Disinfectants are used on inanimate objects and cleaning ensures the removal of organic matter and allows the disinfectant to come into complete surface contact with the article to be disinfected. The chemical disinfectants used generally for patient-care equipment are alcohols, glutaraldehyde, formaldehyde, hydrogen peroxide, iodophors, ortho-phthalaldehyde, peracetic acid, phenolics, quaternary ammonium compounds and chlorine. The choice as to which disinfectant can be used depends upon the article being disinfected and the purpose of use of the article. Some microbes are resistant to a number of commonly used chemicals and hence this should be given consideration while making a choice of the disinfectant.
The constant patient inflow leads to a continuous circulation of micro-organisms in the hospital setting. Operation theatres, intensive care units, emergency rooms, labour rooms are areas where patients are at a higher risk of acquiring infection. These areas are cleaned using separate equipment with detergent/disinfectant solutions more so as the spills of body fluids are disinfected. Though the routine use of germicidal disinfectants for environmental surfaces like the hospital floor is a debatable subject, there are studies which prove that there is not much difference in the rate of healthcare infections after either a detergent or disinfectant cleaning protocol. However, there are many studies which prove beyond doubt that disinfectants are more effective in reducing the microbial load as compared to detergents.
Sources of infection
There are interventions and operations which could lead to spillage of blood, body fluids and spillage or overflowing of bio medical waste in these areas. This leads to the usage of a variety of disinfectants and cleaning agents on the patients, instruments and OTs. People coming in for deliveries and labour rooms tend to have more body fluids and more dirt than in any other area of the hospital. It is difficult to clean this area because of the volume of the patients in this area.
There are monitors on the shelf, machineries on the floor and tubes running and curtains all around which can accumulate dust and can be the potential source of bacteria, fungi, spores and microorganisms because of the very continuous nature of patient care in the ICU. It cannot be vacated randomly. Therefore certain strategies need to be devised to take care of this department. Patients succumb to their illnesses and are taken to the mortuary until the family takes control. Depending on the number of the patients, the load on the mortuaries can be tremendous particularly in government hospitals.
Visitors intervene with the housekeeping activity and are also likely to harm themselves by coming in contact with physical objects, electrical objects or body fluids, disinfectants, chemicals and other hazardous material that are used in the hospital.
Indian hospitals also have the problem of bed bugs. Bed bugs are very difficult to eliminate. Fumigation is not the solution as they do not live on the surface. They get into corners, crevices, mattresses, pillows, clothes etc. where no cleaning agent or disinfectant can reach. Any cleaning agent which we use to kill the bugs can just as likely kill the patient as well. Besides this, rats and mosquitoes are ubiquitous. Treated patients going outside fortunately carry their illnesses and bugs away with them but they leave behind bio medical waste, kitchen waste, food waste, general waste – cardboard cartons in which material comes to the hospital for pharmacies, general store, engineering store, construction material, paint and a spectrum of engineering residues which are being generally thrown in some corner of the corridor.
Cleaning/ Disinfection Protocols
Hospitals have various areas where patients & healthcare personnel are exposed to different kinds of risks of developing infection. Areas like the canteen & administration sections in the hospital have minimal exposure to infections. These areas are cleaned using detergents and water. OPDs and wards which house patients are also cleaned with detergent and water.
Disinfectants are used in areas where there is a spill of a body fluid. Isolation wards are areas where infected patients are admitted and detergents/disinfectants are used with separate cleaning equipment for each individual patient room.
The categories of risk involving patients when equipment are used include critical or high risk items, semi-critical or intermediate risk items and non-critical or low risk items. Critical items enter sterile areas in the body like the blood and hence carry a high risk of infection if they are contaminated. This category includes surgical instruments, cardiac, urinary catheters, implants and ultrasound probes used in sterile body cavities. Most of the items in this category are sterilized with steam if possible. Heat-sensitive objects can be treated with ethylene oxide, hydrogen peroxide gas plasma; or if other methods are unsuitable, by liquid chemical like >2.4% glutaraldehyde based formulations.
Semi-critical items come in contact with mucous membranes or non-intact skin. This category includes respiratory therapy and anesthesia equipment, some endoscopes, laryngoscope blades, esophageal manometry probes, cystoscopes , anorectal manometry catheters and diaphragm fitting rings. Semi-critical items minimally require high-level disinfection using chemical disinfectants. Glutaraldehyde, hydrogen peroxide, ortho-phthalaldehyde, and peracetic acid with hydrogen peroxide can be used for this purpose. Non- critical items are those that come in contact with intact skin but not mucous membranes. These items include bed pans, blood pressure cuffs, crutches and computers. They are de-contaminated after use.
