Impact of Cleaning and Disinfecting on Full-Body Support Surfaces

INTRODUCTION Improper care and management of full-body support surfaces places patients at risk in healthcare facilities today. Examples of full-body support surfaces include mattresses, stretcher pads, operating room table pads, and examination tables. They are intended to support patients' full bodies in various positions while minimizing the risk associated with pressure injury (PI) development. 1 Beginning in 2008, PIs and facility-acquired infections were deemed "never events" by the Centers for Medicare and Medicaid Services.2 To prevent facility-acquired infections, and as a result of the COVID-19 pandemic, facilities have heightened cleansing and disinfectant practices with the use of harsh chemicals to ensure prevention of cross-contamination. However, inappropriate disinfectant use degrades full-body support surfaces and allows contaminants to enter, not only damaging the surfaces but also creating an increased risk of cross-contamination. STATEMENT OF THE PROBLEM Damage to support surface covers is due not only to normal wear and tear, but also to repeated and frequent exposure to harsh, and improperly used, hard surface disinfectants. Hard surface cleaners are used to prevent the spread of virulent organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile (C-diff), and SARS-CoV-2. However, they are not meant to be used on support surface covers. When these hard surface cleaners are improperly used on support surface covers, the covers becomes damaged, and the outside waterproofing component is eroded. Damage can begin with micro-hole formation long before visible damage is evident (Figure 1). After the waterproofing is damaged, contaminants seep into the surface (fluid ingress), increasing the possibility of damage to the internal components of the support surface as well as cross-contamination (Figure 2). Damaged or uncovered zippers on the surface are another entry point by which fluid may penetrate the surface (Figure 3).Figure 1.: INVISIBLE MICRO-HOLE DAMAGE WITH FLUID INGRESSSource: Jackie Todd.Figure 2.: WATERPROOFING DAMAGE TO TOP COVERS FROM HARSH CLEANING CHEMICALSSource: Kristen Thurman and Rachel Moseley.Figure 3.: DAMAGED ZIPPERS AND COVERS ALLOW FOR FLUID INGRESSSource: Jackie Todd.From January 2011 to January 2013, the US Food and Drug Administration (FDA) received 458 reports associated with medical bed mattress covers failing to prevent blood and body fluids from leaking into the mattress (fluid ingress; Figure 4).3 Studies also show that over 50% of support surfaces are compromised in just 3.8 years, well before their full intended useful life. Reports indicate that if blood and body fluids from one patient penetrate a surface, they can later leak out from the surface when the next patient is placed on the support surface (Figure 5).4 All of the examples shown in the figures were obtained through support surface audits, which includes inspection of the outer covers as well as internal components of support surfaces.Figure 4.: BLOOD AND BODILY FLUID INGRESS CONTAMINATING INTERNAL COMPONENTSSource: Jackie Todd.Figure 5.: FLUID INGRESS NOT VISIBLE ON THE TOP COVER IS POSSIBLE SOURCE OF CROSS-CONTAMINATIONSource: Jackie Todd.A study conducted at 85 acute care facilities (evaluating 5,121 support surfaces) and 522 postacute facilities (evaluating 36,207 support surfaces) revealed that 59% and 50.6% of the support surfaces, respectively, required replacement due to loss of pressure redistribution capability or contamination of internal components.5 Frequent reasons for support surface damage and subsequent need for replacement include but are not limited to:6 repeated and frequent exposure to disinfectants designed for hard surfaces; failure to rinse the disinfectant off the support surface after the kill time; failure to allow the support surface to dry before applying linens; and the use of abrasive cleaning supplies (brushes, etc.) that weaken the mattress cover material causing premature aging of the support surface. Study results are consistent in finding that many surfaces throughout healthcare facilities have suffered damage that can be detrimental to patient outcomes.1 SUPPORT SURFACE COVERS Healthcare support surface covers generally have the following characteristics to enhance patient outcomes: waterproofing and breathability. The waterproofing is designed to protect the internal components of the surface from both visible and nonvisible contaminants. Visible contaminants include urine, stool, blood, wound drainage, other body fluids, procedural solutions (surgical scrub solution or irrigation solution), and disinfectants used to clean the surface, whereas nonvisible contaminants include microorganisms, especially virulent pathogens (e.g., MRSA, C-diff, SARS-CoV-2), that can seep into the surface as the cover waterproofing degrades. Over the years, support surface manufacturers have increasingly used the most chemically resistant cover materials in an attempt to combat the impact of the misuse of disinfectants over time. More recently, an increased demand for higher breathability in polyurethane covers has been realized to aid in PI prevention. However, the fabric chemistry needed to maximize breathability can also dramatically reduce the cover's chemical resistance to harsh disinfectants such as chlorine. DISINFECTANTS The most prevalent disinfectant solutions for cleansing support surface covers are active chlorine (bleach), accelerated hydrogen peroxide, and quaternary ammonia. The