Patients need to be confident that they will encounter a safe, disinfected environment when they arrive for care and throughout their stay. Providing patients with that assurance requires proactive steps to prevent the spread of disease, particularly as facilities transition from COVID-19 crisis mode to normal operations conducted in the presence of the SARS-CoV-2 virus. In other words, cleaning and disinfection (C&D) practices will be central to recovery efforts.
ECRI’s Tips for Effective C&D
Failure to properly disinfect contaminated areas and equipment can have widespread consequences, endangering patients and staff. Following are some of ECRI’s key recommendations for preventing such harm. To learn more, check out the nonprofit organization’s webcast “SARS-CoV-2 Disinfection: Killing the Spread,” available at: https://www.ecri.org/landing-covid-19-killing-the-spread/.
Consider containment and cohorting
During outbreaks, consider setting up COVID-specific units, wings or hallways where COVID patients will be cared for by teams of cohorted health care personnel (HCP), including respiratory therapists, nurses, physicians and environmental services (EVS) staff. Grouping infected patients, potentially exposed individuals and potentially contaminated equipment within a defined area can help limit the spread, and it can help ease the logistics associated with C&D.
Provide appropriate PPE and restrict room entry
Staff entering the room of a suspected or confirmed COVID-19 patient – for patient care, cleaning or any other purpose – should use the same personal protective equipment (PPE) as that required for routine care of such patients. Typically, this will mean donning a facemask, face shield, isolation gown and gloves. If an aerosol-generating procedure (AGP) is to be performed, an N95 or higher level respirator should be worn in place of a facemask, and only essential personnel should be present in the room.
To limit exposure to COVID-19 patients and to conserve PPE, facilities may wish to assign routine C&D of high-touch surfaces to nurses who will already be in the room providing care to the patient. This prevents EVS staff from having to don PPE and enter the room for this purpose.
Requirements are different for terminal C&D, which is a more thorough cleaning that is performed by EVS staff after a patient has been discharged (or the room otherwise has been vacated). If an AGP had been performed in the room, staff must first allow sufficient time to elapse for potentially infectious aerosols to be removed by the air handling system. Then, they may enter the room wearing an isolation gown and gloves as PPE. A facemask and eye protection should also be worn if the selected cleaners and disinfectants require it or if splashes/sprays during C&D are anticipated.
Update your policies and procedures – and checklists
Review and update existing facility policies and procedures, including checklists, to verify compliance with CDC’s current COVID-19 infection prevention and control (IPC) guidance. If C&D is to be performed by staff who are less familiar with these tasks, training in C&D processes and the use of an appropriate checklist are critical to ensure that steps aren’t missed. ECRI has created a checklist that you can use for routine C&D of suspected or confirmed COVID-19 patient rooms. (See the webcast link above.)
“Education and training are needed,” notes Jim Davis, a senior infection prevention & patient safety analyst at ECRI. “But they only go so far. Simulation in-situ and real-time auditing and feedback (within a just culture) is the whole package.”
Perform both cleaning and disinfection, even when using adjunct technologies
The terms cleaning and disinfection are often used interchangeably, but they are two separate processes. Cleaning is the removing of soil. Disinfection is the killing of germs left behind. Both steps are needed: soil that remains on a surface can shield microorganisms from the disinfectant, rendering disinfection ineffective.
“That’s true even if adjunct disinfection technologies are to be used,” adds Amanda Sivek, Principal Project Engineer 1 in ECRI’s device evaluation group. Technologies such as UV light, hydrogen peroxide vapor or chemical fogging can provide an added level of protection. “But only if the surfaces are first manually cleaned and disinfected,” warns Sivek. “Adjunct technologies shouldn’t be viewed as short cuts or time savers. Their use will add to the room turnaround time, not decrease it.”
Select appropriate disinfectants
Successfully disinfecting surfaces that have been contaminated with the SARS-CoV-2 virus requires the use of an antimicrobial product that has been found to be effective against it. EPA has developed a list of products that meet this criterion. List N, as it is called, includes the product name, its active ingredients and the contact time required to kill the virus. (See: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19.) See that the low-level disinfectants you’ll be using appear on EPA’s List N. You’ll also need to verify that the disinfectants are approved for use by the medical device or equipment manufacturer.
Pre-position C&D supplies
Provide all needed C&D materials at or near the point-of-care. These include cleaning products, disinfectant (diluted per product label instructions, if applicable), water, containers and clean or new cloths/sponges/wipes.
Know the “wet time”
To achieve disinfection, disinfectants must remain in contact with surfaces for a specified period of time, referred to as the contact time, kill time or wet time. The amount of time depends on the composition of the disinfectant and will be specified on the product label. It may be as little as 15 seconds or as long as 15 minutes. Users may need to rewipe the surface if it dries too quickly. Checklists should specify that the disinfectant should be reapplied as needed to keep the surface visibly wet for the contact time.
Toward a New Preparedness
The term “new normal” is used a lot these days, but it’s not a favorite of ECRI’s Jim Davis. “It’s like saying we’re willing to accept subpar levels of supplies like PPE and disinfectants; and we’re willing to tolerate situations where workers of all types are not able to protect themselves.” Instead, Davis advocates for a “new preparedness,” where lessons learned from SARS-CoV-2 lead to policies and practices that ensure the availability of the supplies that staff need to maintain clean, sanitary and safe care areas and workplaces.
More resilient inventory management practices will be essential for that new preparedness. To help facilities source key supplies, ECRI has provided the health care community access to many of its proprietary resources throughout the early stages of the pandemic. These include ECRI’s functional equivalence data for PPE and other categories of supplies, as well as guidance documents describing measures to mitigate device or supply shortages and to safely implement COVID-driven changes in practices.
This article is adapted from multiple resources that ECRI developed to help healthcare personnel conduct effective cleaning and disinfection of patient care areas. These and many additional resources are available through ECRI’s COVID-19 Resource Center, a free public resource to help hospitals protect healthcare workers and patients during the COVID-19 pandemic. Access that site at www.ecri.org/coronavirus-covid-19-outbreak-preparedness-center. To learn more about ECRI’s technology decision support solutions, visit https://www.ecri.org/solutions/technology-decision-support, or contact ECRI at (610) 825-6000, ext. 5891, or by e-mail at firstname.lastname@example.org.
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