Types of Disinfectants
Disinfectants can be divided into high level disinfectants, intermediate level disinfectants and low level disinfectants. High level disinfectants are chemicals which can destroy most micro-organisms but are unable to kill bacterial spores ex Glutaraldehyde & Orthophthaldehyde. Intermediate level disinfectants are able to kill Mycobacterium, most viruses and fungi. Low level disinfectants kill most vegetative bacteria, some viruses and some fungi. Examples of intermediate and low level disinfectants are Ethyl/Isopropyl alcohol and phenolic germicides.
Sanitization
Sanitizers are used in the hospital for the purpose of hand hygiene. They are known as hand rubs and are an alternative to soap and water. Hand rubs that can be used include alcohol based rubs and those containing povidone-iodine, benzalkonium chloride or triclosan. Alcohol-based hand sanitizers need to have a minimal concentration of 60 per cent and are effective against multiple common disease agents (e.g., shiga toxin-producing E. coli, Salmonella, and Campylobacter). However, they are ineffective against certain organisms (e.g., bacterial spores, Cryptosporidium and certain viruses). However, if the hands are visibly soiled, then it is always better to use an antimicrobial soap and water as hand sanitizers are ineffective in these situations.
Measures to control disinfection
Hygiene is those conditions and practices which are conducive to health or the science for the establishment and maintenance of health. This indicates broadly as what hygiene is but does not quite tell us what hygiene implies for different areas in hospitals. A towel in a washroom and mops used by housekeeping staff can be a potential source of microbes in a hospital despite the fact that housekeeping department is claiming of using the best disinfectant and sanitizer. Cleaning items need to be cleaned regularly as a dirty cleaning tool can spoil the facility. Machinery being used in a hospital or the way tissue dispensers are put also has a bearing on the hygiene.
Occupants of the hospital – patients, doctors, nurses, technicians, paramedical staff, kitchen staff, HK staff – have a dual role in hospital infections. One as a recipient of good hygiene and at the same time as also responsible for the poor hygiene in one way or the other. In general, it is the impact of the patient population, the movement of people across wards from the interior to the exterior, from the exterior to the interior and from one service area to another, which causes the possibility of infection. Personal hygiene is not only applicable to patients but also to other healthcare providers. Workload is another important determinant. There are people who work in air conditioned operation theatres, out-patient departments and clinics whereas housekeeping, engineering and the kitchen staff have to work in hot humid environments and travel through dusty cellars and basements to carry out work. They also have to visit patient care areas in the hospital. Tables, curtains, floors and walls also form the entire gamut of factors when work environment and hygiene are taken into consideration.
Infection control practices
There are standard protocols for surgical sterilization and disinfection of surgical/medical equipment. Pest Control is a problem because there is no omnibus solution for all pests. Each pest requires a different solution. Some solutions are as hazardous to the human beings as they are to the pests themselves. Antibiotic abuse is causing lot of drug resistant micro-organisms which are responsible for Hospital Acquired Infections (HAI). To control HAI, hospital hygiene and cleanliness is very important. Cleanliness of a hospital is a major Quality Indicator. There should be a proper hospital infection programme in each and every hospital. Unfortunately, it has taken a backseat in India. Centers for Disease Control and Prevention (CDC), Atlanta had started the hospital infection control programmes and management of bio medical waste in 1960s. They started the programme/guideline for the use of appropriate disinfectants and antiseptics, cleaning agents and sterilizing methods.
Challenge and Solution
Challenges which infection control personnel face are identification of a single disinfectant which can be used in most of the hospital areas and educating healthcare personnel about the proper use of disinfectants and monitoring their use in the hospital. Microbiologists need to be aware of various disinfection guidelines and protocols to ensure minimal rates of hospital infections.
Administrators generally have the tendency to go for the lowest quoted disinfectant and sanitizer, which may not always work. Hygiene gets compromised due to the strict costing measures in order to run a hospital. An integrated model of cleaning solutions needs to be set up in supplementing proper infection control practices to achieve the desired results. Kitchen and Laundry in a hospital set up should also be considered when following proper infection control practices.
In MBBS course, there is no topic of hospital infection control programme. House surgeons therefore are not knowledgeable about sterile precautions, surgical side wound dressing, hospital hygiene and cleanliness. Infection control also includes waste segregation and management. Waste has to be segregated at the source of generation, which many hospitals fail to follow. About 85% of the hospital waste is non-hazardous and non infectious which should not be allowed to mix with the general waste. Infection control policy and procedures need to be strictly followed. There should be a Clinical Microbiologist and Infection Control Nurse for a minimum 250 bed hospital who can monitors hygienic practices and develop monitoring tools in consultation with Infection Control Doctor.
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