Aseptic Technique: Preventing Infections

Understanding Disinfectants vs. Antiseptics

• Disinfectants are chemical materials used for sterilization.
• Disinfectants are toxic to human tissues and cells.
• They are designed for cleaning surfaces and equipment only.
• Antiseptics are chemicals for sterilization that are not toxic to the human body.
• Antiseptics can be used on living tissues, like mouth gargles and skin preparations.

Common Chemical Disinfectants

• Phenol and Derivatives include products like Dettol and are effective against bacteria and fungi.
• Halogens include chlorine and tincture iodine, and are powerful broad-spectrum antimicrobials.
• Ethyl alcohol (70%) is commonly used for surface disinfection and skin antisepsis.
• Glutaraldehyde (CIDEX) and formalin kill all microorganisms, including spores.

Alcohols as Disinfectants

• Ethanol and isopropanol are optimally effective as disinfectants at 70% concentration.
• At least 30 seconds of wet contact time are needed for proper disinfection.
• Alcohols are effective against bacteria, fungi, and many viruses, but not bacterial spores.

Alcohol-Based Disinfection Applications

• Alcohols are ideal for hand hygiene when soap and water are unavailable due to their quick-drying properties.
• Alcohols are perfect for disinfecting small, non-porous surfaces like stethoscopes and small equipment.
• They are commonly used for disinfecting thermometers and other small medical devices between patient use.

Limitations of Alcohol-Based Disinfectants

• Alcohols cannot effectively penetrate organic materials like blood or bodily fluids.
• Quick evaporation limits contact time on surfaces, potentially reducing efficacy.
• High flammability requires careful storage and handling away from heat sources.
• Alcohols may damage certain materials like rubber, plastic, or lens coatings with repeated use.

Chlorine and Chlorine Compounds

• Chlorine compounds are effective against bacteria, viruses, and spores at appropriate concentrations.
• They are widely available as sodium hypochlorite (bleach) and calcium hypochlorite.
• They can be used for large areas, equipment, and bodily fluid spillages.
• Chlorine can be corrosive to metals and irritating to skin and the respiratory system.

Preparation and Dilution of Chlorine Solutions

• Always follow manufacturer guidelines for correct concentration.
• Use cold water because hot water causes chlorine to evaporate.
• Prepare only the amount needed for immediate use.
• Never mix with acids or ammonia products.

Contact Time for Effective Disinfection

• Ensure a minimum contact time of 10 minutes.
• Keep surfaces visibly wet throughout the contact time through surface saturation.
• Reapply the solution if the surface dries prematurely.

Factors Affecting Chlorine Efficacy

• Warmer water increases the disinfection rate.
• The optimal pH range is 6.0-7.5; effectiveness decreases in acidic or alkaline environments.
• Dirt, blood, or other organic materials reduce available chlorine, decreasing effectiveness.
• Higher concentrations work faster but increase the risks of corrosion and irritation.

Safety Considerations for Chlorine Handling

• Ensure adequate airflow when preparing and using chlorine solutions to prevent inhalation of toxic fumes through proper ventilation.
• Wear gloves, eye protection, and protective clothing for personal protective equipment.
• Never mix chlorine with ammonia, acids, or other cleaning products to avoid toxic gas formation through chemical segregation.
• Always label chlorine solutions with concentration, preparation date, and hazard warnings with clear labeling.

Best Practices for Chlorine-Based Cleaning

• Use the recommended concentration for the specific application and surface type through proper dilution.
• Ensure a minimum of 10 minutes of wet contact time for adequate contact time.
• Completely wet the surface and reapply if it dries before the contact time is met for thorough application.
• Implement proper ventilation and use personal protective equipment when handling in safety protocols.

Dwell Time Requirements for Different Disinfectants

• Alcohol-based disinfectants typically require a shorter dwell time than others.
• Chlorine-based, quaternary ammonium, and phenolic disinfectants require longer dwell times.
• Effective disinfection requires allowing products to remain wet on surfaces for their specified dwell time.
• Following dwell time recommendations ensures thorough elimination of pathogens.

Quaternary Ammonium Compounds (QACs)

• QACs are cationic detergents with antimicrobial properties that disrupt microbial cell membranes.
• QACs are effective against bacteria, fungi, and enveloped viruses, but not bacterial spores.
• They are ideal for non-critical surfaces like floors, furniture, and walls in healthcare settings.
• They are less irritating and non-corrosive compared to chlorine, with good cleaning properties.

Hydrogen Peroxide as a Disinfectant

• Hydrogen peroxide functions as a powerful oxidizing agent that damages cellular components of microorganisms through free radical formation.
• Low concentrations (3-6%) are used for surface disinfection.
• Higher concentrations (7-30%) are used for equipment sterilization.
• It breaks down into water and oxygen, leaving no toxic residues and being effective against a broad spectrum of pathogens.

Phenolics and Aldehydes

• Phenolics are effective against bacteria, mycobacteria, and fungi but less effective on spores.
• Glutaraldehyde provides high-level disinfection and sterilization.
• Formaldehyde is highly effective but toxic, requiring well-ventilated areas.

