Hospital Cleaning products and machines

In a health facility, there are a wide range of chemicals and disinfectants used for various clinical, nursing, laboratory and radiological procedures.

Cleaners and disinfectants for use in healthcare settings

The following cleaning and disinfecting materials are commonly used in healthcare settings:

1. Soap
2. Alcohols 60-90% ethyl or isopropyl alcohol/denatured ethyl alcohol
3. Iodophors
4. Quaternary Ammonium Compounds (‘QUATs’)
5. Chlorine and Chlorine Compounds:- (in order of preference)
6. NaDCC (Sodium dichloroisocyanurate)
7. Calcium Hypochlorite
8. Sodium Hypochlorite (‘bleach’)
9. Phenolic
10. Aldehydes (to be used only for environmental and/or equipment disinfection as per product contents)
11. Hydrogen Peroxide (to be used only as an antiseptic)

Soap

Soaps are generally alkaline compounds used to remove dirt and organic matter from surfaces. They act mainly by loosening the dirt and organic matter from the surface. Hence, the mechanical action of scrubbing/brushing followed by a water rinse is important when using soap for cleaning any surface. Soap has little or no antimicrobial activity. Soap solutions can allow growth of bacteria when used for environmental cleaning, they should be prepared just before use; used immediately and the leftover discarded. Soap can be used to clean large environmental surfaces to remove dirt, organic matter, grime, oils, and residues of disinfectants. It is cheap, easily available and along with proper mechanical scrubbing/brushing can remove almost 80-90% of microbes on a surface. The surfaces should be adequately rinsed to remove all soap residues. This increases the effectiveness of subsequently used disinfectants.

Alcohols

In healthcare settings, “Alcohol” generally refers to two water-soluble chemical compounds – ethyl alcohol and isopropyl alcohol. Alcohols are rapidly bactericidal rather than bacteriostatic against vegetative forms of bacteria; they also are tuberculocidal, fungicidal, and virucidal but do not destroy bacterial spores. Optimum bactericidal concentration is 60%–90% solutions in water (volume/volume). The most feasible explanation for the antimicrobial action of alcohol is denaturation of proteins.

Alcohols can be used for disinfecting small surface items such as thermometers, stethoscopes, equipment buttons, rubber stoppers of medication vials etc. The main use of alcohol in healthcare settings is as an antiseptic and for disinfection of small items/surfaces.

Alcohols are not recommended for sterilising medical and surgical materials principally because they lack sporicidal action and they cannot penetrate protein-rich materials. They should not be used to clean/disinfect large surfaces as they evaporate quickly leading to unreliable disinfection. They can also denature and fix proteins to the surface. Alcohols are highly flammable – they should be stored in a cool ventilated area and should not be used near open flame. They damage the shellac mountings of lensed instruments, tend to swell and harden rubber and certain plastic tubing after prolonged and repeated use, bleach rubber and plastic tiles and damage tonometer tips.

Iodophors

An iodophor is a combination of iodine and a solubilising agent or carrier; the resulting complex provides a sustained-release reservoir of iodine and releases small amounts of free iodine in aqueous solution. The free iodine is responsible for the antimicrobial action. The best-known and most widely used iodophor is povidone-iodine.

Iodophors are bactericidal, mycobactericidal, and virucidal but require prolonged contact times to kill certain fungi and bacterial spores (weak sporicidal activity). In a hospital, they are often used for ‘’Part Preparation’’ prior to surgery or any invasive procedure.

Antiseptic preparations of iodophors should not be used as environmental or equipment disinfectants because of concentration differences and surface staining.

Quaternary Amonium Compounds (QUATs/QACs)

Chemically, the quaternaries are organically substituted ammonium compounds. Examples of the chemical names of quaternary ammonium compounds are Benzalkonium Chloride, Benzethonium Chlorite, Cetrimide etc.

The quaternaries can be used in ordinary environmental sanitation of noncritical surfaces (e.g., floors, furniture, and walls), and for disinfecting medical equipment that contacts intact skin (e.g., blood pressure cuffs).

Although QUATs are widely used as disinfectants, they should not be used to disinfect patient care items such as catheters, cystoscopes etc. as infections have been reported from such use. The quaternaries are good cleaning agents, but high water hardness and materials such as cotton and gauze pads can make them less microbicidal because of insoluble precipitates or cotton and gauze pads absorb the active ingredients, respectively.

As with several other disinfectants (e.g., phenolics, iodophors) gram-negative bacteria can survive or grow in them. Therefore, cleanliness in preparation and immediate use are important practices to be followed in their use. Prepared solutions should not be stored for extended periods of time.

Chlorine and Chlorine Compounds

Chlorine products are available as liquids or solid powders. The strength of a chlorine solution is expressed in ppm of free chlorine. They have a broad spectrum of antimicrobial activity, do not leave toxic residues, are unaffected by water hardness, are inexpensive and fast acting, remove dried or fixed organisms and biofilms from surfaces, and have a low incidence of serious toxicity.

NaDCC (Sodium dichloroisocyanurate) should be the preferred one. Use of powder/granules should be more than liquid preparations in view of significant differences in storage requirements, shelf life and potency.

Sodium hypochlorite (‘bleach’) should be the last choice, if other chemicals are not available. Hypo is unstable and the disinfection efficacy of the final prepared solution varies widely. If used, it should be procured within one month of the manufacture and used as soon as possible. The can label should mention manufacture and expiry dates, batch number and concentration (minimum 5%).

