Recently released guidelines from Ontario’s Provincial Infectious Diseases Advisory Committee (PIDAC) address the cleaning and disinfecting challenges that housekeeping staff continue to face in healthcare facilities. In a third edition of Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, the multidisciplinary scientific advisory body advising Public Health Ontario on the prevention and control of healthcare-associated infections (HAIs) zeroes in on the selection of environmental surfaces in healthcare settings.

PIDAC released its first best practices document in 2009 to ensure the critical elements and methods of decontamination, disinfection and sterilization are incorporated into healthcare facility procedures. Specifically, it addressed the healthcare environment and equipment cleaning.

Citing numerous studies, the committee acknowledged the physical setting can harbour bacteria and viruses that may be transferred to patients and equipment via the hands of healthcare professionals, potentially causing infection in susceptible individuals. As a result, PIDAC affirmed that maintaining a clean and safe environment is essential to infection prevention and control, and integral to patient safety. This was an important step forward in the selection process of environmental surfaces for healthcare settings, but was not enough to make a dramatic difference in the type of surfaces entering such facilities.

Preventative purchasing practices

In 2012, the second edition of the best practices document was released, which addressed the selection of finishes and surfaces. In a bold statement, PIDAC stated: “If you can’t clean it, don’t buy it.”

The committee emphasized this point to ensure healthcare purchasing practices considered the importance of selecting finishes that are cleanable and stand up to hospital-grade disinfectants. This applies to medical equipment and all finishes and surfaces, including materials for floors, ceilings, walls and furnishings.

Cleaning is the physical removal of foreign material, while disinfection is the inactivation of disease-producing microorganisms. Surfaces must be cleaned thoroughly before effective disinfection can take place. If a surface can’t be cleaned, then it likely can’t be effectively disinfected.

The 2012 edition recommended clear purchasing policy statements and input from environmental services and occupational health and infection prevention professionals in the selection of finishes and surfaces. Combined, this would help ensure hard-to-clean items do not arrive in healthcare facilities.

The document also encouraged the implementation of a process to report and remove damaged items. Notably, torn fabrics and cracked, chipped or scratched items allow microorganisms to enter and accumulate, and are more difficult to clean and disinfect.

Adding “musts” into the standards

In April 2018, the third edition of the best practices document was released. Building on previous publications, it reflects increasing evidence that the environment plays a role in the transmission of microorganisms in a healthcare setting and uses the word “must” to set a minimum standard based on current recommendations in medical literature.

PIDAC reiterates that all surfaces, items and equipment installed or used within a healthcare environment should be cleanable and this must be a central consideration when facilities are designed, redesigned or renovated, and when new equipment is obtained. Surfaces and equipment that are difficult or impossible to clean and disinfect should not be purchased, installed or used.

The goal is to positively transform the supply industry. Once manufacturers realize they can’t sell certain products, they will move to develop those that meet PIDAC guidelines.

There is an additional statement of accountability regarding surface selection. The administration of the healthcare setting is responsible for ensuring and verifying that any item used in the provision of care is capable of being cleaned and disinfected according to current standards and guidelines.

This includes purchased, borrowed or donated equipment, and equipment used for research purposes if such equipment will be used within the care environment. Equipment that is used to clean and disinfect must also meet these standards.

Shared purchasing agreements present a potential roadblock because they often don’t include appropriate stakeholder input on surface selection. PIDAC stresses that infection prevention and control, occupational health and safety and environmental services personnel must be involved in the selection of environmental surfaces, equipment, furniture and finishes in healthcare settings.

The new document decrees that equipment, furnishings, finishes or surfaces must be repaired, replaced or removed from use within clinical areas if they are damaged and cannot be effectively cleaned. In addition, healthcare settings must have a process in place to meet this provision.

Upholstery and carpeting

Upholstered furnishings and other cloth items that cannot be cleaned should not be used in care areas, including nursing stations that support clinical activity. Upholstered furniture that is used in care areas should be covered with fabrics that are fluid-resistant, nonporous and can withstand cleaning with hospital disinfectants. Many healthcare facilities need to address this guideline as cloth-type seating is still often used in nursing stations.

Carpeting has been associated with an increased risk of HAIs in immunocompromised populations. Carpeted floors are more likely to become contaminated with C. difficile than non-carpeted counterparts.

PIDAC recommends against carpeting in areas that house immunocompromised patients at risk of invasive fungal infections, such as in transplantation and high-risk oncology units. Nor should carpeting be installed in clinical areas. If present, it should be removed, particularly within immunocompromised patient populations.

Keith Sopha is an environmental consultant and founder of CleanLearning.