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With good planning
and
oversight, green cleaning offers a high-performance cleaning
process that prioritizes infection control but also reduces
waste, risks to workers and building occupants, and negative
impacts on the environment.
According to Hospitals for a Healthy Environment
(H2E), a joint effort of the American Hospital Association, the
EPA, Health Care Without Harm, and the American Nurses
Association, cleaning practices may involve changing
long-standing protocols.
A successful program focuses on overall “quality
cleaning,” standardized operations, effective
tools
and cleaning chemicals, uniform dispensing systems,
comprehensive staff training, proper protective equipment, and
clearly written policies and protocols for the various levels of
cleaning and response to blood and body fluid spills.
1. Establish goals: the first step, according to
H2E, is to define and clearly articulate the objective of the
effort to transition to greener cleaners for improved IAQ,
worker and patient safety concerns and/or improved environmental
performance.
Start by identifying your facility champions,
who will support the objective. Include housekeeping and
environmental services staff and supervisors, nurses, employee
health representatives, and someone from public affairs, as well
as EH&S staff and purchasing personnel.
Of course, it is essential to
include Infection Control and other high-level staff who may
have concerns about the changes, including operating room and/or
emergency room staff.
2. Products and Practices: Quality improvement
initiatives typically require doing a baseline assessment before
implementation,
in order
to measure progress and improvement.
Inventory Cleaning Products: First, review
purchasing records to determine current inventory of cleaning
products.
Next, conduct a walkthrough survey to determine
what products are being used. Record the following information
for each product found during your research:
• Product cost—to be used later when comparing
alternatives;
• Manufacturer, vendor and/or distributor
information;
• Material Safety Data Sheets (MSDS) and label
warning language;
• Personal protective equipment (PPE)
requirements;
• Special handling and disposal requirements;
• Where the product is used and for what
application.
Identify any products that have been linked to
worker injuries or staff or patient complaints. Investigate
whether specific products have been implicated in any regulatory
compliance issues.
Note areas where unapproved items are being
used, or unusual quantities are found, etc.
Inventory Cleaning Equipment
This step shouldn’t yield any
surprises, but quantifying your tools and equipment, including
paper products, is an important step when addressing process
changes.
Record the following
information for equipment found in your research:
• Number and types of
equipment located in different departments;
• Purpose of equipment and how
often it is used;
• Identify type of filtration
on vacuum cleaners;
• Determine if high speed
floor machines use vacuum attachments;
• Investigate what
treatment—laundering, disinfection, disposal—different cleaning
tools require, to compare with proposed alternatives;
• Review processes currently
used in your facility, including: Body fluid spill cleanup
policy, as required by OSHA; and disinfection policies,
including where EPA-registered products are required.
3. Evaluate and categorize
facility areas:
Identify critical,
semi-critical and non-critical care areas
facility-wide, to strategically determine the need for
disinfection versus general cleaning, and to develop thoughtful
and effective cleaning protocols. The CDC offers helpful
guidance on characterizing the different areas of health care
facilities according to criticality.
Critical care areas include the operating room,
isolation rooms, and acute care areas, and should be disinfected
as part of the cleaning process. Disinfection is necessary for
surfaces or equipment that will come into contact with broken
skin or mucous membranes.
The CDC recommends these critical care surfaces
be cleaned, then disinfected. Use EPA-registered intermediary
grade disinfectants that kill pathogens causing TB and Hepatitis
B10 if the surface is contaminated with blood or body fluids.
When identifying surfaces to disinfect, consider
level of hand contact and likelihood of body substance
contamination. Semi-critical areas include exam rooms and a
variety of treatment rooms. The multidisciplinary team can
identify which areas are semi-critical, since this category can
vary from hospital to hospital.
Non-critical care areas such as offices, waiting
areas, hallways and the cafeteria, should be cleaned with
general cleaners and need little disinfection. Interestingly,
non-critical care areas account for anywhere between 45 to 65
percent of the average facility.
Patient rooms present a wide variety of needs
depending on the potential for infection posed by specific
illnesses and conditions, and will require the team to evaluate
and discuss the appropriate level of disinfection and cleaning
necessary on a case by case basis.
4. Determine Evaluation Criteria: Confirm
performance and environmental criteria goals identified in Step
1, and include additional criteria developed since the project
started. Evaluate the different methods for assessing required
cleaning product performance and environmental attributes.
It is crucial to include infection control in
this part of the process, as they need to feel comfortable with
the efficacy, as well as the environmentally friendly aspects,
of the new products chosen.
In addition to determining desired product
criteria, consider physical plant and process changes, and new
tools. Preventive
strategies like removing absorbent materials (i.e. carpet) from
areas where moisture is present to addressing mold
contamination; or reducing cleaning of walls and blinds to only
when soiled, and then, only upon patient discharge.
Reduce soiling and wear on floor surfaces by
installing walk off mats at all entrances, which can reduce the
need for cleaning with harsh chemicals. Eliminating spray
application in favor of pour and wipe products wherever possible
can significantly reduce airborne contamination inside your
facility.
Reducing the frequency of floor-finish buffing,
which can aerosolize finish polymers and cause respiratory
problems, and using buffing equipment with active vacuum
attachments, can minimize patient and staff exposures. New tools
such as microfiber mops and automated equipment such as auto
scrubbers and extraction machines can significantly reduce
chemical and water usage as well as improving the ergonomics of
floor cleaning.
