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WARNING!!! The following may be a bit graphic.  If you have a weak stomach you may want to
refrain from eating while reading this blog!

The well trained and well equipped Housekeeper is on the
frontlines in the war against healthcare acquired infections.  Honest, hardworking and often overlooked (or
looked down upon), she struggles to make ends meet. She shows up every day ready to work,
regardless of the pressures at home; getting kids ready for school or worrying
about her husband’s job security. As she
clocks in and gets to her assigned floor or patient care area, she wonders how
Mrs. Simmons in 8707 is doing. Her
daughter and husband looked worried yesterday when she was in cleaning Mrs.
Simmons room. That’s the toughest part
of the job she thinks to herself; seeing people hurting and at times,
hopeless. 

This is a more common occurrence than one might think. In fact, this is an actual question that my colleagues and I are presented with on a regular basis. So what may you ask is our brilliant response? Quite frankly, one must realize that no guideline can realistically evaluate and include reference to all suitable disinfectants. There are over 8000 disinfectant products registered in North America. Can you imagine having to evaluate all of those products? Nor is it possible for the committee whom created the guideline to continually amend the document to include any new disinfectants that are brought to market between the date of original publication and any subsequent revision – which is typically several years later. For these reasons, there could very easily be several disinfectants that would be deemed satisfactory for use but have not been referenced in the guidelines and there also may have been changes to contact time or claims on products that had been included in the earlier version of the guideline. For the reason, the product label as approved by Health Canada, US EPA or FDA should always take precedence.

The versatile phenolic compound, in all its derivatives and variations, has become accustomed to a more scrutinized disinfectant portfolio. Suffice it to say that the young guns of disinfection technologies have boasted more impressive characteristics as opposed to the withered profile of phenolics. However, the phenol family of disinfectants, unlike many things its age, have managed to avoid extinction altogether. In this week’s blog we will thoroughly analyze the characteristics of this adaptive disinfectant technology in today’s dynamic environment.

There are numerous variations of phenolic disinfectants. This adaptive quality is an important factor in the use of phenols today, as they can be synthesized to serve specific purposes. Common examples of these derivatives include thymols, xylenol, o-phenyl-phenol (OPP) and triclosan. Phenols used today do not pose an extreme health risk because the more volatile versions have been banned. However, even the most common phenol used, OPP, is considered moderately toxic and an indirect carcinogen. Furthermore, triclosan, a common disinfectant used in hand and oral hygiene applications has been shown to produce bacterial resistance upon repeated exposure. These are alarming factors in considering the usage of phenols.

Many moons ago I attended a management seminar entitled something like, “Five Essential Qualities of the Modern Manager”. The second through fifth qualities might very well have been brilliant, though they have disappeared into the fog of the intervening years. What I have never forgotten was the first essential quality, which was … wait for it … “Be self-aware”!!

I don’t know about you, but when I recite that title in my head that stereotypical organ music synonymous with an ominous statement – “Dum, Dum, Dummmm...” – follows suit.

So what’s the verdict?

BOTH!

I think we can all agree that toys bring a lot of joy to a young child. Certainly I’m preparing myself for the mountain of toys that will soon take up residence in my living room as my 8-week old daughter grows older. Unfortunately, these items can also be a reservoir for potentially pathogenic microorganisms that may be present in saliva, feces and other bodily secretions. This begs the question – how can we address this potential contamination?

When I start a blog I like to get the creative juices flowing by running a series of Google searches to see what pops up for the concept or key points I plan to talk about in my blog. Most are generally irrelevant to the concept of cleaning and disinfection, but you never know what you may learn that can take you down a path that may lead to an “Ah-Ha” moment. As the title alludes to the focus of this blog is our obsession of shiny surfaces and the unfortunate correlation that if it is shiny the surface or medical device must be clean and free of germs.

