Home
Programs
Center for Health Care Quality
Healthcare Associated Infections
Environmental Cleaning: Effective Cleaning Strategies

healthcare-Associated Infections (HAI) Program

Effective Cleaning Strategies

EVS cart with cleaning supplies

Cleaning FAQs

What general strategies can be used to reduce environmental bioburden?

Improve the cleaning and disinfection of rooms after discharge of patients/residents known to carry healthcare-associated pathogens, such as CDI
Daily clean and disinfect all high-touch surfaces
Clean and disinfect portable equipment
Improve cleaning and disinfection of all rooms and areas of the healthcare facility

Donskey. AJIC. 2013 (Does improving surface cleaning and disinfection reduce health care-associated infections? article via PubMed)

What is cleaning? Why must an object or surface be cleaned prior to being disinfected?

Cleaning removes large numbers of microorganisms from a surface that would otherwise interfere with the disinfection process
Disinfectants are not a s effective in the presence of organic material
Important: A thorough cleaning must occur before a surface can be disinfected

HICPAC /CDC 2003 (Guidelines for Environmental Infection Control) (PDF) updated July 2019

HICPAC /CDC 2008 (Guideline for Disinfection and Sterilization) updated May 2019

What is the difference between a detergent and a disinfectant?

Detergent

A cleaning agent that contains surfactants; lifts dirt
Does not kill microorganisms
Can become easily contaminated
Less toxic, less odor and less costly than disinfectant

Disinfectant

Inhibits growth and/or kills microorganisms
Also referred to as a germicide, which is a disinfectant that kills organisms that can cause disease
More toxic, more odor, and more costly than detergent

Emerging multidrug-resistant bacterial pathogens "superbugs": A rising public health threat (2023)

Candida auris: Disinfectants and Implications for Infection Control (2018)
A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

What are the factors that influence selection of disinfectant?

Nature of the item to be disinfected
Amount of organic soil present
Number of microorganisms present
Innate resistance of microorganisms to the inactivating effects of the germicide
Type and concentration of germicide used
Duration and temperature of germicide contact
Other specific indications and directions for use

HICPAC /CDC 2003 (Regulatory Framework for Disinfectants and Sterilants)

What are the different antisepsis, disinfection, and sterilization types, actions, and resistance?

Not all microorganisms are the same.  Some are more resistant to disinfection than others and require stronger germicides to eliminate. 

Viruses, fungi, and bacteria, including MRSA, VRE and CRE, can be eliminated with germicides containing quaternary ammonium compounds (“Quat”) or organic acids. 
Mycobacteria, including TB (and viruses, fungi, and bacteria as above) can be eliminated with germicides containing a phenols, Quat plus alcohol, iodophors or alcohols.
Bacterial spores, including C.difficile, Carbapenem Producing Organisams (CPO), Candida auris, and mycobacteria require germicides containing hypochlorites (bleach at the recommended dilution), aldehydes, peroxides, chlorine dioxide, or ethylene oxide.

Bacterial spores including C. difficile are in the most resistant category of microorganisms. 

Adapted from: McDonnell G. Antisepsis, disinfection and sterilization: types, action and resistance. 2007.

What is an EPA label claim? What should I look for on an EPA label?

Chemical germicides are regulated by the Environmental Protection Agency (EPA)
The EPA label claim states if the product is bactericidal, virucidal, tuberculocidal, fungicidal, or sporicidal 
The label clarifies the manufacturer's instructions for use, including wet contact time required to achieve the desired degree of microbial killing

CDC. MMWR. Dec 19, 2003 (Guidelines for Environmental Infection Control in Health-Care Facilities)

Rutala et al. ICHE. 2014 (Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? article via PubMed)

Why is bleach or a disinfectant with a sporicidal claim used to clean CDI patient rooms?

C. difficile spores are difficult to kill and adhere to environmental surfaces for extended periods
Only relatively high concentrations of bleach and certain other disinfectants (e.g. hydrogen peroxide, peracetic acid) have been shown to be effective against C. difficile spores
EPA publishes a list of  disinfectants with a label claim for killing C. difficile spores

CDC Strategies to Prevent C. difficile in Acute Care Facilities 

LIST K: EPA’s Registered Antimicrobial Products Effective against C. difficile Spores

What is wet contact time? Why is it important and required?

The time required for a disinfectant to kill microorganisms on a pre-cleaned surface
The disinfectant must remain wet long enough to achieve the claimed level of surface disinfection
Follow manufacturer's guidelines for achieving the appropriate wet contact time

Rutala et al. ICHE. 2014 (Selection of the ideal disinfectant article via PubMed)

What are best practices for efficiently cleaning a patient care room?

Ensure proper hand hygiene and use of gloves
Focus on frequently touched surfaces
Work from clean-to-dirty and high-to-low areas
Avoid generating aerosols
Change cleaning cloths after cleaning a heavily soiled area or surface (i.e. toilet) and when going from one area to another
Ensure equipment and supplies are clean
Ensure proper use of cleaning and disinfecting products
Remember: A surface must be physically cleaned before it can be disinfected
Communicate issues to your supervisors

CDC Cleaning procedure summaries for general patient areas

Approaches to multidrug-resistant organism prevention and control in long-term care facilities for older people: a systematic review and meta-analysis

Implementation of human factors engineering approach to improve environmental cleaning and disinfection in a medical center

Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach (2019)

Multimodal environmental cleaning strategies to prevent healthcare-associated infections (2023)

Is there evidence that the environmental cleaning with bleach can reduce CDI rates on high-incidence units?

