Surface disinfection may rank low on your list of infection control concerns and challenges, far beneath such practices as hand hygiene, waste disposal and instrument processing. But letting your staff dismiss the importance of surface disinfection puts them and your patients at risk. The trouble starts when wiping surfaces becomes a ho-hum bore of a chore for your staff.

"They've done it so often and for so long that it becomes rote. They go in, hit certain things and then walk out of the room. Instead of really evaluating what they're doing, they just go through the motions," says Gwenda Felizardo, RN, BSN, CIC, an infection preventionist for the Group Health Cooperative's infection prevention and control department in Tacoma, Wash. "People are in such a hurry to turn the room over for the next case that they my cut corners without realizing it."

Solutions to such slip-shoddiness? Ms. Felizardo suggests 2.

• Make staff accountable. Clearly define who's responsible for wiping down which items between patients. "You know what's required," she says, "but your staff may not have a clear understanding." For example, who's responsible for cleaning the knobs and buttons on the anesthesia cart? What about the keyboard and mouse? A checklist and communication with the circulating nurse are helpful, especially if staff who do the cleaning weren't in the room during the case. They may not know which surfaces and items were touched.
• Observe and report. Observe your cleaning team in action between cases and under training conditions. Your secret weapon in this exercise is a product called Glo Germ (brevis.com), a lotion that you put on a Q-tip and swab various items in the OR before staff come in to clean the room. When they're done, turn out the lights and shine an ultraviolet light over the items dabbed with Glo Germ. Items that staff glossed over, didn't wipe with enough friction or completely missed will glow under the UV light. "You can't see germs, so this is a very effective training tool," says Ms. Felizardo. "Staff will say, ???I didn't do a good, flat-handed wipe over this area' or ???Gee, I missed this one area totally.'"

The right disinfectant
Leslie Cottrell, RN, the director of nursing at Baptist-Physicians' Surgery Center in Lexington, Ky., speaks of other quandaries when it comes to surface disinfection — wait times and staff acceptance of the disinfectant. For her, both were lacking at her 8-OR, 6-procedure room ASC that hosts 14,000 cases a year.

The disinfectant her ASC was using had a 3-minute wait time. "I know darn well when we clean the OR beds, we weren't waiting 3 minutes before we'd wipe." Her ASC is located on a hospital campus, so she reached out to the environmental services staff at the hospital, which was using the same product, but had no problems with wait times. "Because the hospital's turnover times are much longer, they spray the room and then go do something else while they wait the 3 minutes."

A note about wait times: The labels of most products registered by the EPA for use against HBV, HIV or M. tuberculosis specify a contact time of 10 minutes, too long to be practically followed. "Such a long contact time is not practical for disinfection of environmental surfaces in a healthcare setting because most healthcare facilities apply a disinfectant and allow it to dry (~1 minute)," says the CDC's Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. "Multiple scientific papers have demonstrated significant microbial reduction with contact times of 30 to 60 seconds."

Still, rather than try to change her staff's behavior, Ms. Cottrell changed to a disinfectant that has a contact time of 1 minute. This solved one problem, but created another. "Nobody liked the smell of the new disinfectant. It was too strong. It made people's eyes water. It made some cough," says Ms. Cottrell. And if the disinfectant got on uniforms, if would discolor them. "Not a small deal, because staff buy their own scrubs," she says.

"Skin irritation and allergies are 2 of the most common occupational diseases in housekeeping personnel and nurses, and almost all surface disinfectants pollute the environment," says the CDC's guideline, which notes that many surface disinfectants contain quaternary ammonium compounds (quats), phenolics and sodium hypochlorites. Quats and hypochlorites can cause skin irritation and asthma. Benzalkonium chloride is one of the leading allergens for healthcare personnel.

Ms. Cottrell considered switching to impregnated wipes, but they didn't fare well in a cost analysis. The manufacturer of the 1-minute disinfectant she was using came out with a scented product. "That was better, but staff still complained about discolored scrubs," says Ms. Cottrell.

In the end, Ms. Cottrell had to look beyond — and she had to get her staff to look beyond — product usage and preference problems and focus on the bigger picture: patient and staff safety. The fact remains that surface areas are a prime source for indirect or secondary transmission of infectious diseases for both your staff and your patients. "My primary concern was that we use a product that is actually killing everything. Surface disinfection is a key safety precaution to them and the patient."

Besides picking products that your staff will like and use, Ms. Felizardo, a spokeswoman for the Association for Professionals in Infection Control and Epidemiology, says selecting the right environmental disinfectant means evaluating the manufacturer's studies on the disinfectant that include the organisms it kills (you'll want a product effective against both gram-negative and gram-positive bacteria) and kill times. You also want to make sure the manufacturers of the items you're going to clean (equipment and surfaces) have approved the chemical for cleaning the item. For example, does the equipment manufacturer OK an alcohol-plus-quarternary ammonia compound or just the quaternary agent ?

Is routine disinfection necessary?
Surfaces are considered non-critical items because they contact intact skin. As such, they carry little risk of causing an infection in patients or staff. So why routinely disinfect them? In the CDC's guideline, William A. Rutala, PhD, MPH, and David J. Weber, MD, MPH, list 4 reasons.

• Shoes, wheels and spills contaminate floors. In an investigation of the cleaning of hospital floors, the use of soap and water was less effective in reducing the numbers of bacteria (80% reduction) than was a phenolic disinfectant (94% to 99.9% reduction). Note: The bacterial count was nearly back to the pretreatment level a few hours after floor disinfection.
• Studies have shown that, when a cleaning cloth failed to eliminate contamination from a surface and the cloth is used to wipe another surface, the contamination is transferred to that surface and the hands of the person holding the cloth.
• The CDC recommends that you clean and disinfect non-critical equipment contaminated with blood, body fluids, secretions or excretions.
• OSHA requires that surfaces contaminated with blood and other potentially infectious materials be disinfected.

Do the right thing
Don't underestimate the importance of cleaning and disinfecting surfaces between patients. "MRSA and vancomycin-resistant enterococcus (VRE) can live for months on unclean surfaces," says Ms. Felizardo. "If you don't clean the surface, staff who touch those items can transfer organisms to clean items. Get staff to refocus on the importance of what they're doing. Tell them, ???You may be the person on the operating room table. How would you want the room cleaned?'"

She offers 2 rules of thumb:

• If the surface has no visible body substances, thoroughly wiping the surface with a disinfectant will adequately clean and disinfect.
• When body substances are visible on surfaces, first thoroughly clean the surface to remove all the visual soil. Use a flat-handed wipe. Toss that rag and wipe the surface again with a new rag saturated with disinfectant. Let the surface air dry, which should take no more than a couple of minutes. Don't dip a dirty rag into clean solution and use it to wipe the surface.

"Everybody in the OR wants to do the right thing," says Ms. Felizardo. "It's just a matter of keeping priorities focused."