APSIC Guidelines for environmental cleaning and decontamination

This document is an executive summary of APSIC Guidelines for Environmental Cleaning and Decontamination. It describes best practices in routine cleaning and decontamination in healthcare facilities as well as in specific settings e.g. management of patients with isolation precautions, food preparation areas, construction and renovation, and following a flood. It recommends the implementation of environmental hygiene program to keep the environment safe for patients, staff and visitors visiting a healthcare facility. Objective assessment of cleanliness and quality is an essential component of this program as a method for identifying quality improvement opportunities. Recommendations for safe handling of linen and bedding; as well as occupational health and safety issues are included in the guidelines. A training program is vital to ensure consistent adherence to best practices.


Background
Contamination of hospital equipment, medicines, and water supplies with hospital pathogens is a wellrecognized cause of common-source outbreaks of infection [1][2][3][4][5][6][7][8][9]. The intent of this document is to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in implementing an environmental hygiene program.
This document is a summary of the APSIC Guidelines For Environmental Cleaning And Decontamination developed by the Asia Pacific Society of Infection Control (APSIC).

Review
Workgroup composition APSIC convened Infection Prevention and Control experts from Asia Pacific region to develop the APSIC Guidelines For Environmental Cleaning And Decontamination. The members of this workgroup are the authors of this paper.

Literature review and analysis
For the APSIC guideline, the workgroup reviewed previously published guidelines and recommendations relevant to each section and performed computerized literature searches using PubMed.

Process
The workgroup met on 2 occasions as well as discussed via email correspondences to complete the development of the guideline. Criteria for grading the strength of recommendation and quality of evidence are described in Table 1. The draft was then submitted to APSIC Executive Committee and national Infection Control societies in Asia Pacific. Comments obtained were then reviewed by the workgroup for necessary edits, following which the final copy was circulated for approval and endorsement by the APSIC Executive Committee and national societies from the Asia Pacific region.

General cleaning practices
Health care settings comprised areas that require either Hotel Clean or Hospital Clean based on the risk of the patient population in the area. Hotel Clean is a measure of cleanliness based on visual appearance that includes dust and dirt removal, waste disposal and cleaning of windows and surfaces. In addition to routine cleaning, additional cleaning practices and/or the use of personal protective equipment for cleaning may be required in health care settings under special circumstances. Hotel Clean is the basic cleaning that takes place in all areas of a health care setting [2].
Hospital Clean is a measure of cleanliness routinely maintained in care areas of the health care setting. Hospital Clean is 'Hotel Clean' with the addition of disinfection, increased frequency of cleaning; auditing and other infection control measures in client/patient/resident care areas [2].

Components of hotel clean
Floors and baseboards are free of stains, visible dust, spills and streaks Walls, ceilings and doors are free of visible dust, gross soil, streaks, spider webs and handprints All horizontal surfaces are free of visible dust or streaks (includes furniture, window ledges, overhead lights, phones, picture frames, carpets etc.) Bathroom fixtures including toilets, sinks, tubs and showers are free of streaks, soil, stains and soap scum Mirrors and windows are free of dust and streaks Dispensers are free of dust, soiling and residue and replaced/replenished when empty Appliances are free of dust, soiling and stains Waste is disposed of appropriately Items that are broken, torn, cracked or malfunctioning are replaced Cleaning best practices at patient care areas [10][11][12][13][14] Housekeeping in the health care setting should be performed on a routine and consistent basis to provide for a safe and sanitary environment. Maintaining a clean and safe health care environment is an important component of infection prevention and control. The frequency of cleaning and disinfecting individual items or surfaces in a particular area or department depends on: a) Whether surfaces are high-touch or low-touch; b) The type of activity taking place in the area and the risk of infection associated with it (e.g., critical care areas vs. meeting room); c) The vulnerability of patients housed in the area; and d) The probability of contamination based on the amount of body fluid contamination surfaces in the area might have or be expected to have See example in Table 2.

Infection control during construction and renovation
Construction and renovation activities in the hospital may be associated with transmission of pathogens such as filamentous fungi, including Aspergillus spp, Candida spp, Fusarium and also bacteria such as Legionella and Nocardia [15,16]. The most commonly reported hospital construction-related infection is Aspergillus, which represent the greatest threat to neutropenic patients. 'Construction Clean' is the level of cleaning performed by construction workers to remove gross soil, dust and dirt, construction materials and workplace hazards within the construction zone. This is done at the end of the day, or more frequently if needed, to avoid accumulation of dust. Hotel Clean and Hospital Clean begin where the construction site ends, i.e., outside the hoarding and are generally done by the staff of the health care setting.
Prior to the construction and renovation activities, an 'Infection Control (IC) Risk Assessment' (Appendix A 1, 2, 3) must be completed. The risk assessment consists of the following 3 steps:-I. Identify the type of construction project.
(Appendix A1) II. Identify those patient areas at risk. (Appendix A2) III.Match the type of construction activity with the patient risk group. (Appendix A3) Infection control precautions to be taken for respective class of risks are described in Appendix A3. 1  Environmental cleaning after flood Flood waters are characterized as either clear water, gray water, or black water [17]. Clear water refers to water from tap or rain water, while gray water refer to water from sinks, showers, tubs, and washers. In contrast, black water refers to flood water contaminated with waste from humans and animals [17]. The recommended post-flood cleaning and disinfection processes are contingent upon the type of flood water and the material to be cleaned. A Spaulding classification is generally recommended for cleaning and disinfection for all healthcare equipment [18,19]. Special approaches for area decontamination may be needed related to use of ultraviolet light C (UVC) and use of hydrogen peroxide vaporizers, in situations where fungal bioburden were higher than acceptable level [20][21][22][23][24][25][26][27][28][29].