I’m a girl; I like shiny things…especially when they come wrapped in a Tiffany box. If I’m honest any box bearing the logo of a Jeweler will do! While “girls” are certainly known to love shiny things, a verifiable truth if I use one of my female colleagues as a case study, men are by no means impervious from the predilection towards shiny objects. In fact, as I learned in my Google search the fall of the Roman Empire can be attributed to Augustulus Romulus’ distraction on the battle field by something shiny. It is said his last words before being struck down were "Give me liberty or give me death! Ooh shiny!" (DISCLAIMER I did not verify accuracy…I am simply using the example found to illustrate my point)

Similar to quaternary ammonium solutions, most people are very familiar with the antimicrobial qualities of chlorine based solutions. Chlorine compounds were recognized for their deodorizing and disinfecting properties in 19th century and their wide use began soon thereafter. Today, chlorine’s antimicrobial capabilities are most commonly harnessed for use in water treatment or surface disinfection.

A few years back, I became hooked on Trashopolis. It’s an incredible look at some of the world’s major cities and their relationship with trash. While an interesting part of the story is that some civilizations not only lived amidst but also in some cases, such as Mexico City and Mumbai, advanced with the help of trash, there are far more stories about how trash and a lack of cleanliness equated to certain death.

How many times over the course of your life have you been asked “May I top up your coffee? Would you like more water? Can I get you another refill of pop?” I bet nine times out of ten you respond “YES PLEASE!” Has it ever occurred to you that by mixing new or fresh with old we could be creating an inferior product?

Take coffee as an example. Restaurants are notorious for providing mugs that are too small. I mean who wants a cup of coffee that is gone in five sips – certainly not I! I’m a StarBucks Venti kinda gal…give me enough to last and I’m happy to drink the bottom quarter cold. But at a restaurant when the waitress asks “can I top your coffee off” I almost always say yes and that simple, seemingly innocent agreement creates an inferior product. I have just knowingly agreed to add hot coffee to my now luke warm cup screwed up the optimal drinking temperature and completely thrown off my cream to coffee ratio!

If we are predisposed to ruin a perfectly good cup of coffee, is it any wonder that housekeeping staff can without thought top off their bottle of disinfectant? Housekeeping staff are trained to be prepared. We instruct them to make sure they have all of the products they are going to need on their carts and as a result many housekeeping staff prefer to see their bottles full and not half empty….so they “top up” their bottles during the day and at the end of each shift. The end result is a bottle that does not have the right concentration of disinfectant because new product has been mixed with old. I’ve affectionately dubbed this efficient group the Top-Off Artists.

Would you select a single cleaning product to use on all surfaces in your home? One product to clean your stainless steel fridge, hardwood dining table, glass coffee table and leather sofa? If I were to hazard a guess, I would assume you’ve all responded with a resounding, “NO!!”. Am I right?

It seems obvious, why would we ever consider something so impractical as to expect a single chemical to be compatible with those various surfaces. So why is it that we have this expectation when disinfectants are used in commercial settings such as healthcare? The sad state of affairs is that disinfectants are expected to be 100% compatible with all surface materials and devices that they may be applied to. In reality, that is a chemical impossibility. Particularly so, when you factor in that disinfectants need to be formulated to kill the various classes of microorganisms in rapid and realistic contact times. No disinfectant is ever going to be compatible with every surface material we encounter in the vast world of healthcare.

So what then of compatibility issues that may crop up from the use of disinfectants? Well as the title implies, these are often the unintentional consequences of improving infection prevention. With the increasing prevalence of antibiotic resistant pathogens and more virulent strains of various microorganisms, the focus has shifted from being reactive in nature to that of a proactive, preventative position. With this comes the use of potentially more aggressive disinfectant chemistries to address these troublesome pests on an ongoing basis. As identified by the CDC and Ontario’s Provincial Infectious Disease Advisory Committee (PIDAC), disinfectants should ideally be effective against a broad spectrum of microorganisms, elicit this effect in a rapid and realistic contact time, remain safe to use (non-toxic and non-irritating) and carry wide material compatibility. The disinfectants that perform equally well across all criteria will prevail. However, compatibility issues are likely to still be encountered despite following PIDAC and CDC’s recommendations for the reasons listed earlier. What then?

