Looking for answers?

Since the launch of the Infection Control Hotline column, we’ve received a number of follow-up questions from readers. We forward these questions on to authors of the column so they can provide additional feedback. We thought we’d share some of the more interesting exchanges between readers and authors. If you have a follow-up question to one of the columns you’ve read, e-mail your question to associate publisher Bob Kehoe at [email protected].

Q I have been looking for the most up-to-date information on Clostridium difficile and cleaning, but really don’t see anything new. One of my concerns is that a bleach solution used alone without precleaning with a detergent/surfactant is not going to physically remove spores.

Having a two-step process is labor intensive. Using a quat with the proper friction and rinsing should remove the spores, but that may not be true. Since the CDC says use bleach only in a proven outbreak, this leaves me wondering what really needs to be done. I think most of us have gone to bleach for C. difficile rooms, but I see bleach being used elsewhere, too, which I would prefer not to do.

Also, in the January 2008 column Jean Fleming recommended the use of alcohol hand sanitizer for patients. The Joint Commission has discouraged us from using alcohol-based products or surface wipes where they may be used improperly. Even small alcohol wipes must be contained. We have hand rub mounted on the wall in every patient room. We have benzalkonium chloride wipes with a small percentage of alcohol for routine patient hand hygiene when they are not able to get out of bed.

Can you tell me what references you used for these two topics?

Amy Hughes
Infection Control
The Lankenau Hospital
Wynnewood, Pa.

The reader is correct in that there are no new recommendations for disinfecting rooms of C. difficile. Sodium hypochlorite in diluted form is still recommended by the CDC for disinfecting rooms of patients with C. difficile or in areas where C. difficile is endemic.

Should soil be present, precleaning with a detergent is always recommended. Thus, it would require a two-step process, which is labor intensive. Some bleach-based hospital disinfectants contain detergents and thus serve as both cleaners and disinfectants—therefore, a one-step process. 

Creating friction is always important in both cleaning and disinfecting surfaces with any germicidal product. The goal for using bleach products is to prevent spore formulation or replication. The EPA does not currently recognize a test for inactivation of C. difficile spores. Additionally, the EPA is no longer accepting claims for C. difficile in its vegetative state. Today, many facilities use bleach for C. difficile rooms and for disinfecting some medical devices/equipment that have specific recommendations for cleaning/disinfection and do not recommend certain quaternary ammonium-based disinfectants.

In the constantly changing health care environment, it is my opinion that there is a need for facilities to have both a bleach-based product and an EPA-registered germicidal product (quat or combination quat/alcohol) for disinfecting noncritical patient care items and environmental surfaces. Bleach products can be corrosive and leave an odor, which can be disturbing to patients and caregivers; thus, a facility may not want to use bleach as the primary disinfectant.

One should always use caution when cleaning using both a chlorine-based product and a quaternary ammonium-based product simultaneously (when both products are wet on the surface) as noxious fumes can be released and can cause breathing difficulties. 

In response to the reader’s comments about alcohol hand sanitizer for patients, there are hospitals throughout the nation that are using alcohol-based hand sanitizers for patients (on patient trays, in waiting rooms). The use of the alcohol-based hand products is one means to meet the Joint Commission’s patient safety goal #13 (“involving the patient in their care”). The CDC Hand Hygiene Guidelines (2002) discouraged the use of impregnated novelettes as they “contain a limited amount of alcohol.” However, I want to point out that these recommendations are based on references with a lower percentage of alcohol and since the publication of these guidelines, alcohol gel wipes impregnated with a greater than 60 percent ethanol alcohol (CDC’s recommended amount) have come on the market. 

