By Mitch Birchfield, Special to the Healthcare Facilities Today

Many advancements in modern medicine and environmental services (EVS) have helped us live longer and have cleaner indoor environments. We can attribute this success in part to:

• Development of certain pharmaceutical drugs;

• Better sanitizing and disinfecting.  

It is hard to imagine life without the current array of potent disinfectants and cleaning products, advances in equipment and applications such as automatic scrubbing machines for floors, microfiber for hard surface cleaning, and many other tools and interventions that reduce labor, make jobs easier and cost effective, and protect public health. (There is a wide range of chemical disinfectants in daily use, e.g., the author counted as many as eight types of disinfectants being used at hospitals for cleaning in the surgical environment).

Ironically while we have achieved “cleaner” indoor environments in aspects of microbial-control, keeping us safer from certain pathogens, the use of more chemical disinfectants poses problems related to human and mammalian toxicity and sensitivity, as well as planetary ecology issues related to disposal of hazardous chemicals in the environment.

The introduction of more specialized chemical disinfectants to combat multi-drug Resistant organisms (MDROs) and other pathogens, places us squarely in an environmental contradiction: we are making environments increasingly unfriendly to both pathogens and people. 

This paradox is perplexing for cleaning managers seeking to balance microbial control concerns with indoor and outdoor environmental protection, a concern that is further amplified by the disconnect between “infection prevention” and “environmental services” and the intense, relentless pressure on healthcare facilities to prevent HAIs.

It is time to:

• Examine the impact of  routine, universal use of chemical products, including titrated and ready-to-use (RTU) versions, with viable alternatives such as “chemical-free” dry steam vapor;

• Better integrate infection prevention/control and EVS or housekeeping functions, and;

• Validate what works in the context of protecting people, planet, profits — and the fourth “P” — performance.

Products, processes and equipment should also be easy to understand and use, as incorrect use of chemical disinfectants, e.g., the lack of proper mixing, pre-cleaning and dwell time, is the norm rather than the exception.

Consider that the recommended efficacy dwell or contact time for disinfectants ranges from several to 10 minutes or more, while dry steam vapor contact time for full-spectrum kill is nearly instantaneous.

Chemical dispensing innovation

Still, chemical dilution stations are innovations that:

• Largely eliminate the need to manually mix products;

• Reduce unsafe, wasteful practices such as the “glugging” of chemicals;

• Curtail the dangerous practice of mixing incompatible concoctions such as bleach and ammonia; and 

• Prevent the wasteful, hazardous “more chemical is better” practice.

Using chemical-dilution titration stations helps to ensure efficacy, and to keep environmental and housekeeping workers safer. 

Chemical-mixing station dependency, maintenance 

However, we are over-reliant on these modalities to the point where scrutiny of chemical use via titration stations is almost nonexistent. 

Chemical-titration strips can check for correct disinfectant dilution or concentration, and system pumps, suction, tubing, calibration tips, chemical dispensing volume, and ASME air-gap compliance requirements can and should be checked/verified via a quarterly onsite visit by the product-provider, visually documented by a dated service sticker and recording outcomes in a log book.

Replace complacence about managing chemicals and delivery stations with vigilance and trackable metrics shared between EVS and Infection Prevention/Control teams.

RTUs and the sporicidal dilemma 

Of course, not all disinfectants can be easily titrated using dispensing machines, largely because some disinfectants lose efficacy over time and are not stable; for example, a one-in-four-part bleach to water mix will lose stability in a 24-hour period. 

Since these products cannot maintain effectiveness when titrated using common dispensing machines, some healthcare organizations resort to costly RTUs such as bleach derivatives and hydrogen peroxide products to deal with hardy spore-form microbes such as C-diff.

Cost tracking 

Know the costs of diluted and RTU products as these can total $ thousands or $10s of thousands annually compared with non-chemical interventions.

Cost of chemical disinfectants

Here’s a quick analysis on the cost of disinfectants in a 250-bed hospital, contrasting the cost of an RTU product such as an “embedded-bleach” or a peracetic acid wipe and a dry steam vapor device:

RTU spray*           RTU Bleach           Derivative-Wipe**            Steam Vapor***

Per room               .67 cents              $2.00                             .10-.20 cents

Daily Cost             $168.00                $500.00                          $50.00 

*Estimating 30 one-ounce sprays per room @ 2.2 cents per ounce.