Speaking from experience, it is often more than a case of “Solution A” being incompatible with “Surface B”. In the vast majority of situations, it is the process with which that disinfectant is used on that surface that determines if any ill effects are encountered. It is this process, or the art of cleaning and disinfecting as one might call it, that may need to be modified to mitigate the issue.

In those rare cases where the disinfectant solution is in fact incompatible with the surface material, alternatives to both(surface or disinfectant) should be investigated. The alternative selected should be based upon which choice reduces the level of compromise needed. Will a different surface or device serve the same purpose without the disinfectant needing to be changed? Or, if the disinfectant needs to change, can the alternative fulfill the same performance and safety profiles? Or, is it a case where the alternatives require too great a compromise and the “incompatibility” becomes a cost of doing business in today’s world?

If you were faced with such a situation, how would you address it?

The Germinator
Lee

I’m a self-taught golfer. I thought I was pretty decent, I can drive well if I ignore the fact that I slice to the right and rarely land on the fairway, I can putt and bunkers don’t faze me in the least, but my short game is crap. As I primarily play with men and being “slightly” competitive, I got to the point I wanted to improve so started taking lessons. I now have a new grip, a new swing and I SUCK!!! Why? I had bad habits. If I want to be truthful, I was doing it all wrong, but because I could hit the ball off the tee and putt into the cup I thought I knew how to golf. The same goes for everyone we hire into our Environmental Services programs. It’s virtually impossible to hire someone who has no experience cleaning. Everyone at some point in their life has likely done dishes, tidied their bedroom or cleaned a bathroom and all done without any formal education on how to properly use the cleaning chemicals our mom’s had handed us.

http://www.youtube.com/watch?v=_0e8SxK-_qw

Happy New Year fellow clean freaks and germaphobes! I too would like to take a moment to mirror Nicole’s sentiments from our last blog, thanking each and every one of you whom have read our blog. It is a truly rewarding experience to know that the stories we share are making an impact and hopefully helping some of you in the process. For 2012 we hope to build on the momentum we’ve created in 2011 and take the Talk Clean to Me blog to be to the next level in the process. In addition to our typical weekly blogs and monthly posts by interesting and exciting guest bloggers, we intend to build a broader base of learning into the blog content for 2012. In particular, one posting a month will be dedicated to a comprehensive review of the key attributes of a specific disinfectant chemistry. I’m sure many of you are yawning at the thought of this, but trust me, we are going to try our hardest to deliver this information in a fun and interesting manner. Just think, you may have the opportunity to heckle us if our performance is subpar. Ultimately, this is all in an effort to equip each of you with a solid foundation of general knowledge pertaining to the different disinfectant actives routinely used throughout North America and around the world so that you can make a more educated decision when faced with this dilemma in the future. Starting in January, we will review the good, the bad and the ugly about quaternary ammonium compounds (Quats, QACs). We hope you will stick with us throughout 2012. Please keep your comments and suggestions coming. We are always open to more ideas. Here’s to a great year of “Talking Clean”!

Did you know that on average adults can or will touch as many as 30 objects within a minute and that over the course of a year we can encounter about 60,000 different types of germs? I’d like to say that those stats surprise me, but with the number of media articles and new clips in recent months talking about the dirtiest or germiest public places it seems entirely plausible. Like me, some of you may have the “pleasure” of travelling for work and today after reading an article by Dr. Oz that talked among other things about dirty places I spent the day while travelling to and from Ottawa contemplating what surfaces I had touched.

While Lee & I have not focused on specific diseases in our past blog posts, while getting my flu shot this week and noticing that the chair in my doctor’s office is covered with fabric that could not easily be cleaned or disinfected and that the exam table had most definitely NOT been cleaned or disinfected between patients I thought perhaps this week would be a good time to start. After all, it is flu season for many countries around the globe!

