The fight against healthcare associated infections (HAIs) covers many areas but foremost among these are hand hygiene and surface disinfection. Studies suggest around 80 per cent of all infectious diseases are spread by touch[i]. This can be through personal contact or touching a contaminated surface. It follows that breaking this chain should help reduce the number of infections.
Healthcare cleaning teams now have access to a wider range of products to help them eliminate the pathogens that cause HAIs. These include innovative disinfectant formulations that are more effective, quicker and safer than traditional disinfectants complemented by advanced adjunct technologies such as UV-C light that can give the added level of protection against pathogens of concern.
The link between hand hygiene and the spread of infections was established long ago. Yet there is still much to be done to change the behaviour of individual healthcare workers to optimise compliance with hand hygiene at the recommended points to improve patient safety. The best healthcare sites globally have reduced their infection rates to around five per cent through diligence and a rigorous application of best practice. In the UK the average infection rate is nearer to ten per cent.
The World Health Organisation promotes hand hygiene through a number of high-profile initiatives. Its annual Clean Your Hands Day, for example, was established in 2005 and has been a global success. This and related WHO programmes are based around the concept of a multimodal hand hygiene improvement strategy. This incorporates five components or building blocks including system change, training, evaluation, awareness and an institutional safety climate that lead to long-term and sustainable improvements. This framework is complemented by the WHO’s focus on the five moments of hand hygiene – the critical times when healthcare professionals should wash their hands: before touching a patient; before a procedure; after body fluid exposure; after touching a patient; after touching patient surroundings.
These recommendations can mean a lot of washing during a normal day. This is not only time-consuming but conventional soaps can strip natural oils which protect the skin, leading to an increased risk of damage through conditions such as dermatitis. Under these circumstances it is sensible to use an alcohol-based hand sanitiser that kills pathogens faster than soap without removing protective oils.
Whatever products are chosen, they must be available and ready to use whenever required. Dispensers should be situated conveniently to encourage regular and proper use. At the same time, they should ideally contain enough product to prolong the interval between refills and therefore minimise the risk of outages and reduce necessary restocking burdens.
Another way to encourage compliance is to monitor usage. While it is rarely desirable to monitor individuals, it is helpful to know how often a particular dispenser has been used and how much product has been consumed. Knowing how many times a dispenser has been used and comparing this with the number of patient contacts by the clinical and nursing team should give a reasonable indication of whether they are complying with agreed standards. If not, additional awareness and training can be provided and the subsequent change in usage patterns assessed.
Surface disinfection is another critical aspect of infection prevention. It is vital to choose the right disinfectants to improve environmental hygiene in healthcare settings. However, not all disinfectants are created equally.
Healthcare cleaning professionals have traditionally chosen disinfectants with chlorine as the active ingredient (usually as bleaches) for cleaning hard surfaces.
While widely used, the drawbacks of these formulations are well noted in terms of effectiveness as well as safety and there seems to be a gradual shift towards safer, quicker and more effective disinfectants. Alternative formulations with Accelerated Hydrogen Peroxide (AHP) as the active ingredient offer numerous advantages with few limitations.[ii]
The key requirement from any disinfectant in healthcare settings is efficacy – to prevent the introduction of potentially harmful pathogens and infections. These can range from hospital associated infections such as MRSA and C. diff to infections common in any setting, such as influenza and Norovirus. Effective surface disinfection is especially important in healthcare because patients are likely to be frail and vulnerable.
It is important to select disinfectants capable of killing pathogens of concern. Problem pathogens, such as norovirus and C. diff., might not be killed by conventional disinfectants. Contact times must be realistically short so that any pathogens are killed before the surface dries. Disinfectants with long contact times may require reapplication to ensure pathogens are killed. This can be impractical, time-consuming and inefficient.
