Re: Environmental hygiene and disinfection as part of Standard Precautions model

[John Ferguson]

Dear All,

In NSW there is current debate about the role of environmental disinfection. My view is that we should mandate the routine cleaning AND DISINFECTION of near patient touch sites, bathrooms and toilets. This requirement forms part of the CDC 2007 Isolation guideline Standard Precautions model which is arguably the basis for IPC practice around the world.

The NHMRC IC Guideline hedges its bets with a uninterpretable requirement (below) under use of disinfectants to determine whether there is uncertainty about the nature of soiling on the surface!! This is a nonsense. We know from many sampling studies that the near patient surfaces are frequently contaminated with MROs etc and also that unadequate management of env hygiene leads to increased risk of MRO acquisituion in patients managed later in the same room (see attached recent review for a summary of the evidence).

Over to you all! This is an issue, along with fomite management (clean between is not good enough!) that I think is overdue for local debate! Should we start to talk in detail about “Environmental Hygiene” (rather than Env Cleaning) as a companion standard to Hand Hygiene under Standard Precautions?

Kind regards
john
John Ferguson
Infectious Diseases Physician and Microbiologist,
Hunter New England Health, John Hunter Hospital, Newcastle
Conjoint Associate Professor, University of Newcastle
Tel 61 2 49214444, Fax 61 2 49214440, Mobile 0428 885573

CDC 2007 Excerpt (p60 under Fundamental elements needed to prevent transmission of infectious agents in healthcare settings):

“Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. In general, these procedures do not need to be changed for patients on Transmission-Based Precautions. The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) 11, 72, 73, 835. The frequency or intensity of cleaning may need to change based on the patients level of hygiene and the degree of environmental contamination and for certain for infectious agents whose reservoir is the intestinal tract 54. This may be especially true in LTCFs and pediatric facilities where patients with stool and urine incontinence are encountered more frequently. Also, increased frequency of cleaning may be needed in a Protective Environment to minimize dust accumulation 11. Special recommendations for cleaning and disinfecting environmental surfaces in dialysis centers have been published 18. In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission. During a suspected or proven outbreak where an environmental reservoir is suspected, routine cleaning procedures should be reviewed, and the need for additional trained cleaning staff should be assessed. Adherence should be monitored and reinforced to promote consistent and correct cleaning is performed.”

NHMRC excerpt:
Recommendation
11 Routine cleaning of surfaces

Grade

Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination.
Clean general surfaces and fittings when visibly soiled and immediately after spillage.

GPP

Use of disinfectants
In acute-care settings where there is uncertainty about the nature of soiling on the surface (e.g. blood or body fluid contamination versus routine dust or dirt) or the presence of MROs (including C. difficile) or other infectious agents requiring transmission-based precautions (e.g. pulmonary tuberculosis) is known or suspected, surfaces should be physically cleaned with a detergent solution, followed or combined with a TGA-registered disinfectant with label claims specifying its effectiveness against specific infectious organisms.

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