first two disinfecting solutions work by oxidation, a destructive chemical process that not only kills the pathogens but also degrades the surface to which it is applied. Quaternary ammonium compounds contain positively charged ions that break down the negatively charged membranes of germs. These can also negatively impact the surface to which they are applied over time, although to a lesser extent than oxidation. These disinfectant solutions, therefore, all need to be wiped off once they have reached the designated kill time. The "kill time" is the amount of time that a disinfectant needs to be in contact with a surface to kill the microorganisms. These disinfectant solutions are particularly damaging if they are not wiped off once the kill time has passed. Destruction of the support surface cover is cumulative over time and, when exposed to active chlorine and other hard surface disinfectants, almost all hospital mattress covers are not immune. This degradation should not necessarily be viewed as a major material weakness: vinyl, rubber, and even stainless steel and concrete are all corroded by active chlorine/bleach over time.6 Controlling the exposure time needs to be part of the cleaning process when using a highly aggressive, oxidizing disinfectant based on accelerated hydrogen peroxide or active chlorine designed for hard surfaces. If the recommended dwell or kill time is 4 minutes to maximize the sporicidal impact, it is important to rinse and dry the surface after 4 minutes to protect surface integrity. If, for example, the disinfectant is left on for 8 minutes each time the surface is cleaned, the efficacious lifetime of the cover will be halved. If the cleansing solution is left on the support surface cover for 12 minutes with each cleaning, the lifetime of the support surface cover is expected to be reduced to one-third. If the solution is merely left to dry each time and takes 40 minutes to do so, the anticipated lifespan of the support surface cover is reduced to just 10% of what it would have been with appropriate care. Often a single type of disinfectant will be chosen to be used on all surfaces in the patient environment (room), including support surfaces, for ease of use and to shorten the time it takes to prepare the room for the next patient. Support surface manufacturers recommend using disinfectants with a pH of 5 to 9 to prevent damage to the surface cover materials. In comparison, the pH of the 1:10 dilution of bleach, the only sporicidal disinfectant deemed effective against the bacterial spores of Cdiff, is approximately 11 to 13. Although chlorine bleach is a highly effective, inexpensive disinfectant (roughly $2 per gallon), its use on support surfaces may lead to thousands of dollars in support surface cover and full replacement costs. THE HIDDEN COST OF REPLACING SUPPORT SURFACE COVERS In addition to the physical impact of improper cleansing and disinfection of support surface covers there are also hidden costs associated with improper maintenance. A new support surface cover can range from $100 to $350 or more.7 Further, support surface cover replacement is usually not covered under the support surface warranty; the manufacturer's warranty typically only covers manufacturing defects and does not include normal wear unless specific warranties are associated with cleansing and disinfecting practices. Any internal component such as air cells or interconnecting tubing that can be cleaned and disinfected should be treated in the same manner as the cover, except for contaminated foam. In the case of a foam support surface, if the cover is breached and the internal foam becomes contaminated then the entire support surface should be replaced. Following manufacturer recommendations and regulatory guidelines for the care of support surfaces can prolong the life of the support surfaces and, more importantly, protect patients from cross-contamination and other adverse events (e.g., hospital-acquired infections, PIs). HEED THE WARNINGS Numerous organizations (e.g., National Pressure Injury Advisory Panel, Wound Ostomy Continence Nurses Society) and federal agencies (eg, FDA, CDC, Centers for Medicare and Medicaid Services) have raised awareness and expressed concern that the instance of damaged surfaces is widespread and recommend that surfaces be regularly inspected for damage to reduce the risk of both facility-acquired infections and PIs.3,6 The CDC and the Association for Professionals in Infection Control and Epidemiology work in tandem to develop clinical infection control guidelines for healthcare facilities. These government and healthcare specialty organizations provide practical and effective options for preventing facility-acquired infections, following evidence-based practice. Having consensus among healthcare key opinion leaders and government health agencies improves uniformity, effectiveness, and quality in infection control guidelines to drive implementation of best practices. In 2017, the FDA published posters to guide healthcare facilities in the inspection and maintenance of support surfaces.6 Recommendations include: discard mattresses that become/remain wet or stained, particularly in burn units; clean all support surfaces using US Environmental Protection Agency-approved disinfectants that are compatible with the cover materials to prevent cover breakdown; replace support surfaces that have become breached and are no longer fluid-repellent or are contaminated; and do not stick needles into the mattress through the cover (this contaminates internal