The combination of a nonwoven wipe with a closed-bucket system was found to outperform an open-bucket system with three different types of wipes: reusable cotton, microfiber and disposable cellulosebased wipers. Another benefit to a closed-bucket system is that it helps to avoid contamination of wipers and the cleaning solution because it eliminates any opportunity to re-dip wipers into an open bucket.33
“Most healthcare-associated infections are preventable through good hand hygiene –cleaning hands at the right times and in the right way.”
World Health Organization (WHO)
Clean Care is Safer Care Program 34
The importance of hand hygiene in preventing the spread of germs is a well-established principle. Following proper hand hygiene protocols for washing and drying is key. The issue almost always comes down to compliance. How compliant are your staff members? One study found that perceptions and expectations of hand hygiene compliance and actual compliance varied greatly, with actual compliance between 15 and 40 percent and expectations/self-perception ranging from 60 to 95 percent.35
Hand washing protocols
To help prevent the spread of infection, it is recommended that workers use soap and water or alcohol-based hand sanitizers with 60 percent alcohol. Alcohol-based hand sanitizers can quickly reduce the number of microbes on hands in some situations, but sanitizers do not eliminate all types of germs. Specifically, C. difficile spores are not inactivated by alcohol-based hand sanitizers.36 It is also important to use hand sanitizers correctly by applying the product to the palm of one hand (reading the label to determine the correct amount) and rubbing hands together. Make sure to rub the product over all surfaces of your hands and fingers until your hands are dry.
Hand hygiene truly saves lives. The barriers to compliance include belief, process and environmental obstacles, such as inadequate sinks or location of hand sanitizer dispensers. There are, however, ways to overcome them, including:
• Education and knowledge
• Product selection tailored for compliance
• Product availability and placement in the workplace
• Staff empowerment
• Real-time feedback
• Leadership commitment
Knowledge is power
A study published in the American Journal of Infection Control demonstrates how a hand hygiene intervention significantly impacted virus transmission in a long-term care facility. The study found that education combined with the right solutions in the right locations greatly reduced the spread of viruses. As a result of the hygiene intervention, the amount of viruses on surfaces was reduced by 99.9 percent and the presence of viruses on hands was reduced by 99 percent. The probability of the risk of infection from rhinovirus, influenza and norovirus was also significantly reduced due to the use of these interventions.37 What this and the other studies cited in this paper demonstrate is that following proper hygiene and disinfectant practices can make a significant difference in reducing the spread of bacteria and HAIs. And that education translates into improved behavior in everyday life. By adopting best practices for hand hygiene and surface disinfection, you can make tremendous strides in enhancing cleanliness and reducing the spread of germs in your facility.
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1 Centers for Disease Control and Prevention (CDC). March 2016. https://www.cdc.gov/hai/surveillance/
2 Scott, II, RD. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC); March 2009. https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf
3 CDC. https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf
4 CDC. https://www.cdc.gov/hai/surveillance/
6 Beamer PI, Plotkin KR, Gerba CP, Sifuentes LY, Koenig DW, Reynolds KA. “Modeling of human viruses on hands and risk of infection in an office workplace using micro-activity data.” Journal of Occupational and Environmental Hygiene. 2015. 12: 266-75. PMID 25436665 DOI: 10.1080/15459624.2014.974808
8 Koenig, D, Korir-Morrison, C, Hoffman, D. “Transfer Efficiency of Staphylococcus aureus Between Nitrile Exam Gloves and Nonporous Fomites.” American Journal of Infection Control; 2016; 44(2): 245–246
11 Otter, JA, et al. “Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings.” American Journal of Infection Control, 2013, Volume 41, Issue 5, S6-S11; CDC,
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13 Science Daily. 2005. “Northwestern Memorial Study Finds That Computer Keyboards May Harbor Harmful Bacteria.”
14 HealthDay. 2005. “Computer Keyboards Spread More Than Words.”
15 Green, J, Wright, PA, Gallimore, CI, Mitchell, O, Morgan-Capner, P, Brown, DW. “The Role of Environmental Contamination with Small Round Structured Viruses in a Hospital Outbreak Investigated by Reverse-Transcriptase Polymerase Chain Reaction Assay.” The Journal of Hospital Infection. May 1998; 39(1):39-45.
16 Kramer A, Schwebke I, Kampf G. “How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.” BMC Infectious Diseases.
17 Koenig DW. Korir-Morrison C, and Hoffman DR. “Transfer Efficiency of Staphylococcus aureus Between Nitrile Exam Gloves and Nonporous Fomites.”
American Journal of Infection Control; 2016; 44(2): 245–246. http://dx.doi.org/10.1016/j.ajic.2015.09.018.
18 Weber, DJ., Rutala. W, “Understanding and preventing transmission of healthcare-associated pathogens due to the contaminated hospital environment.” Infection Control & Hospital Epidemiology 34.05 (2013): 449-452.; Otter, Jonathan A., et al. “Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings.” American Journal of Infection Control. 2013. 41.5 (2013): S6-S11.; “Understanding the Role of Health Care Facility Design in the Acquisition and Prevention of HAIs.” Content last reviewed September 2013. Agency for Healthcare Research and Quality, Rockville, MD.
19 Block, S. “Disinfection, Sterilization, and Preservation,” Fifth Edition, 2001. Chapter 2.
21 Schulster, L, Chinn, R. “Guidelines for Environmental Infection Control in Health-Care Facilities.” CDC.
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25 CDC, https://www.cdc.gov/hicpac/Disinfection_Sterilization/acknowledg.html
26 Gerba CP. “Quaternary ammonium biocides: efficacy in application.” Applied and Environmental Microbiology 2015. 81:464–469.
27 Engelbrecht, K, Ambrose, D, Sifuentes, L, Gerba, CP, Weart, I, Koenig, D. ”Decreased Activity of Commercially Available Disinfectants Containing Quaternary Ammonium Compounds When Exposed to Cotton Towels.” American Journal of Infection Control. 2013 Oct;41(10):908-11
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33 Engelbrecht, K, Ambrose, D, Sifuentes, L, Gerba, CP, Weart, I, Koenig, D. “Decreased Activity of Commercially Available Disinfectants Containing Quaternary Ammonium Compounds When Exposed to Cotton Towels.” American Journal of Infection Control. 2013 Oct;41(10):908-11.
34 World Health Organization, http://www.who.int/gpsc/country_work/en/
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36 Jabbar, U, Leischner, J, Kasper, D, Gerber, R, Sambol, SP, Parada, JP, Johnson, S, Gerding, DN. “Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.” Infection Control Hospital Epidemiology. June 2010; 31(6):565-70. doi: 10.1086/652772.
37 Sassi, H, Sifuentes, L., Koenig, D, Nichols, E, Clark-Greuel, J, et al. “Control of the Spread of Viruses in a Long-Term Care Facility Using Hygiene Protocols.” American Journal of Infection Control. 2015 Jul 1;43(7):702-6.