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Environmental cleaning versus hand hygiene
Is one more important than the other?
By Patti Grant, RN, BSN, MS, CIC
Infection Preventionist, Dallas, TX
Many will have an opinion, yet the question in the headline cannot be definitively answered. I will not attempt to solve the debate, but let me try to shed a little light on it.
Much of what we use in the delivery of healthcare is so commonplace that bedside staff may not always think about these as potential infection risks: bedside carts for computerized charting, computer keyboards at the nurse station, and phones carried by staff provided by their facility, just to name a few. Absolutely, these items need to be routinely disinfected according to your policy as non-critical items. (As this topic is explored please note this column excludes items classified as "Critical" or "Semi-Critical" under the Spaulding Classification System.)
Healthcare is witnessing a potentially unprecedented emphasis on the 'timing issues' of disinfectant application to these surfaces. Placing most infection prevention eggs into this one basket can inadvertently provide a 'false sense of security' in bedside staff if emphasized as the most important factor in a safe infection prevention (IP) milieu on a daily basis.
Within the past two years I've noticed a subtle yet constant escalation in IP listserv chatter and informal conversations during routine networking that involves "how many minutes exactly for what germ, on what surface, wet time, dry time, etc." My informal opinion is that infection preventionists are discussing this ad nauseam in part because our litigious society keeps the interpretation of manufacturer's official directions and our scientific community recommendations at odds. As a result, the official time span for routine disinfection of non-critical items remains in a quandary.
In spite of this debate we know for survey purposes the official manufacturer's label takes precedence despite what our scientific guru's publish in the peer-reviewed literature. Regardless of the answer to this 'timing debate,' give your front-line staff the big picture and help them see, process, and practice the first (and last) line of IP defense.
With the current emphasis on "disinfecting everything" including items that do not touch the patient it is not surprising our bedside staff might be confused and stressed into possibly forgetting one of the most important aspects of safe bedside care. Yes, the environment needs to be clean, yet consistent compliance with good hand hygiene immediately before direct patient care reigns supreme. Those eggs also need to be prominent in the IP basket to secure consistent patient safety.
Bedside staff must be thinking clean hands before I touch my patient. This one thought in action is the beginning and end of most patient safety IP concepts. One way to help them live this habit is to teach the cleaning of hands upon entering a patient room. This action alone would go far in decreasing the transmission of organisms. The next step is cleaning of hands immediately before any invasive procedure such as starting or manipulating intravenous access, dressing changes, or emptying urine bags.
The staff must be able to speak to this truth when facing the proverbial survey question: "Who cleans that keyboard at the nurse desk, how often, with what disinfectant, and for how long does the product remain wet/dry"? Their response needs to reflect daily practice and include an emphasis on decreasing the risk of microorganism transmission as a legitimate stop-gap measure:
Having the perfect policy and staff correctly reciting what a surveyor perceives as most important, does not equal safe bedside IP care. Help them keep it real and protect their patients.