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Today, environmental services is developing into a science that no healthcare facility can afford not to integrate into its infection-prevention program. The payoff is real, in both lives and dollars.
Soft surfaces as a source of infection
A number of industry experts weighed in on soft surfaces, one area of environmental services that is garnering increased attention recently. Soft surfaces can be a source of cross transmission and is why disinfection of soft surfaces should be an important part of an effective environmental-services and infection prevention program.
According to Lynda Lurie, Marketing Manager, Clorox Healthcare, Pleasanton, CA, "Soft surfaces, such as privacy curtains, upholstered furniture, and clothing, comprise roughly 50 percent of the healthcare environment; yet, they are often overlooked in infection-control protocols. Research shows that microorganisms can survive on soft surfaces for extended periods and can contribute to cross-contamination and spread of infection. A comprehensive infection-prevention program needs to include the treatment of soft surfaces, because, if left unaddressed, contaminated soft surfaces can undermine hard-surface disinfection protocols and put patients, visitors, and staff at greater risk for infection."
Karin Mueller, Vice President, Marketing, Noble Biomaterials Inc., Scranton, PA, added, "Soft surfaces represent a huge gap in infection prevention practice and protocols today, even though they constitute a majority of the direct patient-contact environment. Scrubs, patient apparel, privacy curtains, and bed linens should be given as much attention as any other fomite in the healthcare setting, including hands and hard surfaces."
Salah S. Qutaishat, PhD, CIC, FSHEA, Senior Clinical Advisor, Infection Prevention, Diversey Care, and Carolyn Cooke, Vice President, Healthcare, North America, Diversey Care, Sturtevant, WI, also talked about the relation between hard and soft surfaces and cross-contamination. "Surfaces in patient-care areas, such as privacy curtains, are touched frequently. Studies have shown they can become contaminated quickly and that contamination levels can be quite high.1 Hands can become contaminated by touching both hard and soft surfaces; so, cleaning and disinfecting both surface types is critical to a successful and effective infection prevention program."
"There are now more than 20 published studies that identify soft surfaces as a risk for transmitting pathogens that cause infection and illness in healthcare and household settings," said Uncas Benjamin Favret III, President and CEO, Vestagen Technical Textiles LLC, Orlando FL. "The link between hands, textiles, and surfaces for transmitting pathogens is well-documented. Successful infection-prevention programs must address all of these links."
Lisa Grimes, CEO, PurThread Technologies, Durham, NC, pointed out that, while hand hygiene is an important component of keeping surfaces free of pathogens, it simply is not enough. "Soft surfaces, especially privacy curtains, are touched frequently by healthcare workers. Although fundamental to infection prevention, hand hygiene is insufficient to the challenge facing many healthcare facilities. It is still too easy for freshly washed hands to be contaminated before touching the patient."
Considering the advantages, why might there be hesitation to include soft-surface decontamination in environmental services and infection-prevention programs? "Most regulatory guidelines and recommendations are outdated," stated Mueller, Noble Biomaterials, "so, it is sometimes hard to convince people to incorporate soft surfaces, particularly when incremental cost is involved. However, when you compare that cost to the loss of human life and the increasing financial impact of healthcare-associated infections on the bottom line, it is minimal. In terms of quality of care, a cleaner environment will always be a safer environment."
Tips for containing cross-contamination
Since it is unlikely that medical facilities can completely divest themselves of soft surfaces, what can be done to minimize the risk of cross contamination via soft surfaces? The experts had some definite opinions and some good advice on that front.
Mueller suggested, "Take a soft-surface risk assessment. This will be the foundation for an intervention and help address priorities, whether that is specific floors, units, staff, or types of soft surfaces. Understand behaviors and staff perceptions in regard to soft surfaces." The reason? "Education drives adoption," said Mueller. "Staff should be educated on the risks of coming in contact with soft surfaces throughout the delivery of care."
Mueller outlined the next step. "Evaluate potential product solutions. Laundering needs to be included in a soft-surface protocol, but multiple studies prove it cannot be the only line of defense. Only consider solutions that are EPA-registered, proven to be safe, do not lose antimicrobial activity over time through laundering, and do not require behavior modification for patients or staff. Without a permanent solution, staff would have to wash continuously or disinfect after every hand contact, which is unrealistic."
