Cleaning Recommendations for Prevention of Infectious Agent Transmission
Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities

Environmental hygiene is cleaning and disinfecting environmental surfaces and medical equipment to remove soil and contamination. It is as important as hand hygiene in preventing the transmission of infectious agents in health care facilities.

Published studies show that regardless of the original site of the infection (e.g., wound, respiratory, etc) or colonization (e.g., nares) infectious agents such as MRSA, VRE, C. difficile can contaminate all or parts of the patient’s skin surface, especially those sites that are moist (e.g., groin, axillae, etc). The bacteria are then shed in the skin squames (cells) onto environmental surfaces such as bedrails and tabletops in the patient’s immediate environment. These organisms can survive on dry environmental surfaces from several hours to years and serve as a source of hand, glove and clothing contamination.
Facility environmental cleaning policies should take into account that studies have shown shedding of C. diff bacteria up to 6 weeks after resolution of diarrhea.

Observation of Environmental Hygiene

The infection prevention professional or other designated person specifically trained to observe and document compliance with facility procedures should, at least every 2 – 3 weeks, visually observe employees responsible for environmental hygiene. Non-compliance should be immediately addressed.

• Assign responsibility and accountability for environmental hygiene to each department manager, supervisor and employee.
• Develop and implement a schedule for cleaning and disinfecting air vents, supply storage cabinets, offices, waiting areas, carpets, medication and treatment carts as well as other equipment.
• Develop and implement a schedule for cleaning and disinfecting beds, furniture, storage closets, and equipment in rooms assigned to long-term residents.

General Cleaning and Disinfection Guidelines

• Use an Environmental Protection Agency (EPA) registered detergent/disinfectant in all resident care areas. The manufacturer’s recommendations for amount, dilution, and contact time should be followed.
• An EPA-approved disinfectant (EPA: LIST K: EPA’s Registered Antimicrobial Products Effective against Clostridium difficile Spores) or 1:10 dilution of 5.25% sodium hypochlorite (household bleach) and water freshly mixed daily should be used to disinfect the rooms of those residents with symptomatic (e.g., diarrhea) infection. If there is evidence of ongoing C. difficile transmission, the facility should consider using a bleach solution daily in all resident rooms until transmission has ceased.
• Use a clean cloth saturated with a properly diluted disinfecting solution for each residents’ area of the room. Work from clean to dirty (e.g., bedside tables, bedrails to bathroom). Spray bottles should be replaced with bottles that pour the disinfecting solution onto a cloth or surface.
• Replace mop bucket solution every third room and when debris is visible in the solution. Wash and dry cloths and mops daily.

Daily Activities (Or More Frequently if Visibly Soiled)

• Environmental services employees should clean and disinfect frequently touched surfaces and objects (e.g., bedrails, tabletops, chairs, television and nurse call and television controls, etc.) in resident-occupied rooms, nursing stations, and other areas as assigned.
• Nursing service employees should clean and disinfect equipment such as monitors, fluid administration pumps and other equipment directly related to the care and treatment of a resident.
• Clean and disinfect equipment such as computer keyboards as well as other frequently touched peripheral equipment.
• Clean and disinfect reusable medical equipment (e.g., surgical instruments and other equipment) according to the manufacturers’ instructions prior to sterilization. Cleaning to remove organic material must always precede disinfection and sterilization because residual blood and body fluid reduces the effectiveness of the sterilization process.
• Clean and disinfect multiple-resident use equipment (e.g., commodes, shower chairs, bedside scales, lifts, blood pressure cuffs, electronic thermometers, etc.) between each resident use.
• Locate disinfectant impregnated disposable wipes close to shared, moveable monitoring equipment such as electronic thermometers and blood pressure devices. Shared equipment such as thermometers, stethoscopes and blood pressure cuffs should be disinfected between each resident encounter.
• Clean and disinfect glucometers and other point-of-care testing devices after each use. Consult manufacturer’s recommendations for disinfecting solution concentration.

Discharge - Transfer Rooms

• Terminally clean and disinfect all equipment, furniture, cabinets, and shelves and change privacy curtains in discharge-transfer rooms.
• Use moisture-resistant mattress covers and replace when soiled with blood and body fluids and at discharge/transfer. Replace torn pillows and mattresses. Wash pillows and their protective covers when soiled

Laundry

• Laundry detergents: Advances in technology allow modern-day detergents to be much more effective in removing soil and reducing the presence of microbes than those used in the past when much of the research on laundry processing was first conducted. The CMS in collaboration with the CDC has determined that facilities may use any detergent designated for laundry in laundry processing. Further, laundry detergents used within nursing facilities are not required to have stated anti-microbial claims.
• Water temperatures and chlorine bleach rinses: Laundry processing conducted within facilities typically occurs in a low water temperature environment. Many laundry items are composed of materials that cannot withstand a chlorine bleach rinse and remain intact. The chlorine bleach rinse is not required for all laundry items processed in low temperature washing environments due to the availability of modern laundry detergents that are able to produce hygienically clean laundry without the presence of chlorine bleach (The Association for the Advancement of Medical Instrumentation defines the term "hygienically clean" as "free of pathogens in sufficient numbers to cause human illness.”). However, the chlorine bleach rinse may still be used for laundry items composed of materials such as cottons. Hot water washing at temperatures greater than 160 degrees F for 25 minutes and low temperature washing at 71 to 77 degrees F (22-25 degrees C) with a 125-part-per-million (ppm) chlorine bleach rinse remain effective ways to process laundry. If a facility chooses to process laundry using a hot water temperature environment, the temperature maintained for 25 minutes should be 160 degrees Fahrenheit.
• Maintenance of equipment and laundry items: Facilities are not required to maintain a record of water temperatures during laundry processing cycles. The CDC recommends leaving washing machines open to air when not in use to allow the machine to dry completely and to prevent growth of microorganisms in wet, potentially warm environments. Facilities are required to follow manufacturer’s instructions for all materials involved in laundry processing (e.g., washing machines; dryers; any laundry detergents, rinse aids, or other additives employed during the laundry process). Facilities should also follow manufacturer’s instructions for clothing, linens, and other laundry items to determine the appropriate methods to use to produce a hygienically clean product. Facilities should also consider a resident’s individual needs (e.g., allergies) when selecting methods for processing laundry. Facilities should have written policies and procedures including training for staff who will handle linens and laundry.

References

1. “Clarification of Interpretive Guidance at F Tag 441- Laundry and Infection Control”, CMS, 2013.
2. Cohen, SC et al. “Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Health care Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)”. Infection Control and Hospital Epidemiology. Vol 31. May 2010.
3. Sethi, AK et al. “Persistence of Skin Contamination and Environmental Shedding of Clostridium difficle during and after Treatment of C. difficile Infection”. Infection Control and Hospital Epidemiology. January 2010, Vol. 31, No. 1