The COVID-19 outbreak has thrown the spotlight on hospital cleanliness and hygiene. We look at how this is impacting on hospital infection control and facilities managers
Hygiene has been top of the agenda since the beginning of the coronavirus outbreak, and nowhere is it more important to ensure the environment is clean than in hospitals.
With thousands of patients being treated for COVID-19, and patients in hospital for other reasons often much more vulnerable to contracting the bug, effective decontamination measures are crucial in the current pandemic.
At the start of the crisis, the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England published joint guidance for infection prevention and control in healthcare settings.
It states that patient isolation rooms, cohort areas, and clinical rooms must be decontaminated at least once daily, and all clinical rooms should be decontaminated after sessions involving patients with suspected, or known, coronavirus.
In addition, patient isolation rooms must be terminally cleaned following discharge or transfer, or when vacated by staff following an aerosol generating procedure (AGP); and it says decontamination schedules should be carried out more frequently in areas where there may be higher environmental contamination rates, such as toilet facilities; and where there are high-touch surfaces such as medical equipment, door handles, and call bells.
In this case the guidance states that these surfaces should be cleaned at least twice daily, or when known to be contaminated with secretions, excretions or bodily fluids.
But what does this mean for estates and facilities teams?
A spokesman for the Infection Prevention Society said: “Studies tell us that COVID-19 behaves like SARS-CoV and is associated with significant contamination of the environment.
“The solution to this problem is regular cleaning of the environment, especially high-touch surfaces, with detergent and chlorine-based solutions.”
But, in recent years, a new, and more-effective, tool has come to the fore in the shape of Accelerated Hydrogen Peroxide (AHP) and this is being widely used to help combat environmental contamination in hospitals across the UK and overseas.
Though no specific products had been thoroughly tested on the latest coronavirus strain, studies to date highlight its efficacy on numerous similar microorganisms.
A spokesman for hygiene and cleaning solutions company, Diversey, explains:
“Cleaning professionals have traditionally chosen disinfectants with chlorine as the active ingredient, usually as bleaches, for cleaning hard surfaces in care settings.
“However, there are some drawbacks that can limit their usefulness.
“Alternative formulations with AHP as the active ingredient offer numerous advantages with few limitations.”
And the key requirement from any disinfectant in healthcare settings is efficacy.
Dr Stefan Wagener, a scientific advisor and trainer at the Global Biorisk Advisory Council (GBAC) and executive director of Biorisk International, revealed that the virus can stay on certain surfaces for up to a week or longer and touching these surfaces, and then your mouth, nose, or eyes, is considered a potential route of transmission.
Coughing and sneezing are particular problem areas, with faecal matter also assumed to be a source.
The right information
Dr Wagener said: “As the coronavirus has been identified as an enveloped virus, similar to influenza, we have proven cleaning methodologies and protocols which we can bring to bear as we try to combat its spread.
“However, the amount of misinformation or misuse of industry terminology is leading to greater confusion, higher risk of spread, and a higher potential for dissatisfaction.
“For COVID-19 we need to disinfect surfaces and objects that are potentially contaminated with the virus AND are frequently touched and/or used.
“For surfaces that are soiled we need a two-stage process. First, surfaces must be cleaned to remove soil. Secondly, they should be disinfected with appropriate chemicals and processes.
“It’s about selecting what is most suitable and what is approved.”
A number of manufacturers provide AHP decontamination services, which they are offering more widely to hospitals as a result of the COVID-19 outbreak.
Diversey’s Oxivir range is one such solution, with the Excel product available in a ready-to-use form.
It can be used for regular and daily cleaning on a wide range of surfaces and gets to work in just 30 seconds.
Also advising hospitals up and down the country is Medical Air Technology (MAT).
Its business development manager, Will Evans, said: “There is currently a lack of direct evidence for any disinfectant efficacy against coronavirus. However, in the absence of direct evidence, disinfection would still be a good thing to do.
“Whole-room decontamination through airborne fogging or spraying is likely to be the most-suitable and effective intervention as it disinfects the air and uses smaller particles sizes, enabling a disinfectant to reach the areas that viral particles may reach.”
Like Diversey, he advises the use of hydrogen peroxide (H2O2), particularly via ‘fogging’, where hydrogen peroxide is delivered into the environment through either a dry mist or vapour.
“Touchless H2O2 disinfection has many benefits,” he says.
The best approach
“It is effective, always killing 99.99% of harmful pathogens; it’s quick, taking just a few minutes to treat a standard area; it can be undertaken with minimal disruption, which is important in healthcare settings; it is suitable for many different environments and surfaces; it is delivered in a single application; and it is non toxic and non allergenic. Additionally, it costs less than many traditional cleaning methods.
“The process of airborne fogging is quick to deploy and is the most-effective kill solution for airborne viruses, which seldom simply rest on surfaces, to be cleaned away.
“Due to the particle size, particles will also remain in the air and our process is dry and can be used on all surfaces and materials, including paper and electrical items. And it does not put any additional risk on the user as the process is touchless.”