Since the first blog hit the air in May, Lee and I have strived to provide educational and entertaining ways to talk about chemical disinfectants. From what to consider when choosing a product to how you can ensure a successful cleaning and disinfection program regardless of your facility type. While certainly drawing on our experience, the content has always been factual and credible. Which leads me to this week’s topic – how to spot the wolf in sheep’s clothing. Helpful tips to use to identify if the information you’ve been given or read about in a magazine or journal is factual and credible.

For those of you that have been following our blog from the beginning, or those of you whom have joined us more recently but took the time to go back and read our early posts, you’ll recall my love of fine automobiles. I don’t think any of us would argue that following a strict preventative maintenance schedule for our vehicles – whether it’s a Kia or Porsche – is critically important to the longevity, safety, efficiency and performance of the vehicle. To put it plainly, we all readily recognize the importance of regular oil changes, tire rotations and fluid checks. Unfortunately for me, the maintenance costs for my beloved Porsche 911 Turbo are just another reason I’ll likely never be able to afford to own one.

Why then, when dealing with automated dilution control systems which are responsible for the safe, accurate and efficient dilution and dispensing of disinfectant chemicals, do we not necessarily share the same recognition for the importance of preventative maintenance and quality control? For instance, when was the last time your organization verified that all dilution control systems were working effectively? Considering these units single handedly control the concentration of disinfectant and thereby the effectiveness of that product, they have the potential to play a critical role in an organization’s overall infection prevention and control practices. A study conducted by Hamilton Health Sciences (HHS) in 2009 identified the importance of conducting regular quality control checks on chemical dispensers and having a preventative maintenance plan in place to ensure their continued effective operation. Unfortunately for HHS, it was an increase in infection rates that prompted this plan of action to be implemented and for them to share their story with us. By no means had HHS been negligent, this was simply the standard of practice in most healthcare facilities at the time. Regardless, their findings were eye opening for many and had numerous healthcare facilities evaluating their practices.

So what does an effective quality control and preventative maintenance plan look like? It can take many forms, but the foundation of one includes the regular confirmatory testing of the diluted product and a schedule to examine and replace any components in the dispenser that may wear over time. By testing the active ingredient concentration of diluted solution on a regular basis (quarterly or monthly dependent on degree of risk) this will ensure any issues are potentially identified prior to posing a major risk. An annual or bi-annual overview of the dispenser itself will also assist in identifying any components that may fail and cause future issues.

The list of Do’s & Don’ts should also include don’t ignore the label instructions by over or under mixing the cleaners and disinfectants that we intend to use.

As Lee and I have attempted to describe in our blogs, the use of disinfectants takes more than just the consideration of what a product kills.A key consideration is appropriate dilution and with that consideration of a product’s shelf life once diluted.Disinfectant manufacturers provide dilution instructions for a very specific reason, and it is not just to please Health Canada or the US EPA.The dilution instructions provide the ratios and therefore the In Use Solution concentration that a product should be used at.This is the concentration that the product’s efficacy has been tested and approved by the appropriate regulatory body and this is also the concentration that the required toxicity data and subsequent MSDS information is based on.It is also the concentration that the shelf life, once diluted has been determined.

Over diluting of a product means you are using less chemical than necessary to achieve the label kill claim and this leaves you open to the chance that the pathogens you are concerned with are not going to be killed.Inversely under diluting means you are mixing the disinfectant too strongly, and contrary to what many of us believe more is not necessarily better.Additionally, as I hope everyone who uses a concentrate that requires dilution before use knows, once the product has been diluted into a closed container there is a shelf life that has been determined by specific test methodology that needs to be adhered to in order to ensure product efficacy.

This leads to the importance of using test strips to ensure that the disinfectant you are using has been mixed correctly.It is important to understand first and foremost that as chemicals are different in nature so too are the test strips you will use.A QUAT strip cannot be used to test a H2O2 or Chlorine-based disinfectant, so before starting to test, make sure you have the test strip that is designed to test the product on hand.Secondly, know the dilution you are using and what the expected parts per million or ppm of the active chemistry you are testing.Thirdly, know the shelf life.Test strips are NOT designed or intended to extend the shelf life of a product beyond that recommended by the manufacturer regardless of what the test strip reading is.Fourth, is your intention to use the test strips to verify the product has been diluted correctly, use them to verify that the solution is the bottle is still appropriate to use or a combination of both and then determine the frequency with which you intend to test.