Additionally, as the reader mentioned in her comments regarding friction created for cleaning, the wiping action of a hand wipe creates the necessary friction to remove soil plus 99.999 percent of bacteria on the skin. This is more effective than some popular gels after a 15-second application. The Joint Commission recommends alcohol-based hand sanitizers for health care workers because alcohol-based hand sanitizers are antimicrobial (i.e., effective against viruses, bacteria and fungi) and proven to be more effective. In addition to health care workers, the CDC recommends the use of alcohol-based hand sanitizers for waiting rooms, schools and for public use.

With today’s concern with antimicrobial resistance and virus transmission, the use of an alcohol-based hand sanitizer for patients has merit based on these CDC recommendations. According to the CDC, benzalkonium products for hand antisepsis are primarily bactericidal and are less effective in decontaminating hands than alcohol-based products. 

As with any products, patient safety must be considered. Placement of surface disinfection wipes and hand sanitizer products (i.e., any hand rub product) in patient care areas must always be carefully considered so that there is not a risk of error in proper usage. Surface disinfectant wipes should have signage that states “not for use on skin.”

The manufacturer of Sani Cloth disinfectant wipes provides such signage for customers and the canisters are labeled with this warning. The key to a safe environment is educating patients, visitors and caregivers about proper application and usage. With proper signage and evidence of education, the Joint Commission should not have an issue with use of both surface wipes and hand sanitizers in patient care areas.

Jean Fleming, R.N.
Clinical Director
Infection Prevention & Education Professional Disposables
International Inc.
Orangeburg, N.Y.

Q I am the central supply manager for my hospital. The nursing floors have asked us to sterilize bed linens for patients that claim they are allergic to them. Our laundry process is very proficient in removing all cleaning agents produced during the laundering of linens. In fact, the laundering process contains [fewer] chemicals than city water. I have explained to them that sterilizing linens will not change their values. In fact, it makes them more abrasive. They still insist that we follow through and sterilize the linens.

Is it advisable to sterilize linens for patients who say they are allergic to them? These linens are not being used in a sterile environment or for burn patients. Once they open them, they may as well have taken them off the linen cart.

Marcia Zello
MidState Medical Center
Meriden, Conn.

This allergic reaction by patients needs to be validated by a dermatologist or allergist. The condition could be a side effect from medications or other sources, rather than laundry processing agents and fabrics. Sterilizing linen does not ensure cutaneous reactions will be resolved; plus, this is not a standard intervention for a patient-proclaimed condition. Laundry facilities employ specific formulas and concentrations in textile processing to safeguard human contact/reactions and to prolong the life cycle of fabrics. Aside from textiles used as sterile fields, sterilizing textiles is not routinely performed per patient request. The manager is correct in denying the sterilizing request.

Nancy B. Bjerke, R.N.
APIC HLAC Coordinator
APIC Practice Guidance Council
San Antonio

Q I am a surgical tech and I work in a three-suite OR. We have a lot of cases and sometimes we have to use the STERIS machine [System 1 sterile processing system] to sterilize equipment. I want to know the proper way to bring it to the sterile field.

The way I was taught was that the scrub had to come out of the room and take it out. There are a few here who say that the circulator has to bring it into room and place it on a Mayo stand, open the lid and the scrub takes the item.

I do not think that this is the correct way to do this because the tray has holes on the bottom to drain the water. If you can help me with this question or direct me to someone who can, I would appreciate it. What is the proper method?

Cheryl Wanner
St. Joseph’s Hospital
Dickinson, N.D.

The most common and effective aseptic transfer of a sterile device from System 1 sterile processing system is as follows:

The circulator, who is masked and wearing clean gloves, takes the container from the SS1 processor and walks the container into the surgical suite. Then he/she lifts the lid like a “clam shell” and presents the devices to the sterile scrub nurse. The sterile scrub nurse takes the devices without touching the external surfaces of the container and places the sterile devices on the back table or  Mayo stand, where at this point, the surgical sterile field has been created.

John Kurowski, R.N.
Director clinical education
STERIS Corp.
Mentor, OHIO

This article first appeared in the March 2008 issue of Materials Management in Health Care.

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