What goes into hospital cleaning and hygiene maintenance? When compared to cleaning of other environments, hospital cleaning is much more complex, and can have a huge impact on patient safety.
For hospital infection control professionals, cleaning and environmental maintenance is a science. For example, assessing the approach for the hygiene of a toilet seat seems almost redundant. However, for effective infection control, many of the questions around this require study and scientific assessment.
In their investigation of the matter, a group of infection control researchers highlighted the considerations to be made for this task. “One must decide material to use to clean the toilet seat (e.g. microfiber or cotton cloth), which liquid agent to use (e.g. a detergent or a disinfectant and, if a disinfectant, which one), and the ideal frequency of the cleaning and disinfection (e.g. daily, after each use, or both),” they wrote.
In particular, the choice of chemical agents or disinfectants requires careful assessment by the hospitals. Each chemical has its own set of pros and cons and are suited for different purposes.
At Bagan Specialist Centre (BSC) in Malaysia, different chemicals are used for different equipment, based on the category of contamination level. For example, for non-critical instruments (where contact occurs with only intact skin, such as wheelchairs and crutches), intermediate level disinfectants in the form of alcohol-free disinfectant wipes are used. In contrast, semi-critical instruments (where contact occurs with mucous membranes or skin, such as endoscopes and respiratory therapy) are cleaned using high level disinfectants such as peracetic acid are used instead. For critical and surgical instruments that penetrate tissue, bone or contact the bloodstream, autoclave sterilisation is performed.
“When selecting the type of chemicals used, we have a set of criteria,” said Mr Cheow Jen Hurn, Chief Executive Officer of BSC. “They must have proven efficacy and sensitivity to the targeted bacteria, mycobacteria, yeasts, viruses and spores; and must comply to established testing standards such as EN Standard or MS Standard.”
“They should be compatible to the surfaces and equipment in the area they are used in, and must be safe for our staff, patients and visitors.”
Choosing the right chemicals
The hospital currently uses three main types of disinfectants, all of which are EPA (Environmental Protection Agency) registered, proving they have gone through rigorous assessment of safety and efficacy.
One type used is Quaternary Ammonium, a low-level disinfectant effective against a wide range of bacteria, viruses and fungi. Hypochlorite (of which sodium hypochlorite is available as liquid bleach) is also used as a widely available, stable and effective disinfectant. Lastly, paracetic acid is a rapid-acting chemical that can kill a wide range of microbes and pathogens.
However, Mr Cheow highlighted that each chemical has its own drawbacks. For example, Quaternary Ammonium may cause health issues in high concentration, while hypochlorite can cause skin and eye irritation, and is corrosive to some metals. Similarly, peracetic acid has been found to be unstable after dilution, and is also corrosive on copper and brass.
As such, besides selection of the most suitable chemicals, learning the correct procedures and usage methods is also crucial. “Our personnel are trained to clean according to the procedures in place, to ensure the techniques are standardised for all staff,” said Mr Cheow. “We make sure to follow the manufacturer’s instructions, such as the dilution recommendation, storage condition and shelf-life.”
If manufacturer instructions are not available, the hospital has a general method for effective cleaning with chemicals:
- Submerge the item to be cleaned in chemical solution (which has been mixed and applied) and use mechanical action (e.g., scrubbing) to remove soil.
- Immerse the item in disinfectant with the correct contact time and rinse with clean water to remove residue
- Allow items to fully dry in a clean area to prevent recontamination. Position mops with the head up to allow the mop head to fully dry
Ensuring safe use of chemicals
While standard cleaning policies and procedures are in place, regular inspections are still held at BSC to ensure cleanliness is up to standards. Mr Cheow shared that they run environmental sampling periodically, to confirm that targeted pathogens are indeed removed.
In this regard, staff training and orientation is key, not just to effective cleaning, and also staff work safety.
“To ensure staff compliance in donning of appropriate PPE, we plan training sessions for all cleaning staff before they commence work,” said Mr Cheow. “Proper use of PPE is crucial to prevent exposure to infectious agents and chemicals, especially into the respiratory system and skin. This includes gloves, aprons, masks and face shield or eye protection shield. The type of PPE to be used depends on the chemical agent used.”
As per regulations, a third-party registered assessor conducts a Chemical Health Risk Assessment of the hospital, to confirm the right type of PPE to be used in each circumstance.
Other safety measures include continuous education programmes on safe handling of chemicals, from the Safety and Health Unit and Infection Control.
Evidently, ensuring cleanliness and hygiene isn’t as straightforward as it seems. There are several variables, from cleaning chemical/agent, processes to personnel, that need to be considered. As the infection control researchers put it, “the best cleaning substance in the world is useless if not applied correctly, and the best-trained personnel are useless if the product they are using is not effective against the particular pathogen that needs to be removed or killed.” Hospitals need to prioritise having a clear assessment of the pathogens present in their environment, and the best ways to remove them.
Bleach is one of the most common disinfectants used. Find out more about its safe use in this brochure.