components). BEST PRACTICE IN CLEANSING AND DISINFECTING SUPPORT SURFACE COVERS Although healthcare facilities' use of harsh chemicals for disinfecting support surface covers is not ideal, understanding best practices when using those chemicals can prolong the life of covers and minimize patients' risk for "never events." Support surface manufacturers have been aware of the corrosive impact these disinfectants have on their products for decades, which is why they advocate for a "rinse and dry" step after the kill time has been achieved in the cleaning and disinfection process. Once the kill time has been met, the disinfectants should be rinsed off the cover with water and a clean cloth to stop further destruction of the surface cover from chemical exposure. Then the cover should be wiped to ensure that as much of the chemical is removed as possible and is not able to seep into the support surface material to cause more damage. However, in a busy hospital, despite this advice, "rinse and dry" is often ignored or forgotten, and "wipe and walk" becomes a custom practice leaving the harsh chemicals to soak into the support surface covers and cause damage. In addition to damaging to the support surface cover, failing to rinse the chemicals off the covers can also result in skin dermatitis. Chemicals left on the support surface cover are absorbed by bed linens, exposing the patient's skin to the chemicals. To decrease the risk of damage to the support surface cover and subsequent patient outcomes, it is important for facilities to establish appropriate cleansing and disinfection practices for their support surfaces. The Support Surface Standards Initiative (S3I) developed a guidance document entitled "Best Practices in Cleansing and Disinfecting Support Surface Covers," which outlines how cleansing and disinfecting can most effectively be accomplished while protecting support surface covers and patients as much as possible.8 Each step in the cleaning process must be performed with nonabrasive facility-approved cleansers and sponges. To cleanse: Initial cleansing readies the surface for disinfection and involves removal of any visible soil (eg, blood, urine, stool) using a nonabrasive means. Wipe all exposed surfaces with a neutral pH detergent. Rinse thoroughly with clean, warm water and a clean cloth. If organic matter is not completely removed, the effectiveness of the disinfectant is decreased because it cannot reach the surface. To disinfect: Once the surface is ready for disinfection, wipe all exposed surfaces with disinfectant. Leave the disinfectant on for the recommended kill time to eliminate all microorganisms. Rinse thoroughly with clean, warm water and a clean cloth. Ensure that the surface is dry before applying linens. Important considerations for cleansing and disinfecting include: As a result of frequent exposure to disinfectants combined with failing to rinse and dry after cleaning, cleanser residue stays on the surface; it acts like a dry alkaline substance and accelerates degradation of the cover, which allows contaminants into the inner core of the surface. What can get in can also get back out and onto the next patient, increasing the risk of cross-contamination. Dry disinfectant can be reactivated in the presence of fluids, such as perspiration or urine; if the patient's skin comes in contact with disinfectant, it may cause dermatitis or other skin issues. Dry residue can be abrasive and increase the degradation of the cover. When following the guidelines set forth by S3I, support surface covers should not degrade as quickly, and the structure and quality of the surface should remain intact longer, assisting in the prevention of hospital-acquired infections and PIs. IMPLICATIONS FOR PRACTICE The medical literature indicates that damaged and wet (soiled) mattresses can be a source of contamination during infection outbreaks.9–11 The FDA is concerned that fluid ingress from worn or damaged medical bed mattress covers may be widespread and largely under-recognized by healthcare providers, healthcare facility staff, and caregivers.6 Take-home messages include: Support surface covers are soft surfaces, yet hard surface cleaners are the current recommended cleaning solution.12 Over time, the detrimental effects of disinfecting inappropriately will dramatically damage the support surface cover. Improper cleansing of a support surface (both cover and internal components) can have a significant financial impact to a health care facility and adversely affect patient safety. Cleaning products should be used according to manufacturer recommendations. Exposure time is critical: leave the disinfectant on for the minimum not the maximum amount of time. Do not skip the rinse! Follow proper cleaning anddisinfecting protocol. Establish a protocol for periodic and ongoing support surface monitoring and assessment and replace as needed. CONCLUSIONS Many healthcare facilities use harsh disinfectants on support surfaces to combat infectious material in the effort to prevent cross-contamination. Unfortunately, inappropriate practices using these disinfectants degrade the support surface materials and allow ingress of fluids and infectious material. To decrease the risk of damage to support surface covers, it is important for facilities to establish appropriate cleansing and disinfection practices for their support surfaces. Following proper cleansing and disinfecting guidelines can increase the longevity of surfaces and, more importantly, decrease the risk of cross-contamination and never events.