Keeping the nursing home clean and dry.

Editor's Note: Nursing homes probably rank with schools and day care centers as potential host environments for infectious organisms. Like the children in those institutions, nursing home residents can be particularly vulnerable--for example, to frequent spills or even embarrassing "accidents" because of continence problems. Maintaining clean environments in these settings is a special challenge. Over the years, Michael A. Berry, PhD, who recently retired from the Environmental Protection Agency (EPA) and now is an environmental research professor at the University of North Carolina, has had frequent contact with facility managers on issues of sanitation. In a recent interview with Nursing Homes/Long Term Care Management, upon which this article is based, he offered suggestions on how nursing homes might meet the challenges of infection control through cleanliness.

When I was asked once what I would use as the descriptor for a healthy indoor environment, I said, "clean and dry." You need to have processes for disposing of unhealthy material and for preventing its promotion. The key word here is "processes"--you need to have a plan for addressing sanitation issues, and then a knowledge of the right technology to bring to bear.

There is no substitute for having a plan, both for regular cleaning and for responding to accidents that might quickly lead to infection-control problems. Each facility must develop a plan according to its own circumstances--the types of residents it has, the number of common areas and the frequency of their use, and the proportion of hard surfaces (floors, furniture, countertops) present and serving as particular breeding areas for microorganism growth if not well attended to.

Nursing homes should also understand their cleaning agents. Aside from household bleach, which I find to be as powerful an agent as we have for the healthcare setting, there are a number of cleaning chemicals available. Some promote a very wide spectrum of activity against common microorganisms in the nursing home--and some are more effective than others. I would suggest that nursing homes look into vendors' test data because, in some cases, the agents have been tested in environments quite different from those found in the field.

Among issues of particular concern to nursing homes are drug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Facilities might start by reviewing the infection rates involving these microorganisms in their areas and localities; data are readily available from the health intelligence system throughout the United States. Many states' public agencies, the Centers for Disease Control and Prevention, and the National Library of Medicine are good starting points for information.

Next, nursing home administrators should then focus on areas within the facility where contact with infected residents might most often occur. In developing a cleaning plan for these areas, it is important to avoid a unilateral approach--for example, concentrating on increased handwashing only or increasing the disinfectant concentration in the cleaning water. Both are important. Focusing on one or the other might miss important sites of contact. In other words, facilities need a total systems approach to infection control, and they must continually review it. No matter what they're doing, they can always improve.

Another area of concern is bloodborne pathogens. A facility should always take a safe approach to cleaning up blood. It should be assumed that all blood is infected with a pathogen--HIV, particularly. Protective gloves should be worn and care taken not to puncture the gloves while cleaning. A suggestion would be to surround any blood spots with household bleach, letting the blood and any glass or other debris mixed with it to become saturated with the bleach and remain saturated for at least 30 minutes. Treat all material that has come in contact with the blood spill as medical waste and dispose of it accordingly.

In reviewing a plan for cleaning, it is important to remember not to focus on the floor as a primary site harboring infectious microorganisms. In my reviews of schools and healthcare facilities, I have found the bulk of bacteria to be situated higher than that. This would include not only the hard surfaces on tables, chairs and counters I mentioned earlier, but also sinks in restrooms and bathrooms, for example, that carry a particularly heavy burden.

Any wall material containing paper is another likely site. Wallboard and Sheetrock are excellent media for the growth of mold and bacteria. Worse yet are the wooden studs behind the walls which, if they become wet, will breed fungi.

But let's look at the floor, too--specifically, carpeting, which some individuals have pointed to as a primary culprit in breeding infection. In fact, it has become politically correct in some quarters to say, "Tear out the carpet if you really want to clean things up." This is a disservice to those who deserve an elevated level of comfort in their environment with the amenities that carpeting can offer: warm colors and noise reduction, for example. In my research at the EPA, I regularly found that the air quality over carpeting was better than it was over hard surfaces.

I must admit that, having worked in government offices for many years, I've seen some filthy carpeting. But that was because of budgetary constraints. If it cost $1.50 a square foot for a decent cleaning program, the government spent 50 cents, but there is no inherent reason why that carpeting can't be kept clean.

Again, there needs to be a regular program for carpet maintenance. Two key elements, in my view, are a hot-water extraction system and a high-quality vacuum cleaner, both of which minimize air contamination during cleaning.

Some points, in particular, about vacuum cleaning machines: If not constructed properly, these can be aerosol generators, simply spreading dust and dirt throughout the air. Several years ago, while at the EPA, I approached manufacturers with the idea of tightening their standards on this, and was essentially told to "get lost," until finally the carpet industry stepped in with its "green label" test program. Machines that pass this test can display the green label of the Carpet and Rug Institute (CRI), signifying the cleanliness of their operation. Nursing homes interested in this can visit CRI's Web site (www.carpet-run.com) for a listing of manufacturers, and they should ask vendors about their test data along these lines.

In conclusion, you have to know your tools, and then organize their use in a way that makes sense for your facility. Following these basic rules will keep the nursing home as clean as it should be. NH

Michael A. Berry, PhD, research professor at the University of North Carolina, served with the Environmental Protection Agency for 27 years. He was deputy director of the National Center for Environmental Assessment in Research Triangle Park, North Carolina, and during eight years of that time oversaw the EPA's research programs on indoor air quality. For further information, phone [phone], fax [phone] or e-mail [e-mail].