The Chain of Infection

• The infectious agent includes bacteria, viruses, fungi, or parasites capable of causing infection.
• The reservoir includes places where pathogens can survive and multiply (e.g., humans, surfaces, equipment).
• The portal of exit details how pathogens leave their reservoir (coughing, wounds, contaminated instruments).
• The mode of transmission refers to how pathogens move between hosts (direct contact, droplets, contaminated surfaces).
• The portal of entry refers to how pathogens enter a new host (mucous membranes, breaks in skin, invasive procedures).
• Environmental cleaning includes removing visible dirt from objects and surfaces, normally accomplished manually or mechanically, using water with detergents or enzymatic cleaners.
• Environmental cleaning refers to general cleaning of surfaces and non-critical equipment in health care facilities.
• This is part of maintaining a clean, healthy, and pleasing patient and work environment.

Breaking the Chain of Infection

• Proper handwashing and glove use in hand hygiene breaks the pathway between patients and contaminated surfaces.
• Regular disinfection of surfaces in environmental cleaning disrupts pathogen transmission from the environment.
• Appropriate personal protective equipment in PPE usage prevents transfer of pathogens between staff and patients.
• Proper disposal of contaminated materials in Waste Management prevents the spread of infectious agents.

Environmental Cleaning Categories

• Routine Cleaning involves daily cleaning and disinfection of patient care areas with focus on high-touch surfaces, ensuring ongoing infection prevention during the patient's stay.
• Terminal Cleaning involves thorough cleaning and disinfection of patient rooms after discharge, including all surfaces, equipment, and fixtures in the room.
• Outbreak Cleaning involves enhanced cleaning during infectious disease outbreaks, with increased frequency and specialized disinfection procedures.

Spill and Contamination Management

• For blood spills, contain the spill, remove with absorbent material, then disinfect with the appropriate concentration of bleach solution.
• For bodily fluids, handle with appropriate PPE, absorb spill, and disinfect the area with an approved disinfectant for proper contact time.
• For chemical spills, follow specific protocols based on chemical type, use appropriate neutralizers before cleaning and disinfecting.

Air and Surface Decontamination

• Hydrogen peroxide vapor is used for simultaneous air and surface decontamination in enclosed spaces, effective against a wide range of pathogens.
• UV light disinfection ultraviolet germicidal irradiation systems decontaminate surfaces and air in unoccupied spaces.
• Aerosolized disinfectants are applied in specialized situations like operating rooms, providing thorough coverage of difficult-to-reach areas.

Hospital Disinfection Methods by Area

• Floors and Walls: Use Phenolic solutions (1-2%)
• Surfaces and Tables: Use Hypochlorite or alcohol-based (0.1% or 70%)
• Hands and Skin: Use Chlorhexidine, iodine, alcohol (2-4%, 10%, 70%)
• Endoscopes: Use Glutaraldehyde (Cidex) (2%)
• Thermometers: Use alcohol (70%)

High-Touch Surfaces: Critical Focus Areas

• Bed rails are among the most frequently touched surfaces in patient rooms and require disinfection multiple times daily.
• Bedside tables are surfaces where food, medications, and personal items are placed and need thorough daily disinfection.
• Doorknobs and handles are critical transition points touched by multiple people and require frequent disinfection throughout the day.

Additional High-Touch Surfaces

• Light switches are frequently touched by both staff and patients and are often overlooked during cleaning processes.
• Call buttons are used multiple times daily by patients, and direct contact with hands makes them significant transmission risks.
• Bathroom fixtures, like toilet flush handles, faucets, and grab bars, require thorough disinfection to prevent cross-contamination.
• Medical equipment, like IV poles, monitors, and other bedside equipment, should be regularly disinfected between patient contacts.

Correct Cleaning Techniques

• Always work from cleanest to dirtiest areas for the clean to dirty principle.
• Clean from higher surfaces to lower ones in top to bottom cleaning.
• Use a systematic left-to-right or clockwise approach to create a methodical pattern.
• Ensure complete surface coverage with overlapping strokes to correct application.

Microfiber Effectivenesses

• Microfiber cloths are significantly more effective at removing and trapping bacteria compared to traditional cotton cloths or paper towels
• Their split fiber design creates more surface area for collecting pathogens.

Strategic Cleaning Flow

• Begin with frequently touched surfaces outside the immediate patient area, for high-touch outside patient zones.
• Move to surfaces within the patient's immediate environment that are frequently contacted, for high-touch inside patient zones.
• Clean patient beds thoroughly before moving to bathroom areas and patient beds.
• Complete the process with bathroom fixtures and toilet areas, for patient toilets.

Proper Cloth Folding Technique

• Start by folding the cleaning cloth in half to create multiple cleaning surfaces for Step 1, the initial fold.
• Fold the cloth in half again to create a total of eight usable cleaning surfaces for Step 2, the second fold.
• Submerge the folded cloth in cleaning solution once, avoiding "double-dipping," for Step 3, the single dip.
• Switch to a clean side after each surface is cleaned, maximizing efficiency for Step 4, surface rotation.