Bleach solution has been shown to be effective in decreasing patients' risk of developing CDI on high-incidence units.
In one study, a significant reduction in CDI incidence was observed when bleach solution was used as an environmental disinfectant ("intervention" period) on the unit with highest baseline CDI incidence
The CDI rate reversed to the baseline CDI rate when a quaternary ammonium was used ("post-intervention" period).
No reductions in CDIs were observed when bleach solution was used as environmental disinfectant on the units with lower baseline CDI rates.

Mayfield et al. Clin Infect Dis. 2000 (Environmental control to reduce transmission of Clostridium difficile article via PubMed)

Where can I find additional resources with best practices for efficiently cleaning a room?

A CDC Toolkit contains example list of frequently touched surfaces and checklists for monitoring cleaning
Hota. CID. 2004 (Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? article via PubMed)
EVS 7 Step Cleaning Procedure- UMC Health System (You tube video)

What are cleaning considerations if a CDI patient shares a room with a non-CDI patient?

Place CDI patient furthest from the door to minimize dirty-to-clean area traffic

Focus on high-touch surfaces and equipment in the immediate vicinity of patient/resident separately
Mop on non-CDI patient's side first; mops should only be used in the one room
Change cleaning cloths after use on one side of the room only
Change privacy curtains more frequently

2007 HICPAC Isolation Guidelines  (PDF)

What are ways to ensure EVS staff adhere to hand hygiene practices?

Emphasize the importance of hand hygiene for EVS staff in helping to prevent infections
Change misconception that hand hygiene is only important for protecting EVS staff. Emphasis that EVS hand hygiene is for protecting patients
Orient EVS staff thoroughly to infection control principles and practices prior to starting work in a clinical area

Lillis K, Hand Hygiene: EVS Personnel Play Key Role in Preventing Spread of Infection, ICT, 2015 (article via Infection Control Today)

What personal protective equipment (PPE) should be used while cleaning?

Choice of PPE is based on:

Type of infection prevention precautions assigned to the patient
Chemicals to be used to clean and disinfect the room

Refer to the Material Safety Data Sheet (MSDS), directions sheet, and facility policy
Appropriate use of PPE is critical

In one study, lapses in appropriate PPE use resulted in contamination in 53% of glove removals and 38% of gown removals

Tomas et al. JAMA Int Med. 2015 (Contamination of Health Care Personnel During Removal of Personal Protective Equipment article via PubMed)

Which is better for cleaning cloths: microfiber or cotton?

Microfiber

Densely constructed synthetic strands
Attracts dust, cleans 50% better than comparable cotton
Easier to use, lighter, designed for repeat usage
In a UC Davis study, microfiber was initially more expensive than cotton, but cleaned better, used less water and chemicals, and decreased labor costs.

Trajtman. AJIC. 2015 (Microfiber cloths reduce the transfer of Clostridium difficile spores to environmental surfaces compared with cotton cloths article via PubMed)

Smith. J Hosp Infect. 2011 (Assessing the efficacy of different microfibre cloths at removing surface micro-organisms associated with healthcare-associated infections article via PubMed)

HICPAC / CDC 2008 Guideline for Disinfection and Sterilization (PDF)

Microfiber Versus Cotton

Microfiber (top) Cotton (bottom)

What is the best way to clean porous surfaces such as a fabric chair or carpeting?

Fabric should be regularly vacuumed and re-covered when worn
Organic material and excess liquid should be extracted as much as possible
Steam cleaning is recommended for carpets as appropriate; carpets should be allowed to dry for 72 hours to prevent growth of fungi
No epidemiological evidence to show that pathogens found on fabric are linked to increased risk of HAIs

MMWR. 2003 Guidelines for Environmental Infection Control

Chou. APIC Text of Infection Control & Epidemiology. 2013 (Environmental Services article via APIC Text Online)

Summary of Key Points

A properly cleaned care environment is essential to prevent or contain HAIs
A surface must be physically cleaned before it can be disinfected
Consistent use of best practices and clarity of roles should be emphasized
Use of technologies such as microfiber, monitoring systems, and whole-room disinfection after cleaning are increasingly becoming the community standard of care
EVS staff should be valued and supported so they can maximize their unique contributions to preventing HAI

Environmental Cleaning Resources

CDC/HICPAC Guidelines for Environmental Infection Control in Health-Care Facilities, 2003 (PDF)
CDC/HICPAC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (PDF)
CDC Options for Evaluating Environmental Cleaning Toolkit (PDF)
CDC Environmental Checklist for Monitoring Terminal Cleaning (PDF)
CDC Environmental Checklist (scroll to bottom of page and download word doc)
CDC Environmental Cleaning Eval Worksheet (scroll to bottom of page and download excel doc)
CDC/HICPAC Guidelines for Hand Hygiene in Healthcare Settings Published 2002 (PDF)
WHO Guidelines on Hand Hygiene in Healthcare (2009)

Page Last Updated : April 30, 2024

What’s New

Administrative

Diseases and Conditions

Family Health

Health and Safety

Health Facilities

Personal Health and Prevention

Licensing, Certification and Other Credentials

Person Interested In