Consider the type of soft surface and its particulars, suggested Favret, Vestagen Technical Textiles. "Contaminated soft surfaces come in multiple forms: those that are fixed, those that are portable, and those that are mobile. Each type of soft surface, depending on its use, has a different set of design needs, manufacturing specifications, and safety considerations. Fixed soft surfaces include items covered in fabric or upholstery, such as chairs and couches. Portable soft surfaces, such as bedding, linens, and privacy curtains, do not travel from patient to patient. Mobile soft surfaces, such as healthcare-worker uniforms, scrubs, and lab coats, move from patient to patient, room to room, environment to environment. It is these mobile soft surfaces that need to be addressed urgently."
"Think of soft surfaces just like you think about hands and hard surfaces," recommended Favret. "You wash your hands and wipe surfaces to remove visible soil or bulk contaminant, then disinfect, which is two steps. To prevent spread of pathogens from soft surfaces during a work shift, bulk contaminants, in the form of blood or body fluids, must be repelled to reduce bioburden; then, the residual microorganisms need to be inhibited, a dual mechanism of action, two steps."
Cooke, Diversey Care, suggested minimizing the use of soft surfaces in the healthcare environment, where possible. "There are many substitutes for porous fabrics in a healthcare setting that can be considered attractive and create a warm, caring, inviting environment. While soft surfaces are part of creating a more visually appealing environment for the patient, they also cannot be disinfected; so, inherently they are believed to carry more risk."
"When the use of soft surfaces is desired," said Cooke, "it is important to have a consistent cleaning process in place to reduce the potential pathogen load on these surfaces. They should be put on a regular cleaning schedule to help reduce the risk of cross-contamination. For items that may be laundered, such as privacy curtains, the curtains can be changed between patient discharge and admission of new patients. For stationary objects, such as furniture with soft surfaces, these should be cleaned regularly and extraction-cleaned on a rotating basis."
According to Grimes, PurThread Technologies, "Continuously active soft surfaces are a valuable tool for hospitals' broader infection prevention efforts. Hospitals have two clear choices: increase the frequency of cleaning patient rooms and facilities or increase the amount of active surfaces in the patient environment. It is simply not practical or cost-effective to clean every surface after each touch. That is why continuously active soft surfaces will be a key part of infection-control efforts moving forward."
Lurie, Clorox Healthcare, summed up the basics: "Healthcare professionals can help prevent soft-surface contamination by ensuring these simple steps are included in their facility's cleaning and disinfecting protocols: routine laundering of privacy curtains, linens, employee uniforms, and other soft surfaces in their facilities; use of an EPA-registered product to kill bacteria on soft surfaces between laundering and on soft surfaces that cannot be laundered; and hand-hygiene practices by healthcare professionals during and between patient care."
Products that reduce bioburden on soft surfaces
Among those Healthcare Purchasing News talked with, some offered disinfectants, some offered active textiles. The vendors talked more specifically about how their products work to reduce cross-transmission of pathogens related to soft surfaces.
Lurie described Clorox's disinfectant product. "Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Spray and Citrace Hospital Disinfectant & Deodorizer are EPA-registered to kill microorganisms on both hard and soft surfaces [100% polyester and 100% cotton; soft-surface claim has been registered by the federal EPA, but may not be available in all states]. For soft surfaces, simply spray either product on the fabric and bacteria will be eliminated in just 30 seconds. Our multiuse products offer simple solutions for eliminating microorganisms quickly from high-touch hard and soft surfaces such as bed rails, light switches, infusion stands, privacy curtains, chairs, couches, and cushions. These products address a previously unmet need and offer an easy-to-use solution for soft surface infection prevention."
As always, scientific evidence of a product's efficacy is of paramount importance. When investigating a new product, never fail to ask to see the scientific evidence, particularly evidence published in respected medical or scientific journals or presented at major scientific or medical meetings in the form of papers or posters. Most vendors are delighted to share the evidence with you.
