Bug PATROL

     The value of cleaning, decontamination and disinfection in reducing transmission of disease has long been recognized. People used vinegar for disinfection as far back as the 13th century. In the 1970s, it became routine to clean and disinfect medical equipment to protect patients. In the 1980s, efforts focused on protecting healthcare workers from items and surfaces contaminated with bloodborne pathogens such as HIV, hepatitis B and hepatitis C.

     Now, in this new century, as new drug-resistant organisms emerge, cleaning and disinfection are even more important for patients and providers alike. However, without clear written policies and procedures for the care, cleaning, decontamination and disinfection of vehicles and equipment, both groups may face an increased risk, especially for bacterial infections. (Bloodborne pathogens are caused by viruses, which do not survive well outside the human body. Studies have shown that hepatitis B is the only one that can do so for any amount of time.)

     Study after study on handwashing by healthcare providers shows that compliance with this very basic protective measure is poor. So, what about cleaning routines for vehicles and equipment? How well is your department complying with proper procedures for cleaning and disinfecting these? Is it part of compliance monitoring and your exposure-control plan?

     Although the routine culturing of environmental surfaces is not recommended, it can serve as a valuable tool for identifying problems. In a recent study published in the journal Prehospital Emergency Care, one department conducted environmental culturing of its ambulances. Of 21 ambulances, it found that 10 were colonized with methicillin-resistant Staphylococcus aureus (MRSA). This strongly suggests that adequate cleaning and disinfection were not taking place.

KEY DEFINITIONS
     Cleaning involves the physical removal of dust, soil and foreign material from a surface. It usually entails scrubbing and the use of plain soap and hot water. Cleaning must take place before disinfection can be achieved. This is the most important step in the process.

     Decontamination is the removal of disease-producing organisms. This process renders items safe to handle.

     Disinfection refers to the process of destroying disease-producing organisms using a chemical agent.

     Vehicles should be cleaned after each patient transport. Cleaning is an important activity, but not a time-consuming one. New products make surface cleaning easy, requiring only a wipe-and-go approach. In many areas, medical facilities make cleaning space and solutions available for EMS.

     Cleaning post-transport is a commonsense activity and should focus on the items used for care and areas with which the patient was in direct contact. There is no need to put a vehicle out of service or air it out because of a patient's disease status. Environmental surfaces can be cleaned with any cleaner or disinfectant intended for environmental surfaces. The term environmental surface includes floors, woodwork, ambulance seats, countertops, etc. In some vehicles with special flooring, consult the manufacturer's recommendations for a cleaning/disinfection agent. Not following these guidelines can result in damage to the surface and possibly void its warranty. Routine cleaning of the entire inside of the vehicle should be performed at least weekly.

     Disinfecting patient-care equipment falls into three basic categories: high-level, intermediate-level and low-level disinfection. High-level disinfection is designed to destroy all forms of microbial life except high levels of bacterial spores. It involves the use of a high-level Environmental Protection Agency (EPA)-registered sterilant chemical such as Cidex OPA. This process is to be used for the reprocessing of any medical device that comes into contact with mucous membranes (e.g., laryngoscope blades, endotracheal tubes) or non-intact skin. These agents should not be used on environmental surfaces.

     Intermediate-level disinfection is designed to destroy viruses, vegetative bacteria, Mycobacterium tuberculosis and most fungi. This process does not kill bacterial spores. Bleach and water at a 1:100 dilution (¼ cup bleach per gallon of water) is an intermediate-level agent. This level is recommended for items that come into contact with intact skin (e.g., blood pressure cuffs, stethoscopes, splints). It is important to remember that TB on surfaces does not pose a risk for transmission. The fact that an agent kills the TB bacterium only means it is a higher-level germicidal agent.

     The last category is low-level disinfection. This level agent is designed to kill some viruses and fungi. Solutions in this category are often termed hospital disinfectants and are registered by the EPA.

