Articles

Preparing the Right Cleaning Plan in Age Care Environments

Categories: Cleaning for Health & Safety

The recent, global, COVID-19 outbreak has shone a light on the need for proper outbreak plans within aged care environments. Restrictions on visitors, isolating residents who may have COVID-19, and limiting internal interactions are what has been most prominently discussed. However, a topic that has received less focus, but is equally as important, is proper cleaning and disinfecting to reduce risk not only to residents, but also employees and others. Further, now that facilities are opened to visitor again, there will be a need for heightened cleaning protocols to minimize the spread of the virus, which could threaten this at-risk population.

Every aged care facility will have a common infection prevention protocol. But, typically, those protocols are meant to reduce the risk of a resident catching something. This can leave gaps in protocols that can put employees at risk, as seen by the spikes in infection rates among health care workers in many countries, during the recent pandemic. A new aspect of infectious disease-related safety for cleaning and disinfection, called biorisk management, can help aged care administrators strengthen their protocols and minimizing risk that occupants, or those entering from outside, will spread an infectious disease like the COVID-19 virus.

What is biorisk management?

In simple terms, biorisk management is a comprehensive approach dealing with “risks” associate with “biological materials” (e.g., infectious diseases). Originating in the laboratory setting, biorisk management initially looked at biosafety, biosecurity, and bioethics. Now, it also applies best practices from the health care setting, along with general infectious disease prevention strategies and risk assessments to develop proper, effective, and safe cleaning and disinfection processes and procedures for infectious agents. Specifically, within the aged care environment, that approach will not only cover residents, but also include staff, visitors, and others.

In recent years, during the SARS, MERS and Ebola outbreaks, infection prevention professionals in locations that treated infected patients, worked hand-in-hand with biosafety professionals (from the laboratory environment) to develop more comprehensive protocols for patient care and health care worker protection.

The University of Nebraska Medical Center Biocontainment Unit, which provided care for Ebola patients in 2014, found that cross-training infection control and bio-safety professionals enhanced the safety and reduced risk beyond typical practices.¹ Among the environmental cleaning tasks, the collaborating professionals created more robust protocols for manual disinfecting, cleaning intervals and quality assurance. Areas that were important were that of proper cleaning and disinfecting techniques, proper personal protective equipment (PPE), and proper waste disposal.

An article published in vol 21 of Applied Biosafety, the Journal of the American Biological Safety Association¹ following the 2014 Ebola outbreak, stated, “Since such global infectious disease threats will inevitability occur into the future, now is the time to gain a better understanding of how these professions can work together, by identifying common competencies and highlighting differences. The codification of these similarities and differences can provide a roadmap to new professional development training initiatives for the enhancement of the biosafety profession.”

Patricia Olinger, Executive Director of the Global Biorisk Advisory Council® (GBAC), founded her organization to do just that. GBAC^® STARted with a group of biosafety colleagues who created a variety of special pandemic and forensic protocols, similar to what Olinger created in her prior role as Executive Director of the Environmental, Health and Safety Office (EHSO) at Emory University in the US. GBAC, now a division of ISSA, the worldwide cleaning industry association, offers training and certification in areas of biorisk management, decontamination, and infection control, not just for health care or laboratory facilities, but for any type of facility facing the potential presence of an infectious agent.

Where infection control ends and biorisk management begins

Currently, some official guidance documents from the World Health Organization, European Centers for Disease Control, and the United Kingdom National Health Service refer to their existing infection control and prevention protocols when addressing how to clean and disinfect in the presence of COVID-19.