Lurie pointed to information presented at two high-profile medical meetings focusing on Clorox Healthcare's soft-surface disinfectant products. "Both studies show that routine application of these products can help to reduce the microbial load on soft surfaces and help minimize the risks that contaminated surfaces pose to patients, visitors, and facility staff,' said Lurie. "Both products have been studied in healthcare settings, including acute and non-acute facilities."
"Rutala et al presented results from a pre- and post-intervention study on hospital privacy curtains at the University of North Carolina, which found that Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant achieved an average 98.5% reduction in methicillin-resistant Staphylococcus aureus (MRSA).2 Further, Reynolds and Sexton, from the University of Arizona, tested the efficiency and usability of Citrace Hospital Disinfectant & Deodorizer in 3 different healthcare settings. They found that it was effective at reducing the concentration of heterotrophic plate count bacteria by up to 98.5% on soft surfaces, including waiting-room chairs, patient-room chairs, and privacy curtains."3
Qutaishat, Diversey Care, talked about Oxivir Tb, which she described as "a hydrogen peroxide-based disinfectant that belongs to the improved hydrogen-peroxide class of disinfectants. This class of disinfectants is highly effective against most multi drug-resistant healthcare pathogens. Multiple studies have demonstrated that this class of disinfectants has superb dwell time and excellent log reduction of pathogens for surfaces in healthcare facilities."4
Oxivir Tb is virucidal, bactericidal, tuberculocidal, and fungicidal. It kills MRSA and norovirus, and it meets Bloodborne Pathogen Standards for decontaminating blood and body fluids.
Continuously active textiles work to inhibit growth of pathogenic microorganisms. Favret explained why he believes adding antimicrobial fabrics to the infection-prevention mix is important. "Vestex-protected garments provide both protection and comfort. Vestex-protected uniforms repel fluids, to reduce bulk contaminant and to avoid exposures to blood and bodily fluids. Fluids literally bead up and fall off the garment. Vestex-protected uniforms contain an antimicrobial, to inhibit bacterial growth. Its performance persists for the life of the garment and has been proven to retain effectiveness in the industrial laundry setting."
Favret offered scientific evidence of their products' efficacy. "Bearman et al, Virginia Commonwealth University, found 10,000 times fewer MRSA colonies (4-Iog reduction) on Vestex-protected uniforms, as compared to standard scrub uniforms, in an ICU setting,"5 said Favret. "As it related to other scientific studies, Bearman's results carry a high degree of statistical significance (Pc.005). The study concluded that Vestex-protected uniforms can serve as an adjunct measure for infection-prevention practices."
PurThread Technologies also employ an antimicrobial to inhibit bacterial growth in their fabrics. "PurThread medical textiles incorporate a patented antimicrobial agent developed by Kodak, which is a unique variation of a silver salt that produces a chemical species, known as hydroxyl radicals," explained Grimes. "They attack microorganisms along several parallel pathways, simultaneously degrading the cell's protective biofilm, rupturing the cellular membrane, and disrupting the biological processes within the cell, thereby killing the pathogen."
"The active agent in PurThread textiles is not a topical coating or superficial treatment. PurThread's award-winning manufacturing process incorporates the agent into the core of each fiber, ensuring even distribution of the antimicrobial agent throughout the fabric and the agent's efficacy over time, regardless of wear and washings. PurThread fabrics work just like traditional linens and do not require any special training, equipment, or laundering procedures. Adding PurThread products to current infection-prevention efforts is a simple and cost-effective horizontal strategy to implement that requires no change in behavior."
Grimes referred to research published in a prominent medical journal supporting PurThread's claims. "Results from a double-blinded, randomized clinical trial conducted in two ICUs of a tertiary teaching hospital found PurThread privacy curtains took 7 times longer to become contaminated than control curtains and were 8 times less likely to be contaminated with the superbug vancomycin-resistant Enterococcus."6
Noble Biomaterials also employs silver in its fabrics. Mueller described the product in more detail. "X-STATIC is an EPA-registered antimicrobial agent that uses a proprietary technology to bond pure, natural, metallic silver to textile fibers that are then woven into fabric products such as uniforms and privacy curtains. The release of silver ions will persist for the life of the product and is proven to sustain through hundreds of commercial launderings. This is important because soft surfaces are rapidly recontaminated, particularly with things like privacy curtains, which may be left hanging for weeks or months. X-STATIC will continue to reduce the amount of bacteria on the surface of the fabric while in use, without any action or behavior modification from staff or patients."