Recommendations
1. The recommended post-flood cleaning and disinfection processes are dependent upon the type of flood water and material to be cleaned.
[BIII] 2. Cleaning processes for non-medical devices and surfaces should include detergent and water, clean water rinse, use of 10,000 ppm (1 % available chlorine) chlorine-based concentration disinfection, and air dry. An exception is use of 100,000 ppm (10 % available chlorine) chlorine-based disinfection for non-medical devices and surfaces suspected of fungal contamination.
[BII] 3. Special approaches (e.g., UVC and use of hydrogen peroxide vaporizers) can be used in situations where fungal bioburden were higher than acceptable level.
[BII] 4. No recommendation can be made for other special approaches for area decontamination including use of ozone or other disinfectant (e.g. QUATS).

Care and storage of cleaning supplies and utility rooms
All chemical cleaning agents and disinfectants should be appropriately labeled and stored in a manner that eliminates risk of contamination, inhalation, skin contact or personal injury. Chemicals must be clearly labeled with Safety Data Sheets (SDS) readily available for each item in case of accidents.

Laundry and bedding
Policies and procedures should address the collection, transport, handling, washing and drying of soiled linen, including protection of staff and hand hygiene. National regulations must be followed if the facility does its own laundry.

Recommendations
1. If the facility does its own laundry, national laundry regulations must be followed.
[CIII] 2. There must be clear separation between clean and dirty laundry.
[AII] 3. There must be policies and procedures to ensure that clean laundry is packaged, transported and stored in a manner that will ensure that cleanliness is maintained.
[BII] 4. There must be designated areas for storing clean linen. [BII] Assessment of cleanliness and quality [30][31][32][33][34][35][36][37][38][39] There are several methods for assessing environmental cleanliness: a. Conventional program of direct and indirect observation (e.g., visual assessment, observation of performance, patient/resident satisfaction surveys); b. Enhanced program of monitoring residual bioburden (e.g., environmental culture, adenosine triphosphate -ATP-bioluminescence); and environmental marking tools (e.g., fluorescent marking) Environmental marking measures the thoroughness of cleaning using a surrogate marking system. It involves the use of a colorless solution or Glo Germ powder or gel that is applied to objects and surfaces in the patient's environment prior to cleaning, followed by detection of residual marker (if any) immediately after cleaning, usually involving fluorescence under ultraviolet (UV) light. Environmental marking may be used either on a daily basis to assess routine cleaning, or prior to discharge to assess terminal cleaning.

Staff education
Staff education, thus, plays a vital role in meeting these requirements and in educating involved healthcare personnel on various infection control aspects on hospital environmental control and cleaning, particularly in view of rapid staff turnover that occurs at many resource-limited settings. Management and supervisory staff should receive training and education that also includes chain of infection, pest control, and outbreak response. Informal education should be complemented with in-service education on hand hygiene, appropriate and early diagnosis of infections, indications for area decontamination and hospital cleaning, and isolation precautions and policies [40]. Ongoing staff education is important due to the new research and guidelines published every year, advancements in technology, and regulatory demands. Education should be focused on the role of environmental control to limit the spread of drug-resistant pathogens [41]. Educational campaigns, including facilitywide, unit-targeted, and informal educational interventions, to enhance adherence to infection prevention and control can decrease MDRO transmission [41]. The focus was to encourage a behavior change through improved understanding of the problem MDRO that the facility was trying to control. Whether the desired change involved hand hygiene, antimicrobial prescribing patterns, or something else, enhancing understanding and creating a culture that supported the desired behavior were viewed as essential to success.

Conclusion
We recommend healthcare facilities to include an environmental hygiene program as part of their Infection Control program. The goal of this program is to keep the environment safe for patients, staff and visitors. The best practices set out in the APSIC Guidelines For Environmental Cleaning And Decontamination will provide criteria for cleanliness that may be adopted by Environmental Services managers for their use or for the use of contracted service.

Appendix A2
Appendix A3 Type A Inspection and non-Invasive Activities Includes but not limited to: • Activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection. eg. Removal of ceiling tiles for visual inspection, painting but not sanding, electrical work, minor plumbing that disrupt water supply to localized patient care area (e.g. in one room) Type B Small scale short duration activities which create minimal dust Include but not limited to: eg. Activities that require access to duct spaces, cutting of walls, ceilings, sanding of walls for painting, plumbing that requires disruption to water supply of more than one patient care area (> two rooms) for less than 30 min.
Type C Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Include but not limited to: • Sanding of walls for painting or wall covering • Removal of floor coverings, ceiling tiles and case work • New wall construction • Minor duct work or electrical work above ceilings • Major cabling activity • Any activity that cannot be completed within a single work shift.

Type D Major demolition, construction & renovation projects
Includes but not limited to: • Activities that require consecutive work shifts • Require heavy demolition or removal of a complete cabling system • New construction/New building project.