While useful, they also can only be generic. For instance, here is the WHO guidance² regarding proper cleaning in a COVID-19 patient’s room:

• Hospital-grade cleaning and disinfecting agents are recommended for all horizontal and frequently touched surfaces (e.g., light switches, door handles, bed rails, bed tables, phones) and bathrooms being cleaned at least twice daily and when soiled.
• Visibly dirty surfaces should first be cleaned with a detergent (commercially prepared or soap and water) and then a hospital-grade disinfectant should be applied, according to manufacturers’ recommendations for volume and contact time. After the contact time has passed, the disinfectant may be rinsed with clean water.
• If commercially prepared hospital-grade disinfectants are not available, the LTCFs may use a diluted concentration of bleach to disinfect the environment. The minimum concentration of chlorine should be 5000 ppm or 0.5% (equivalent to a 1:9 dilution of 5% concentrated liquid bleach).
• Cleaners and those handling soiled bedding, laundry, etc., should wear PPE, including mask, gloves, long sleeve gowns, goggles or face shield, and boots or closed toe shoes. They should perform hand hygiene before putting on and after removing PPE.

What is missing here? In essence, these or any other guidelines need to be customized for a specific situation and consequently be more detailed and specific.

For a more comprehensive tip sheet for healthcare environmental services (EVS) consideration for COVID-19, click here.

Tips and governmental or health authority guidance aside, to ensure a comprehensive and accurate approach to cleaning for reduced cross-contamination, GBAC’s biorisk management approach advocates for doing a thorough site risk assessment. This step evaluates the cleaning and disinfecting needs where an infectious disease may be present and then determines which elements of infection prevention protocol apply, and which additional actions are needed.

One of the most important steps in addressing the risks associated with an infectious disease and the aged care environment is the stepwise approach of risk assessment. This process, done within a specific facility, will identify the hazards, associated risks and, as part of the mitigation approach, steps, processes, PPE, and other considerations needed to reduce or eliminate these risks through cleaning and disinfection. Here are simplified key steps based on GBAC’s risk assessment model:

Step 1. Identify the hazards. These involve, for example, potential sites, areas, objects that are potentially contaminated with SARS-CoV-2, the virus causing COVID-19. Special focus needs to be on high touch surfaces. Sometimes this can be done by observation of what people touch, when, and the frequency.

Step 2. Assess the risk associated high touch surfaces. The risk is determined by how likely this surface (an inanimate object) will transmit the virus and, also, how likely it is that this surface becomes actually contaminated.

For example, surfaces that are touched directly after people wash their hands and/or use hand sanitizers will have a lower likelihood to become a source than an object touched frequently by a symptomatic patient.

While this evaluation process might initially appear cumbersome, the huge benefit is the documented knowledge gained for your facility. It will now serve as an inventory for any future processes.

Step 3. Prioritization of risks and classifying them from low to high. This determines which efforts come first in the cleaning and disinfection process and which may need higher frequencies or more specific chemicals or techniques. For example, doorknobs are more likely to be touched by hands before people touch their faces than, say, floors. Leading to doorknobs being cleaned more frequently than the floor. Yet, floors can’t be ignored, as residents, staff, or visitors may drop things onto the floor and shoes can track the virus from room to room.

Step 4. Determination of the cleaning and disinfection processes, frequencies, the determination of the correct PPE as well as any other relevant administrative processes and procedures (e.g., training requirements, verification of the cleaning and disinfection process, waste disposal). This also is where you need to evaluate if the desired outcomes require more EVS staffing to accomplish the tasks.

Step 5. After the cleaning and disinfection has been completed, any lessons learned and next steps should be taken into consideration for continuous improvement.

“The site risk assessment is a critical step not to be missed,” says Olinger. “It assists you in gathering critical incident data. By identifying the hazards, and the risks associated with these hazards, you will be able to develop the risk mitigation steps and strategies that allow for a safe and effective process.”

Proper risk assessment helps define needs prior to entering a resident’s room where an infection may be present, or in addressing any areas where a potentially sick employee has been present, and then continues through to what is needed during the actual work and afterwards. It should be noted that not all outbreak situations are created equal. The specific situation and associated processes and protocols in your aged care facility will define the PPE, the disinfectant to be used, the equipment that will be required and the training that needs to take place.