He adds: “We believe this approach is much more effective than a deep clean because any manual clean process is labour intensive and places the personnel directly at risk from contaminated surfaces. It also allows the opportunity for cross contamination to transfer virus particles through human transfer or via equipment.”
At a practical level, a single fogging process can treat an area of 1,000 cubic metres an hour with a single operator and a single set of personal protective equipment (PPE).
The same area would require a team of 12 to achieve a clean in the same timescale and would utilise 12 sets of PPE, which would then need to be disposed of to avoid cross contamination.
But, whatever approach hospitals use, getting expert advice is crucial.
Reducing the spread
Following an increase in requests for its bio-decontamination services, Interfurn is making its BIOAct-365 decontamination solution available as part of a planned cleaning and maintenance programme, or as a rapid emergency response by hospitals to the current pressures.
As well as general areas, the service is suitable for operating theatres, critical care and recovery areas as well as those housing immune-compromised patients.
It provides a cost-effective and scalable solution for most areas from 5sq m to 200sq m, delivering a highly-purified hydrogen peroxide vapour capable of eliminating 99.9999% of known pathogens and leaving no residue.
A spokesman for Interfurn said: “There are a number of medical-grade disinfectants that are known to eliminate other similar coronaviruses and areas can be ‘misted’ or ‘fogged’ with these to ensure even coverage of all areas, including the inside of cupboards, drawers etc if they are left open during the process.
“The regular disinfection of ‘high-traffic’ areas such as door handles, keyboards, phones, desks, light switches etc – any area that comes into contact with people throughout the day – will further reduce the spread.”
Another company offering advice to hospitals looking for the best approach in the current climate, is Bioquell, which is helping trusts via its Hydrogen Peroxide Vapour Rapid Bio-decontamination Service (RBDS).
A study published in the April 2014 issue of The Journal of Hospital Infection evaluated the in-vitro efficacy of Bioquell Hydrogen Peroxide Vapour for the in-activation of a number of structurally-distinct viruses that could impact the healthcare, veterinary and public sectors.
And the findings showed that after exposure to Bioquell’s Hydrogen Peroxide Vapour, no viable viruses were identified, making it a popular choice to curb the spread of coronavirus.
A Bioquell spokesman said: “Respiratory viruses can contaminate and survive for long periods on environmental surfaces. Therefore, effective disinfection is essential for stopping transmission from the environment.
“However, this is not always achieved by conventional cleaning and disinfection techniques.
“Bioquell’s Hydrogen Peroxide Vapour is a vapour-phase disinfection method that is virucidal on structurally-distinct viruses dried on surfaces.
“Our RBDS can be quickly called upon to eradicate coronavirus from a single area, several locations within a facility, or an entire building.”
The hidden risks
It’s not just the physical environment – walls, floors, ceilings and equipment – that need close attention. Hospitals also need to consider other ‘hidden’ risks, such as HVAC systems, which can provide another way for viruses to spread across wide areas.
Hillary Spicer, managing director of E-CO, a provider of high-intensity UVC solutions for HVAC systems, said: “A particular problem for hospitals is that they commonly recirculate air. This, in turn, recirculates aerosolised viruses such as COVID-19. There is no technology installed that intercepts and kills these viruses.
“However, no pathogen can withstand exposure to Ultraviolet ‘C’ (UVC) or develop ‘resistance’ to it. Correctly deployed, UVC will kill airborne coronavirus dead.”
She advises the use of active and passive UVC through the deployment of hand-held devices which disinfect surfaces; in-ceiling products which can be used in operating theatres and isolation rooms; in-room purification systems such as its SterilZone; and portable UVC, which can be wheeled between rooms.
Also helping to reduce viral burden on surfaces is Biomaster, whose proven antimicrobial technology has been found to be effective at reducing the viability of viruses on porous surfaces, including treated fabrics and papers.
The company’s regulatory affairs officer, Lesley Taylor, said: “COVID-19 relies on a protective lipid coating.
“Unlike many gastrointestinal viruses, such as Norovirus, which have a tough protein shell called a capsid enveloped virus; viruses with this lipid coating are relatively vulnerable and easier to destroy.
“Alcohol-based products, for example, disintegrate the protective lipids. And quaternary ammonium disinfectants, commonly used in healthcare, attack protein and lipid structures, thwarting the pathogen’s typical mode of infection.
“Bleach and other potent oxidisers will also break down the essential components of a virus.
“These methods are highly effective at removing dangerous pathogens from surfaces, but they only remain effective for up to two hours maximum; and any new microbes landing on the surface after that will continue to thrive.”
In independent lab tests, analysis identified that Biomaster fabric spray was effective at reducing the viability of Norovirus applied to textiles, such as protective facemasks and cubicle curtains.
Taylor said: “Biomaster has yet to be tested against COVID-19 on this type of application and currently there is no method available by which it could be tested.
“However, although we do not yet have any data, the microbiology suggests that if Biomaster is effective against Norovirus on porous surfaces, then the active agent is also likely to have an effect on the lipid coating and the essential components required for COVID-19 to function and invade a host.
“The most-important thing at this time is to follow the official advice and keep safe.”