For registration purposes, a manufacturer has to provide data to support the shelf life claims so the “hard work” so to speak has been completed for you and many facilities simply choose to spot check dilution systems to ensure for dilution accuracy (more about that next week from Lee).However, there are times, as specified by Best Practice Guidelines or Public Health Inspectors where products are to be tested daily (such as in an outbreak situation) or hourly (such as in a three-sink sanitation system in a restaurant).There is no hard and fast rule that must be followed, simply put, you want a method to validate for quality control purposes, you want a program that suits the needs of your facility and if required you want a program that meets the needs of your local public health inspector to avoid citations.

That leads me to the last point, if you are using a Ready-To-Use Liquid, the expiry date that needs to be followed is that listed on the bottle.There is no need to test the concentration.If you are using a wipe, again follow the expiry date listed on the bottle.You cannot test the product concentration of a wipe – and yes, I have been asked how to use a test strip to determine if a wipe is still at the appropriate concentration…..

Consider the following scenario: a young woman is raced to the hospital in serious heart failure.Over the following two days it is clear she will need surgery to repair a badly infected heart valve.A surgical team works late into the evening and although it was touch and go for a while, they are satisfied that her new valve is working well.She is transferred to the intensive care unit on antibiotics and rapidly improves to the point that she can be moved to the surgery floor 4 days later.Unbeknownst to her, she was moved into a 4-bedded room that 2 weeks ago had been used to cohort patients with C. difficile. The room had been cleaned many times since then; however housekeeping resources had been cut back on that unit several weeks ago and the staff were also facing considerable pressure from the ED to turn around rooms quickly.

Cleaning is often overlooked as a simple process that does not require much thought or support with respect to education, formal or informal. In many ways as the number of university or college graduates increases so does our belief that cleaning is a mundane task that takes virtually no education or expertise. This belief is fostered from a young age as we witness our parents, primarily our mothers, cleaning dishes, cleaning the house, the laundry and even us! Certainly as we mature, we are taught how to clean up after ourselves and for many your allowance may have been based on the unpleasant task of cleaning your bedroom before you were allowed to watch Saturday morning cartoons. How did we clean? We were given one cloth and whatever cleaning solution was to be used and told to go at it! Sorry mom, you were wrong…….so, so wrong…..

Cleaning and the knowledge surrounding cleaning techniques that need to be used in healthcare facilities is far more complex than we give credit. Like the cleaning of surgical instruments, cleaning of environmental surfaces requires meticulous attention to detail with a well defined and ordered set of procedures. One of the most important concepts that housekeeping and nursing staff need is the knowledge that bugs can be transmitted from surface to surface. Studies have in fact shown that bugs can be transferred from surface to surface with cleaning cloths.

A very integral part of training for Housekeeping and Nursing Staff in healthcare facilities is the importance of moving from clean to dirty with the understanding that surfaces furthest away from the patient should be the cleanest while the surfaces closest to the patient are the dirtiest – just think of all the blood, mucous, pus, vomit, diarrhea that a patient can excrete! This is where the monogamous surface-wipe relationship comes to play. While the areas furthest away are the cleanest…it in no way means they are free from bugs. The area to be cleaned should be viewed as a series of zones. As an example, if cleaning a private room, consider the entry way as zone 1 – door handle, light switch etc should be cleaned with one cloth then move to zone 2 which could be the window area, visitor seating, patient closet etc and clean with a new cloth. Before going to zone 3 the hand hygiene sink &/or nurses storage area, grab a new cloth. Cleaning needs to take place in almost a circular fashion around the perimeter of the room before you move into the “Dirty Zone” – the patient space which includes the bed, over bed table etc. If there is a bathroom or commode leave it until the end and NEVER clean the toilet first! The toilet or commode is the Holy Grail when it comes to the Dirty Zone!!!