Best Practices for Floor Cleaning

• Always display wet-floor signs before beginning the floor cleaning process for Safety First.
• Mop in overlapping figure-eight strokes to ensure complete coverage and efficiency with the figure-eight technique.
• Clean small areas (approximately 3m x 3m) before rinsing the mop and moving on in small sections.
• Use two or three-bucket systems to separate clean solution from rinse water In bucket systems.

Preparing Cleaning and Disinfectant Solutions

• Prepare solutions in a designated environmental cleaning services area with proper ventilation in a dedicated area.
• Provide training and simple instructions, including pictorial job aids like posters with clear instructions.
• Use standardized containers or automatic dispensing systems calibrated regularly in a standardized measurement.
• When feasible, use test strips to confirm correct solution concentrations for concentration verification.

Preparing Chlorine Solutions

• Always wear appropriate PPE including gloves, eye protection, and apron when preparing chlorine solutions for safety precautions.
• Use standardized measuring tools for precise dilution according to the required concentration for accurate measurement.
• Store in covered plastic containers away from direct sunlight to maintain potency, for proper storage.
• Never mix chlorine solutions with any other cleaning products to avoid toxic reactions for chemical segregation.

Color-Coding System for Environmental Cleaning

• Red is used and labeled For High-Risk Areas: which are isolation rooms, toilets, and areas with higher contamination risk.
• Blue is used and labeled For General Patient Areas: general patient areas including bedside tables, bed frames, and non-critical equipment.
• Yellow and labeled For Bathrooms: specifically for bathroom surfaces excluding toilets, such as sinks and shower areas.

Floor Cleaning Equipment

• The double-bucket system uses one bucket for clean solution and one for dirty rinse water, and prevents cross-contamination during the cleaning process.
• Microfiber mops are more effective at removing dirt and microorganisms than conventional mops and require less solution and provide better surface coverage.

Personal Protective Equipment for Cleaning

• Routine Cleaning (standard precautions) requires None (unless spills or contamination risk)
• Terminal Cleaning (standard precautions) requires Reusable rubber gloves
• Blood and body fluid spills requires Gown, rubber gloves, face shield if splash risk
• Isolation rooms (contact precautions) requires Gown, rubber gloves
• Airborne precautions Requires N95/FPP2 respirator, rubber gloves

COVID-19 Specific Cleaning Protocols

• Enhanced PPE Requirements: Gown, gloves, face shield or goggles, and respiratory protection (N95 or equivalent) when cleaning COVID-19 patient areas.
• Increased Cleaning Frequency: High-touch surfaces in COVID-19 areas should be cleaned and disinfected at least twice daily, more often in high-traffic areas.
• Appropriate Disinfectants: Use disinfectants proven effective against SARS-CoV-2, such as 0.1% sodium hypochlorite or 70% alcohol solutions.
• Dedicated Equipment: Use dedicated cleaning equipment for COVID-19 areas to prevent cross-contamination with other hospital zones.

Monitoring Cleaning Effectiveness

• Immediate assessment of cleanliness occurs through direct observation of surfaces after cleaning for visual inspection.
• Detects organic material on surfaces, providing immediate feedback on cleaning effectiveness with ATP Bioluminescence.
• Laboratory testing of surface samples to quantify bacterial presence after cleaning to perform microbial sampling.
• Applied before cleaning and checked afterward with UV light to verify surface coverage with fluorescent markers.

Training Requirements for Cleaning Staff

• Effective training programs include both theoretical knowledge and practical skills.
• Staff should understand infection control principles, proper chemical handling, correct cleaning techniques, and appropriate PPE use.
• Regular refresher training ensures consistent standards.

Environmental Cleaning Documentation

• Implement detailed checklists for each area, clearly indicating which surfaces require cleaning and at what frequency for Daily Checklists.
• Use signature systems or electronic tracking to document completed cleaning tasks and accountability, as Completion Verification.
• Conduct regular audits using standardized assessment tools to evaluate cleaning thoroughness and compliance for Quality Audits.
• Establish mechanisms for reporting cleaning deficiencies and communicating corrective actions through feedback systems.

Future Trends in Environmental Cleaning

• Automation involves robotic systems for consistent application of disinfectants and UV light treatment that reduce human error and increase efficiency.
• Digital Monitoring involves electronic systems tracking cleaning compliance, staff assignments, and effectiveness measurements in real-time.
• Sustainable Solutions involve environmentally friendly disinfectants with lower toxicity profiles that maintain efficacy while reducing environmental impact.

Key Takeaways: Chemical Disinfectants and Environmental Cleaning

• Evidence-Based Selection: Choose appropriate disinfectants for specific pathogens and surfaces.
• Proper Application: Follow correct dilution, contact time, and application techniques.
• Systematic Approach: Implement methodical cleaning patterns from clean to dirty areas.
• Safety Protocols: Use appropriate PPE and follow safety guidelines for all chemicals.
• Regular Training: Ensure staff education on latest practices and procedures.