**Estimating 7 wipes to clean a patient room @ .28 cents per wipe.

***Calculating the cost and depreciation of the capital investment, supplies and electricity using a dry steam cleaning machine. 

Avoid quick, expensive decisions

Disinfecting-system decisions made quickly are often costly, in line with the axiom that it is “simple to make things complicated and complicated to make things simple.”

Thorough analysis of how much each decision costs short and long-term, and working through viable alternative scenarios should be part of this vital public-health-protection process.

Moving forward by looking back

Nikola Tesla, the inventor and creator of many patents, made significant contributions to the design of electrical delivery systems and devices, was not immediately respected by many in his day, and was often viewed as a “mad scientist”. Today, Tesla is known for being well ahead of his time.

Similarly, cleaning managers must step up innovation on the front lines, meet the challenge of leadership and avoid business as usual. The rewards are great, long-term and positive-legacy-forming.

Cleaning managers: Think outside of the chemical box or bottle

The one-size-fits-all chemical disinfectant solution is problematic at best. 

The solution calls for independent thinking outside of the chemical box or bottle. Quaternary disinfectants are fine for everyday disinfection, but C. diff., MDRO and superbugs call for a more aggressive, progressive approach. 

Adding more disinfectants to the chemical tool kit may add to the problem (and costs) rather than solve the problem. 

A dry steam vapor machine is a viable, far less costly option, performs superbly and rapidly, and is not intimidating for EVS staffs to use.

Also worth considering are UV devices — killing pathogens with light — although upfront capital investment is often high, cleaning is still vital, and pre-cleaning and other disinfection will still be needed, especially in shadowed areas.

In short, we owe it our organizations, staffs, customers and global ecosystem to closely examine the challenges and alternatives, and provide a thoughtful, knowledge-driven, innovative approach to a cleaner, healthier and more sustainable environment.

References

1. PNAS, Proceedings of the National Academy of Sciences, November 19, 2010; 

Bacterial biofilm shows persistent resistance to liquid wetting and gas penetration; Alexander K. Epstein; Boaz Pokroy; Agnese Seminara; Joanna Aizenberg. Author affiliations: School of Engineering and Applied Sciences, Harvard University; Kavli Institute for Bionano Science and Technology; Department of Chemistry and Chemical Biology, Harvard University; and Wyss Institute for Biologically Inspired Engineering. Edited by Jerry P. Gollub, Haverford College, Haverford, PA. http://www.pnas.org/content/108/3/995.full 

2. AJIC: American Journal of Infection Control, Volume 37, Issue 1 , Pages 20-27, February 2009; Reduction in infection risk through treatment of microbially contaminated surfaces with a novel, portable, saturated steam vapor disinfection system; Benjamin D. Tanner, PhD.

http://www.ajicjournal.org/article/S0196-6553%2808%2900557-9/abstract

3. AJIC: American Journal of Infection Control, Volume 39, Issue 8 , Pages 655-662, October 2011; Reduction in the microbial load on high-touch surfaces in hospital rooms by treatment with a portable saturated steam vapor disinfection system; Jonathan D. Sexton, MS; Benjamin D. Tanner, PhD; Sheri L. Maxwell, BS; Charles P. Gerba, PhD.

http://www.ajicjournal.org/article/S0196-6553%2811%2900095-2/abstract 

4. AJIC: American Journal of Infection Control, Volume 40, Issue 10 , Pages 926-930, December 2012; Biofilms on environmental surfaces: Evaluation of the disinfection efficacy of a novel steam vapor system; Liyan Song, PhD; Jianfeng Wu, PhD; Chuanwu Xi, PhD. http://www.ajicjournal.org/article/S0196-6553%2811%2901317-4/abstract    

Chemical vs Non-chemical Disinfection – Bleach Versus Steam Vapor

Bleach disrupts microbial cells destroying pathogens, but is known for its toxicity, caustic nature, and ineffectiveness in penetrating biofilms. (See Reference 1 above)

Conversely, steam vapor − first used to power steam engines and thereafter to drive the industrial revolution – is now well established, though under-utilized, as a non-toxic, broad-spectrum antimicrobial agent when used in low-moisture (6%) non-toxic treated tap-water systems while also effective on biofilms (See References 2-4 above).

Mitch Birchfield is an environmental services and waste management consultant.