Disinfectants containing AHP are highly effective against a wide range of viruses, spores, yeasts, and fungi found in healthcare, including C. diff, MRSA, Norovirus, E. coli, and Pseudomonas aeruginosa. This broad-spectrum efficacy has been tested to the latest EN standards and submitted into the Biocidal Products Regulations (BPR) – a standard which all actives and disinfectants need to pass. AHP simplifies processes because just one product is needed – using numerous alternative products to provide the same level of performance adds unwanted complexity.
Disinfectants with AHP can be supplied in ready-to-use and ultra-concentrate formats. Depending on the specific formulation, these are effective against viruses, spores (including C. diff), yeasts and fungi in one minute or less, meeting demand for highly effective products with shorter contact or dwell times.
Traditional products containing chlorine are generally not as effective on spores and require significantly longer contact times. Products containing AHP have been tested and shown to kill viruses such as Norovirus in up to 30 seconds and the most persistent spores such as C. diff in one minute. Chlorine-based products can take up to 30 minutes. Aside from any productivity issues, they are only effective while wet which means efficacy will be lost if they dry within the specified contact time. Under normal conditions the much shorter contact times of AHP products are usually passed before they have dried.
Products containing AHP offer additional benefits that simplify day-to-day cleaning operations. With more cleaning taking place while patients are present, processes must be completed safely and efficiently, so as not to create an unpleasant environment or put patients at risk.
AHP degrades to oxygen and water alone shortly after use which helps make formulations containing it safer to use. Chlorine-based products are suspected of aggravating asthma and other respiratory problems, and forming chlorine compounds in the atmosphere. Another consideration is that some products containing AHP have no safety classification whereas chlorine-based products usually carry a hazard symbol.
Breaking down to water and oxygen alone means products with AHP leave little or no residue on surfaces, helping to promote the appearance of the area being cleaned. They can be used safely on a wider range of surfaces, including wool and other fabrics, with reduced risk of damage. Chlorine based products on the other hand will corrode or degrade many surfaces with regular or prolonged use. Nor can they be used as part of a microfibre system because they damage the material, severely restricting their disinfection potency.
The easier a product is to use, the greater the chance of cleaning compliance. Products should be accompanied by training aids to support members of diverse cleaning teams. Despite proper training, there are still cleaning and disinfection challenges that may arise. It is therefore important to measure performance to determine if additional training is necessary.
The variety of disinfectants has grown in recent years, as manufacturers have developed solutions for specific daily and problem-solving tasks. It is therefore important to match the product to the specific application. This optimises cleaning performance and reduces inefficiencies, poor results, and the need for repeat cleaning. Reputable manufacturers will provide advice on the most suitable products from their ranges to use in every situation. They should also be able to supply the documentation and evidence with independent test data to support product claims.
While disinfectants offer healthcare cleaning professionals effective solutions in many situations there are times when additional measures are necessary or desirable. The latest technology to emerge uses powerful UV-C light to disinfect surfaces quickly and effectively[iii]. This represents a new hands-, chemical- and fume-free way to implement safer disinfection. It is particularly useful for so-called adjunct cleaning which is employed to complement or supplement existing processes and provide additional assurance that frequent-touch and hard-to-clean surfaces have been disinfected. Dr Deverick Anderson published a paper in 2017 that found using UV-C alongside traditional disinfectants reduced HAIs by 33%.[iv]
The infection-killing properties of UV-C have been known for some years and there are at least 40 scientific studies measuring either its biocidal effect on micro-organisms or the impact on HAI rates. UV-C kills pathogens by destroying the nucleic acids in their DNA. This disrupts the normal function of the cells which means they die. Any surface directly exposed to a sufficient amount of UV-C will be disinfected. One of the biggest advantages of UV-C disinfection is that large areas can be decontaminated very quickly without any additional intervention. Because UV-C disinfection is physical rather than chemical it means that there is much less chance of pathogens developing any form of resistance.
