Florence and the machines, Part 2—The Environment. It’s everywhere.

After hand hygiene, the second cornerstone of infection control is using basic knowledge about disease transmission in and from the environment.   Patients need a clean, safe environment.  This includes clean equipment, clean rooms, and clean linens.  When you look around your facility, look at everything and ask yourself ‘How clean is that?’  To know if something is clean, you’ve got to know:

• Who cleaned it?
• How was it cleaned?
• How has it been kept clean?

If you ask who cleaned it, you’re likely to find orphan items.   I worked in an intensive care unit as a nurse for several years.  Later, I moved to the infection control department, and I suddenly had a new set of eyes.  After asking a few questions of the housekeeping staff and ICU nurses, I discovered that IV pumps were rarely cleaned, and flashlights were never cleaned.   The housekeeping staff said they didn’t clean critical patient equipment during their daily work, for fear of accidentally hitting a button that was critical.  Nursing staff certainly didn’t do any routine cleaning.  Only when the patient was discharged was the pump sent to central supply for cleaning.   So, our housekeepers cleaned tables and countertops and floors and chairs in a patient’s room, but never touched the equipment.  I imagine that after just a short time, the entire room was re-contaminated by staff hands touching these towers of germs in an otherwise clean room.  How silly. 

  

And the flashlights? They are left on the work counter in the ICU patient room for pupil checks.  Housekeeping didn’t clean them, neither did nursing.  “Orphan items,” things with no home and nobody to clean them.  Everyone assuming somebody else was doing it.  Do you have some of these?  Don't know til you ask.

How something was cleaned is also important.  Is your staff using an approved disinfectant?  Are they using it correctly?  A story from the lovely IP who trained me in my first job, that I’ve never forgotten:  I was making rounds in the operating room.   In a work room, I opened a cabinet to find dozens of bottles of isopropyl alcohol.  Having not been an OR nurse, I asked the technician nearby what all the alcohol was for (my primary concern then being a large quantity of flammable liquid not stored in a proper cabinet).  She said to me, ‘We use it to clean the counters.’  Eyebrows raised, I said, ‘Show me.’  She said, ‘When an OR case is completed, we sterilize the counters with alcohol.  We pour a half bottle of alcohol on the steel counters and wipe it off.’  I immediately met with the director to discuss what is meant by cleaning, what is sterilizing, and what products are appropriate and approved for use after an OR case.  You must always say ‘Show me.’  You’ll often be surprised by what you see.  What have you seen for cleaning methods?

Lastly, even when something has been cleaned, you’ve got to keep it clean until it’s used.  Clean linens on a bed are ready for use.  But if that bed is pushed into the hallway when it’s not needed for a while, and a lot of traffic passes by it, and occasionally someone puts items down on it, or even sits on it, and then it goes back into a patient room, it’s not really clean anymore, is it?  Not as clean as it could or should be.  I find these beds often in and around the emergency department.  The staff tells me they don’t have a place for the extra bed at the moment.  They can’t put it in storage because admissions are unpredictable: they might need it shortly.  That’s fine, you don’t need to move the bed.  You do need to take the sheets off, though, and put on clean ones for the next patient. Once clean, kept clean.  Apply this rule always. 

There is much, much more to keeping a clean environment than what’s here.  But this is the simple, “Florence Nightingale” approach.  I’ll talk more about cleaning and disinfection in another post.  I’ll probably call it “Why I Love Vendors.”  Which I do.