Common mistakes to avoid

Sometimes, finer points can be missed when addressing the cleaning during an outbreak. It is best to retrain EVS staff on nuances they need to know when increasing cleaning and disinfecting tasks or frequencies. The risk assessment will help identify these areas.

Employees also need to be trained in ways the specific virus can travel and how long it can survive on what surfaces, so they understand how their precautionary measures make an impact, including what mistakes can increase resident and employee health risk.

Common overlooked items:

• Cross-contaminating surfaces by using the same cleaning cloth or tool for multiple areas, such as the resident’s main room and restroom, or between rooms. Color coding the mops and cloths for different areas can help.
• Failure to properly remove, bag and dispose of (or launder in the case of linens) soiled cleaning materials and the employee’s own PPE and clothing.
• Failure to wash hands regularly between tasks.
• Failure of EVS staff to remove their uniform and shoes before leaving work, to avoid tracking infection agents outside the building.

Another topic that the risk assessment should consider is employee-only areas where unwitting carriers could bring the virus into the building. This has been the case in multiple facilities during the COVID-19 outbreak.

There also may be a need to adjust what products are used for cleaning and disinfecting during an outbreak. Due to the higher risk of cross-contamination between rooms, or even between a resident’s room and restroom, administrators may want to consider moving to disposable microfiber cloths and mops.

They may want to evaluate the chemicals used as well. For instance, a dual-purpose cleaning and disinfecting agent can replace a common cleaning chemical for certain high-risk areas or critical touch points. Pre-treated disinfecting wipes may be considered in lieu of reusable cloths, to reduce cross contamination risk. Vacuums with HEPA filters also can help further capture and remove contaminants from surfaces. For advice on proper maintenance and disinfecting of these cleaning machines to reduce cross-contamination, view this tip sheet.

Similarly, if certain products are not available, due to a shortage, it is advisable to adjust cleaning tasks to find the next-best solution with lowest risk to residents, employees, and others. If PPE that is recommended for use with certain cleaning chemicals is not available, it is advisable to move to a cleaning technique that does not require the missing PPE. This may require even higher frequencies of cleaning tasks that rely more on manual removal than chemical deactivation of the virus.

Another situation that may arise is which employees should handle cleaning and disinfecting tasks. Some institutional protocols may state that a healthcare worker handle the cleaning tasks in an infected resident’s room, instead of an environmental services employee. It is normally not recommended to have other employees carry out EVS department tasks unless there is an emergency. The EVS staff are properly trained to clean, sanitize and disinfectant areas to ensure they are acting in accordance with proper resident care. If other employees undertake these tasks without proper training, these processes might be inadequately executed, increasing risk.

When Visitors Return

Once accepting outside visitors again, heightened cleaning and disinfecting steps will be necessary to reduce the risk of another rash of infections, based on introduction of possible outside contaminants. Locations that need to be addressed in a review of the initial risk assessment include: common areas, hallways, public-use restrooms, dining halls, activity rooms, and family entertainment areas.

As you can see, in addition to proper infection control protocols and, for example, limiting visitor access within an aged care facility, there are many important cleaning and disinfection steps to think about when creating the right pandemic response protocols. It is never too late to implement additional steps, even at this stage in the COVID-19 response, especially when the return to routine operations and visitation can still run the risk of further cases.

1. “Comparing the Established Competency Categories of the Biosafety and Infection Prevention Professions: A Possible Roadmap for Addressing Professional Development Training Needs for a New Era”, Applied Biosafety: Journal of ABSA International 2016, Vol. 21(2) 79-83
2. 2. World Health Organization 2020, Water, sanitation, hygiene and waste management for COVID-19, accessed 19 March 2020, https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125.

First published in The Care Home Environment.

About the Author.

Dianna Steinbach is Vice President of International Services for ISSA. Dr. Stefan Wagener is a member of the Global Biorisk Advisory Council®, a division of ISSA.