Disadvantages of hypochlorite include corrosiveness to metals in high concentrations (>500 ppm), inactivation by organic matter, discolouring or “bleaching” of fabrics, release of toxic chlorine gas when mixed with ammonia or acid (e.g., household cleaning agents, urine), and relative stability. In general solid powders with these contents should be preferred over liquid hypochlorite.

Phenolic

These groups of disinfectant chemicals have carbolic acid base, derived from coal tar. Chlorinated fraction and petroleum residues are added to improve their cleansing and physical properties. Usually they are black or white fluids.

Phenolics are mostly used for floor and wall cleaning and can also be used for hard surfaces and equipment that do not touch mucus membrane (e.g. IV stands, wheel chairs, beds etc.)

They are more potent than iodophors. They are irritant to skin and mucosa and corrosive to metal surface. White fluids are emulsified suspension and precipitate on surface and make subsequent cleaning difficult.

Phenolics are not recommended for use in nurseries and food contact surfaces.Although this is a traditional disinfectant, it is damaging to the environment. It is recommended that this chemical should be phased out as soon as possible.

Aldehydes

The biocidal activity of aldehydes results from alkylation of sulfhydryl, hydroxyl, carboxyl, and amino groups of micro-organisms, which alters RNA, DNA, and protein synthesis. They have very good bactericidal, virucidal, fungicidal and sporicidal activity and are often used as HLDs. Aldehydes are generally non-corrosive to metal and do not damage lensed instruments, rubber or plastics.

Hydrogen Peroxide

Hydrogen Peroxide is popularly used in disinfecting equipment and environmental surfaces. It is effective against virus. Using this to clean blood from surfaces and linen is not recommended as it is very costly and corrosive. Can be used for cold sterilisation of heat sensitive critical items.Requires 30 minutes at 20^oC. They are having rapid action and non-toxic.

Choosing a Disinfectant for Health Care Facility

There is no ideal disinfectant, and the best option should be chosen according to the situation. A disinfectant solution is considered appropriate when the balance between the antimicrobial activity, required disinfection level, toxicity of the product, ease of use and cost is satisfactory for the given application.

General Principles while Using a Hospital Disinfectant

1. It is most important that an item or surface be free from visible soil and other items that might interfere with the action of the disinfectant, such as adhesive products, before a disinfectant is applied, or the disinfectant will not work
2. A hospital approved disinfectant may be used for equipment that only touches intact skin
3. It is important that the disinfectant be used according to the manufacturer’s instructions for dilution and contact time
4. Minimise the contamination levels of the disinfectant solution and equipment used for cleaning. This can be achieved by ensuring proper dilution of the disinfectant, preparing the disinfectant fresh before use, frequently changing the disinfectant solution and by not dipping a soiled cloth into the disinfectant solution (i.e., no ‘double-dipping’)
5. Personal protective equipment should be worn appropriate to the product(s) used
6. There should be a quality monitoring system in place to ensure the efficacy of the disinfectant over time (Vendors may also be asked to provide a quality test certificate for each batch for hospital records)

Important: The physical characteristics of the chemical should be considered before choosing a chemical. For example, even though alcohol is a rapid acting intermediate to HLD it is not suitable for disinfection of large surface areas due to rapid evaporation and flammability. Although chlorine is low cost HLD, it is highly corrosive to metals in concentration required for HLD.

Equipment for Cleaning

• Cleaning trolley/bucket – It is preferable to have three bucket trolleys with a wringing mechanism. Prefer a light coloured bucket to enable earlier detection of soiling of the water. The trolley should have provision to store bottles of disinfectant, the hand mops and stick mops on the trolley. A separate storage space for used hand mops should be available on the trolley. Ensure the trolley/bucket is clean before using it for cleaning work. The Three bucket system should be ideally practiced. The first bucket should contain water with detergent used in the beginning. The mop is then rinsed in the second bucket and dipped in the third bucket which can also contain a disinfectant and the mopping done again.
• Wet mops (microfiber mops preferable. If other types are used, use non-lining material). Mops used in critical, semi critical and general areas should be separate. Colour coding can be used to help staff differentiate easily.
• Dry (dust) mops to remove gross debris; brooms are not allowed in patient care areas. Mops used in critical, semi critical and general areas should be separate. Colour coding should be used to help staff differentiate easily.
• Long handled dust mops should be available for cleaning cobwebs and lint from the ceiling. These can be prepared by using any long wooden stick and tying a mop to one end. The mop should be tied in a way that allows wiping with pressure.
• Rubber floor wipers for toilet floor cleaning. Hand held rubber wipers for cleaning kitchen countertops and another set for toilet wall cleaning.
• Hand mops to clean equipment: (microfiber mops preferable. If other types are used, use non-linting material). The size should be large enough to make a palm sized mop when folded twice. Mops used in critical, semi critical and general areas should be separate. Colour coding should be used to help staff differentiate easily.
• Dust pans to gather the particulate waste. The waste should be pushed into the pan using a stiff cardboard/plastic.
• Rubber gloves/utility gloves with long and short arms. These should be size fitted.
• Water: Drinking quality water should preferably be used for preparing all cleaning solutions and rinsing of mops. Aquaguard water can be used. If source water is not clear, filter it using cotton mop/sheet folded twice and disinfect the filtrate with chlorine before use.

Brooms should never be used in patient care areas.

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Source: Guidelines For Implementation Of "KAYAKALP" Initiative