Despite these advantages, no cost-effective practical UV-C systems were available until recently for routine use in healthcare settings[v]. Now the devices used in hospitals produce powerful UV-C light at the optimum wavelengths to provide fast broad-spectrum disinfection. These devices tend to fall into two categories: for broad area and high-touch surface disinfection and disinfection of smaller, portable devices.
Systems designed for disinfection of broad areas and high-touch surfaces can be effective in as little as three minutes. This is more than twice as fast as fogging and almost twice as effective as traditional cleaning and disinfection alone in destroying the pathogens that cause healthcare associated infections. They are an excellent option for on-demand disinfection of high-touch surfaces throughout a hospital, including patient rooms, operating rooms and bathrooms. Such systems can also be used on patient care equipment, fixtures, keyboards, monitors, and workstations.
UV-C is at its most powerful when it hits a surface perpendicularly – at right angles – such as directly from overhead or square on to wall. Any deviation from this angle of incidence will diminish the power. In practice this means that at an angle of incidence of 45 degrees, the surface will only receive around 75% of the energy. At angles between 20 and 30 degrees the energy levels are reduced by around 60%.
Like all electromagnetic radiation, the power of UV-C also diminishes rapidly the further away a target surface is from the source because of the inverse square law. This means that the energy reduces fourfold (ie 2×2 or 2 squared) with each doubling of distance. Alternatively, the intensity at 2m from a light source is just 25% of the level at 1m. Using the same calculations shows that the amount of energy reaching a surface just over three metres (10 feet) from the source is one per cent or the original.
Systems delivering UV-C must therefore ensure the maximum amount hits the target surface to give the most powerful disinfection. One way to achieve this is to mount the UV-C sources on arms that can be positioned independently and pointed towards and set as close as possible to the target surfaces. This ensures more of the UV-C produced will hit the surface at right angles and at the minimum distance to give the best disinfection. When the light sources are mounted on a single, central column that is not easily repositioned, less of the UV-C produced falls on target surfaces perpendicularly and from further away. Either way this means the device will be less efficient.
UV-C systems for portable devices are designed to disinfect items such as tablets and smartphones. These are becoming more widely used in healthcare settings but they are often used by different members of the nursing or clinical team throughout the day. This means that they are not only frequent- or high-touch surfaces but they can also present increased opportunities for pathogens to pass from person to person. There is some evidence that people do not wash their hands after using these devices, or indeed clean the device itself.
As with any routine process, the use of these disinfection systems should be simple and quick to encourage their use. Items to be treated are placed in a secure box which contains the UV-C light sources, safely shrouded from the outside world. This means that they are always close to the items being disinfected for maximum effectiveness. Because items being treated are always close to the UV-C source these units provide extremely effective disinfection. Items can usually be disinfected in around 30 seconds.
Independent tests have shown that there can be an up to 5-log reduction in surface pathogens including MRSA, VRE, MDR-Gram negative, Norovirus and C.diff spores. This means that the number of micro-organisms is reduced by 105 times or by a factor of 100,000.
The power of UV-C to damage DNA and cells means that people would be affected too if they were exposed. Devices are supplied with fail-safe features such as remote control that prevent close-up activation and motion sensors that shut the unit down if anyone should approach too closely.
Hospitals and other healthcare facilities have a wider range of infection prevention tools at their disposal than ever before. The choice available means that there is greater flexibility to specify the right combination to meet infection prevention compliance and reduction targets in the quickest, simplest and most effective way that integrates with the facility’s other processes. The choices can be complex but leading cleaning and hygiene suppliers with experience in healthcare will be able to work with clinical, nursing and housekeeping teams to devise and implement robust infection prevention policies.
[i] Centre for Disease Control & Prevention
[ii] Teska, Peter & Rushworth, A & Theelen, M & Jongsma, J. (2013). O018: Evaluation of the efficacy of a novel hydrogen peroxide cleaner disinfectant concentrate. Antimicrobial Resistance and Infection Control. 2. 10.1186/2047-2994-2-S1-O18.