Like the coronavirus, skilled nursing facilities (SNFs) are under the microscope. The high mortality rate among SNF residents has drawn significant attention from national health organizations and the media. The issue: An estimated 42 percent of America’s 150,000 COVID-19 deaths have been associated with elder care facilities. By comparison, residents of SNFs account for less than 0.62 percent of the population, according to Forbes, on May 22.
To help protect this vulnerable population, the Department of Health and Human Services allocated $5 billion in July to help combat infection in nursing homes. The money included funding for an online infection control training program available to Medicare-certified long term care facilities.
“Education and training is the key for controlling coronavirus,” says Sam Okafor of ServiceMaster Building Services in Portland, Ore. “A facility’s infection preventionist and the environmental services team are the front line for infection prevention. They should receive thorough and frequent training. Cleaning knowledge and diligence will keep residents and staff safer.”
Professional cleaning companies typically have subject matter experts who are highly trained and credentialed in the science of cleaning and disinfecting. ServiceMaster Clean often shares its knowledge with facilities that seek help. Here are some of the most frequently asked questions regarding safety in the era of COVID-19.
Has cleaning protocol changed because of the pandemic? How?
Yes, in three ways: greater frequency of disinfecting, especially high-touch areas; more use of full Personal Protective Equipment (PPE); and the timing of cleanings. Before the pandemic, cleaning was often done after hours. Now, because of the greater frequency of cleaning and the need to reassure residents and guests, cleaning is being conducted throughout the day.
When do you recommend full PPE for cleaning staff? What protection should be worn for normal cleaning duties?
Regarding PPE requirements, we recommend following the Centers for Disease Control & Prevention (CDC), U.S. Environmental Protection Agency (EPA), and any requirements set forth by state or local government. For health care personnel working around residents with Covid-19, CDC recommends a face shield or goggles, an N-95 mask or respirator, a gown or body covering, and gloves. For normal cleaning, gloves and a face mask should be worn. Refer to product labels regarding additional PPE requirements.
Given that CDC now says COVID-19 typically spreads by respiratory droplets, is the cleaning of high-touch points still a priority for stopping the spread of the virus?
Yes, cleaning and disinfecting high-touch areas will always be important. Infected persons could cough or sneeze and contaminate surfaces with their respiratory droplets. Other persons could then touch the contaminated surface, touch their face, and become infected.
Is fogging effective for eliminating pathogens, specifically COVID-19?
The EPA currently does not recommend fogging application as fogging is often imprecise.* That’s why most professional cleaning companies use a hands-on application method for maximum effectiveness.
What would you recommend for a SNF that wants to create a safe space for visitors to interact with their loved ones?
We recommend following CDC guidance.** This would certainly include social distancing of six feet or more. Additionally, we would recommend interaction occur outdoors in fresh air or in an indoor space that is well ventilated with fresh air from outdoors. Furthermore, face coverings should also be worn during interaction.
What are the most important things a facility’s infection preventionist should know about cleaning and disinfecting (priorities 1, 2, and 3)?
1. For Covid-19 purposes, a disinfectant on the EPA’s List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19) should be used and should be applied in a method specified on its EPA product label.
2. Proper disinfection cannot occur without proper cleaning. If gross soiling is present, a one-step cleaner disinfectant can be used. If you are not using a one-step product, the surface must be cleaned first, then disinfected.
3. Appropriate dwell time (time the product must remain wet on a surfact) must be achieved for proper disinfection to occur. The EPA product label will specify the dwell time. The EPA’s List N also will specify appropriate dwell time for each product on the list.
What should residents know about cleaning and disinfecting that will help keep them safer?
Residents should be reminded to perform personal hygiene practices. Emphasize thorough hand washing, performed frequently. This is the No. 1 way to prevent the spread of infection. Meanwhile, avoid touching of the eyes, nose, and mouth. Also, remember that disinfection, while effective if done properly, is only for a snapshot in time. Once someone re-enters the space after disinfection, that space could be recontaminated. For this reason, residents should perform proper hand hygiene immediately after touching surfaces in common areas.
If cleaning is done by an in-house team, how can one be sure they are trained properly to eliminate infection?
Facility cleaning staff should, at minimum, be knowledgeable of the following: CDC guidelines for disinfection and proper use of PPE; EPA guidelines for how to apply disinfectant and each product’s prescribed dwell time; and the need for frequent cleaning of high-touch, high-traffic areas along with a detailed list of those surfaces and appropriate products to use.
If a facility hires an outside contractor to help with cleaning, how do staff know they are qualified to clean and disinfect properly?
An outside contractor should be able to demonstrate the correct protocol for proper cleaning and disinfection. At minimum, their protocol should align with CDC and EPA guidelines. The contractor also should be able to reference their training for cleaning and disinfecting in the health care environment. Furthermore, if the contractor has any certifications for cleaning and disinfection in the health care environment, that would be another good indicator of their qualification.
Is it possible to keep common areas safe, especially dining rooms?
No area of any facility can be guaranteed to be disinfected 100 percent of the time. However, with high-frequency cleaning and disinfection it is possible to greatly reduce the risk of spreading infection.
For dining rooms specifically, here’s a recommended cleaning protocol:
1. Clean and disinfect prior to the first meal of the day.
2. Clean and disinfect after first meal.
3. Clean and disinfect after second meal.
4. Clean and disinfect after third meal.
5. Clean and disinfect after any other events in the dining rooms such as an activity or a facility meeting.
6. Limit access to the dining area at all other times. Have a designated area for residents to obtain snacks and beverages between meals. Ensure surfaces in this area are frequently cleaned and disinfected in addition to full dining room cleaning and disinfection.
If one cleans to eliminate COVID-19, is she also preventing other infectious diseases and irritants such as Methicillin-resistant Staphylococcus aureus (MRSA), influenza, and Clostridium difficile (C. diff)?
Many of the disinfectants on the EPA’s List N that are approved for use against Covid-19 are effective in disinfecting against MRSA and influenza. These disinfectants are acceptable for daily use against most pathogens commonly found in health care facilities. The disinfectant’s EPA product label will list its kill claims and required dwell times.
C. diff requires a sporicidal disinfectant. The EPA has List K, which contains sporicidal disinfectants that are approved for use against C. diff. Not all disinfectants on List N are on List K. In cases of C. diff, the facility should ensure that an EPA-registered sporicidal disinfectant on List K is used.
Daniel Gravatt is business operations manager for ServiceMaster Clean, which has more than 900 franchised and licensed locations around the world. He is a licensed nursing home administrator and a trainer of the Certified Surgical Cleaning Technician program. He can be reached at dgravatt@smclean.com.
*www.epa.gov/coronavirus/can-i-use-fumigation-or-electrostatic-spraying-help-control-covid-19
**www.cdc.gov/coronavirus/2019-ncov/community/retirement/index.html