5. Select Products: When the critical,
semi-critical and non-critical care area have been identified along with the attributes you want your products to possess, it is time to select and prioritize cleaning products to trial. Make sure you stick with the performance and environmental criteria you’ve identified; and require proof, not simply an assurance from a vendor, that a product meets your criteria.
The committee may identify some product changes that can be implemented immediately, facility-wide, without intensive review. For example, glass cleaner is not critical to patient or staff safety, and many environmentally preferable alternatives are available, so you might want to simply select a certified glass cleaner and transition immediately.
Other products such as disinfectants will take serious time and study. When selecting products, make sure to compare their cost to that of conventional cleaning chemicals on a per-cleaning rather than per-ounce cost basis, and include an estimate for avoided costs for worker protection, special handling, or disposal issues.
Many users find that green cleaners that employ one solution at different concentrations for multiple cleaning tasks can save closet space, help staff avoid confusion and reduce costs.
Because all disinfectants have
toxic properties, green cleaning in this area consists of
appropriate and limited use of disinfectants on an as-needed
basis. Disinfectants are toxic by design in order to kill
pathogens. Because of this, there is always a risk of side
effects when using disinfectants.
For example, bleach (sodium
hypochlorite) is an effective treatment against bloodborne
pathogens, but is also highly corrosive and a respiratory
irritant, which makes it dangerous to workers, damaging to many
surfaces, and toxic when released to the environment.
While you can’t always
eliminate their use, limit disinfectant applications to the
appropriate setting, amount, and target organism. When selecting
disinfectant products, care should be taken:
• To choose a product specific
to your disinfection needs;
• To assess and minimize risks
to patients or staff;
• To thoroughly clean before
use;
• To use the product in the
most effective manner.
Some disinfectants, while
highly effective, may pose too much risk to be appropriate in
certain settings; for example, phenolics should be used
sparingly and with extra precautions, if at all, in neonatal or
pediatric care units, since infants and small children cannot
metabolize them.
More is not better with
disinfection. Use of excess product, or broadcast application of
products when targeted surface treatment would be effective
simply increases occupational and environmental risks without
increasing effectiveness.
6. Develop a Pilot Plan: After
having evaluated cleaning area categories and specific products
with which to begin your program, develop a plan to pilot your
choices. You will need to:
• Identify the area(s) where a
pilot will be implemented: You may choose all non-critical areas
to start, or a mixture of levels of criticality to assess
applicability to different environments.
• Determine your evaluation
criteria, do you simply want general feedback from housekeeping
staff? Do you need to do bacterial swipe tests? Do you need to
assess the impact of specific events/conditions (i.e. winter
weather)? Balance your need for detailed assessment against your
ability to devote time, energy and money to following through.
• In addition to alternative
cleaning chemicals, are you also implementing process changes?
If so, consider how new processes or tools may impact the
evaluation of the new cleaning chemicals. How can you control
for one aspect of the program when evaluating another?
• Develop pre-implementation
and post-implementation surveys for facility staff, patients and
visitors based on your team members’ concerns. Questions might
touch on perceptions of cleanliness, presence or absence of
reactions to current products and alternatives, and convenience
of product usage.
7. Execute Your Pilot: Even
effective green cleaners may need an adjustment in cleaning
protocols, and the switch could be a disaster without an
effective training and education program.
Change is a challenge, but the
more people understand, the easier the shift in culture—and
facilities can take this opportunity to improve general training
and awareness for cleaning staff. So educate, educate, educate.
And make sure education is
multilingual in case your facility employs staff with limited
English.
Product vendors should have
training materials and programs to offer you (this is often a
standard certification requirement). Training should address
proper dilution, labeling, standardization of practice,
appropriate residence time for disinfection and cleaning
products, and any protective equipment requirements. Cleaning
protocols for the new products should be posted in janitorial
closets to refresh on methods of practice—remember, some
housekeeping staff may respond better to graphic training
materials rather than extensive text.
During the course of the
pilot, make sure a designated member of your Green Cleaning team
maintains regular communication with key staff in the area where
the pilot is taking place. If there are any complaints or
questions, make sure you field and respond to them immediately,
before staff become frustrated by a lack of assistance.
8. Pilot Evaluation: Pre-pilot
surveys allow you to develop a baseline for staff and patient
response to cleaning methods and products before starting your
pilot effort. When your pilot has run for the designated time
period, begin the next assessment phase.
It is not necessary to stop
using alternative products during this phase, your assessment
may show that they have worked really well, but it is important
to gain some detailed information about how the changes have
been received, and whether they have succeeded at the level of
performance. This will provide support for expansion of the
pilot to full-scale implementation, or let you know that there
are aspects that need to be worked out before expansion is
possible.
Administer post-pilot surveys
to obtain information about staff, patient and visitor reactions
(if any) to the changes. These can be the same survey
administered before the pilot.
Survey janitorial workers,
nursing staff and others who may be involved with the pilot to
see if they have any issues or concerns about using the new
products, tools or processes.
Evaluate any objective data
you have gathered during the implementation Phase, such as rates
of chemical usage, water usage, bucket changes, mop heads
laundered, and so forth.
Use the results of your
surveys to identify those products or processes that are highly
successful and to flag those that did not work as well, and need
to either be readdressed or dropped in future efforts.
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Source: Hospitals for a
Healthy Environment.
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