According to Mueller, X-STATIC has undergone extensive safety testing and is environmentally friendly. "It is important to note that X-STATIC is not a nanotechnology or temporary topical solution, and no metallic silver is released or leeched into the environment. Noble Biomaterials is a bluesign system partner, [which] assures manufacturers, retailers, and consumers that the production of X-STATIC fibers is environmentally friendly and committed to the contemporary sustainable textile requirements set forth by the bluesign system."
Get educated on the solutions
Companies have spent untold resources on research before their products hit the market, so take advantage of this existing body of knowledge. Here is a sampling of the educational offerings from these vendors.
Lurie described information and tools they make available online. "Clorox Healthcare has a variety of resources and tools to help professionals learn more about soft-surface decontamination, including information on soft-surface research, a checklist of soft surfaces to treat in key healthcare environments, a soft-surface poster, and a soft-surface quiz. To download these free educational tools, visit www.CloroxHealthcare.com/SoftSurface."
"Diversey Care provides extensive educational expertise and resources throughout North America in cleaners, sanitizers, and disinfectants, as well as cleaning equipment and tools that can be used to clean and sanitize soft surfaces such as fabrics, carpets, and privacy curtains," said Cooke. Training resources can be found at their eLearning portal, https://learning.sealedair.com.
Favret talked about resources offered by Vestagen. "Vestex fabrics are rooted in research and published evidence. We are committed to sharing information and best practices to optimize health care, patient safety, and quality. We will launch our professional education website this winter, with online and in-person continuing education opportunities. Courses address fundamentals from our WASH, WIPE, WEAR campaign; expand leadership through building a culture of safety; and create foundations through policies of protection. Topics include bloodborne pathogens, aseptic technique, and multidrug-resistant organisms, as well as business skills, such as how to develop policies and procedures incorporating new technologies like Vestex fabrics. Stay tuned at vestexprotects.com."
White papers are not published in medical or scientific journals, but they can still be a good source of information. Mueller pointed to two white papers on soft-surface bacterial management that Noble Biomaterials makes available, "Soft Surface Bacterial Contamination: Considerations for a Complete Infection Prevention Program" and "Soft Surface Fabrics: The Other High Touch Surfaces." To download these whitepapers, go to http://www.infectionpreventiontextiles.com/download-whitepaper.php. For continuing education material, go to www.infectionpreventiontextiles.com
1. Ohl M, Schweizer M, Graham M, et al. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control. 2012;40(10):904-906. Doi: 10.1016/j.ajic.2011.12.017.
2. Rutala WA Gergen MF, Weber DJ. New technology in environmental cleaning and evaluation." Presented at the Association for Professionals in Infection Control and Epidemiology Annual Conference; Fort Lauderdale, FL; June 10, 2013.
3. Reynolds KA, Sexton JD. Evaluation of a soft surface sanitizer in healthcare environments. Presented at IDWeek; San Francisco, CA; October 2013.
4. Rutala WA, Gergen MF, Weber DJ. Efficacy of improved hydrogen peroxide against important healthcare-associated pathogens. Infect Control Hosp Epidemiol. 2012;33(11):1159-1161.
5. Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus aureus burden on healthcare worker apparel. Infect Control Hosp Epidemiol. 2012;33(3):268-275.
6. Schweizer M, Graham M, Ohl M, et al. Novel hospital curtains with antimicrobial properties: a randomized, controlled trial. Infect Control Hosp Epidemiol. 2012,33(11):1080-1085.
By Susan Cantrell, ELS
This article was written by Susan Cantrell from Healthcare Purchasing News and was legally licensed through the NewsCred publisher network. Please direct all licensing questions to firstname.lastname@example.org.