MULTIDRUG-RESISTANT ORGANISMS (MDROs)
     Entering the age of multidrug-resistant bacteria brings additional challenges to cleaning and disinfection. Bacteria (not viruses) may live for extended periods of time on environmental surfaces and can be picked up and transferred to other persons or surfaces. Clostridium difficile (C. diff), an organism that causes pseudomembranous colitis, a complication of antibiotic therapy, is an example. C. diff is a spore and persists on surfaces for long periods of time. Transmissions of C. diff have been reported from blood pressure cuffs, bed rails, stretchers, electronic thermometers and improper gloving or glove removal. Chlorine-based agents have been found effective against this organism.

     Another multidrug-resistant bacterium is MRSA, which was once thought to be a hospital-acquired organism but is now recognized as primarily community-acquired. The good news is that no special cleaning solution is needed to kill this organism. A bleach/water solution is a good and inexpensive choice. However, once mixed, this solution is only good for 24 hours. Lysol concentrate mixed at 2½ teaspoons per gallon of water is another inexpensive and readily available choice.

     Vancomycin-resistant Enterococcus (VRE) is another recognized MDRO. Enterococcus is a normal organism in the lower GI tract, and Vancomycin is an antibiotic used for treatment of serious bacterial infections. This bacterium can live for 5-7 days on a surface and for hours on hands. Fortunately, no additional special cleaning agent is needed beyond what is currently recommended for routine cleaning.

     These organisms and their ability to live on surfaces and hands brings additional importance to following routine cleaning and disinfection practices and underscores the role of good handwashing with an antimicrobial (not an antibacterial) agent. The Occupational Safety and Health Administration (OSHA) requires that employers ensure their staff wash their hands after glove removal. This can be easily observed through periodic monitoring.

SELECTION AND USE
     When selecting products to meet your agency's cleaning needs, limit yourself to those listed with the EPA. OSHA says labeling must show the product is effective in killing HIV and hepatitis B (it withdrew the requirement that products kill TB bacteria in 1997). There are many products to choose from, and selection should be based on the types of surfaces to be cleaned, decontaminated and disinfected. Look at product claims and read the labels carefully. For example, Clorox Disinfecting Wipes suggest they contain bleach; however, if you look at the label, it clearly states "Contains no bleach." The EPA website (www.epa.gov) lists approved disinfectants. Remember, the most expensive is not necessarily the best, and limit the number of products you purchase. This will reduce costs and let you become familiar with what you use.

     Clearly spelling out cleaning routines for vehicles and equipment is a requirement of the OSHA bloodborne pathogen regulation and a required component of agencies' exposure-control plans. Each plan must include a formal cleaning schedule. A form should be used to document compliance (for an example, see Figure 1). This type of documentation will provide protection against liability should a claim be made that infection occurred due to noncompliance with established cleaning routines and schedules.

     Conduct compliance monitoring to ensure department members are following your plan and established cleaning routines. If noncompliance is noted, reeducation and training should be conducted and documented. Any noncompliance should also be addressed in annual update training for the entire department.

Bibliography
Centers for Disease Control and Prevention. Guideline for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public Safety Workers, 1989.
Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.
Crumpecker C, Dunn, TM. Can methicillin-resistant staphylococcus aureus be found in an ambulance fleet? Preh Emerg Care 11(2): 241-44, Apr-Jun 2007.
Hardick M. Clostridium difficile toxin: Diagnosis, treatment and prevention of disease. Infection Control Today, 2004.
Joint Commission on Accreditation of Healthcare Organizations. Medical equipment and infection control. Environment of Care News 6(10), Oct 2003.
Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities. MMWR 52(RR-10): 1-42, Jun 6, 2003.
U.S. Department of Labor. CPL 2-2.69: Compliance Directive, OSHA Bloodborne Pathogens Regulation, Nov 27, 2001.

Katherine H. West, BSN, MSEd, CIC, has worked in infection control since 1975. She lectures both nationally and internationally on the topic, and publishes books, videotapes and articles on related issues. She has served as a consultant to the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health, and as an education specialist for the National Institutes of Health. In 2006, West was voted a "Hero in Infection Control and Prevention" by the Association for Professionals in Infection Control and Epidemiology.