Cleaning is a tedious and laborious task and one that has far too many opportunities for cheating and taking short cuts. A nurse or doctor may be breathing down the neck of the housekeeper to speed things up and ready the room for the next patient so the concept of moving from clean to dirty can be thrown out the window and with it, the importance of changing cloths between zones. We shudder at the images that CNN and other networks have shown with undercover videos of housekeeping staff at hotels wiping glasses down with the same cloth they have used to clean the toilet. In an environment where we know that bugs exists and the economic burden of HAIs do we really want to foster a culture where taking short cuts is acceptable when we have the science to prove we can cause harm by doing so? I think not.

I think we all remember the scene from Karate Kid where Mr. Miyagi teaches Daniel-san the basics of karate/kung-fu by using the principles of waxing a car or painting a fence. Wax On...Wax Off! However, when was the last time your cleaning staff were educated on the appropriate method for cleaning and disinfecting surfaces? I bet if you surveyed your hospital or long term care home’s cleaning staff, each individual would have their own preferred method. Spray On...Air Dry! Spray On...Wipe Off! Wipe On...Wipe Off! Most likely, some prefer to spray the disinfectant or cleaner on the surface while others prefer to wipe it on the surface. So what are the potential advantages or deficiencies in spraying vs. wiping a disinfectant on a surface?

Once upon a time, long, long ago there was door. This door was extremely strong, could rebuild itself and seriously maimed or killed anyone who came in contact with it. In the 1800’s, some bright soul invented a sledgehammer. The people were finally able to break the door down and while the door could rebuild itself, it maimed and killed fewer people. Then in the 1940’s a genius developed a key that could unlock the door and everyone thought the story was over. But this was in fact just the beginning of the Lock and Key war. In 1947 the door changed its lock, the key no longer fit, the door became stronger than ever and the people again began to see the importance of using the sledgehammer. The End.

In June of 1998 my opinion on the common practice of spraying chemicals (cleaners and disinfectants) was forever changed. I hope my story will change yours.

“OMG this disinfectant kills HIV!!!!” is a statement that I have encountered on more than one occasion. Needless to say, each time I’m presented with it I give a little chuckle. You see, for those of us with a rudimentary understanding of microbiology and more specifically how microorganisms interact with disinfectants, this is akin to stating that you’re surprised or relieved that a 12 gauge shotgun will be effective at killing a pesky mosquito. As Nicole highlighted in her blog posting “Strength is NOT always found in numbers”, there is a hierarchy in the microbial world with respect to the susceptibility of microbes to disinfection. HIV is but one of the numerous enveloped viruses that rank at the very bottom of this ladder. In other words, enveloped viruses – including HIV, Hepatitis B, Hepatitis C and Influenza A – are exceptionally easy to kill with disinfectants. In fact, not a single hospital grade disinfectant should have an issue in rapidly and effectively eradicating HIV and other enveloped viruses from the surface. Clearly HIV, HBV, HCV and Influenza remain very clinically relevant pathogens, however because they are so easily inactivated via disinfection, there is no need to focus so greatly on these as critically important disinfection claims. Instead, greater attention should be given to a disinfectant’s effectiveness at killing much more difficult, but equally relevant pathogens such as Norovirus or Rotavirus. As always Nicole and I hope that these little tidbits of information will assist you in making more informed decisions when selecting or evaluating disinfectants.

Hasta la vista!
Lee – The Germinator

For some, choosing a disinfectant can be a daunting task, especially for those in non-healthcare related fields where guidelines are scant and opportunities to attend educational conferences that devote a portion of the day to the use of disinfectants are virtually non-existent. Herein lays the importance of Infection Prevention and Control Professionals, Public Health Inspectors, Chemical Disinfectant Sales Reps and Chemical Disinfectant Manufactures to ensure not only a consistent message with respect to the terminology used for classifying chemical disinfectants but to ensure they are using the RIGHT terminology.