Words: Kathleen Misovic

Imagine a person checks into a hospital and stops by the toilet nearest the registration area. The patient is greeted by paper towels strewn around the sink and on the floor. She enters one stall to find a clogged toilet. The second stall she enters has no toilet paper. After this uncomfortable restroom experience, it’s unlikely the patient will feel confident about the hospital’s cleanliness.

“Your lobby and your bathrooms set the tone as to how your facility is perceived,” said Gregory Gardner, director of environmental services (EVS) at Advent Health Fish Memorial hospital.

“When hospital guests enter those areas and they are clean, they think, ‘you will take care of me. I feel comfortable. I feel safe.’ But if they enter those areas and they are not clean, they will question whether the hospital can properly take care of them or their loved one.”

Germs of concern

People with contagious illnesses who enter hospitals can transmit pathogens to surfaces, including restroom areas. Hospital EVS teams must be diligent in cleaning and disinfecting these surfaces, especially when dealing with bacteria and viruses that require more effort to kill.

“C. difficile [C. diff] is one of the major pathogens we are concerned with, along with methicillin-resistant Staphylococcus aureus (MRSA) and gram-negative bacteria that can cause infections, pneumonia, and meningitis,” said Mark Heatley, a quality and standards manager for Aramark Healthcare+.

“Our goal is to focus on all the pathogens. We know if we can kill C. diff and MRSA, we are also getting all the others.”

Gardner agreed that cleaning to the level that will kill C. diff spores is the goal. “I think the super bug we see more than any other is C. diff, and we see Candida auris (C. auris) every once in a while,” Gardner said. “We clean to that level, using a cleaning agent that will kill C. diff and everything under.”

Arthur Cromartie, who is also with Aramark Healthcare+ and is the director of environmental services at Cone Health Alamance Regional hospital, said his
cleaning crew is more focused on eliminating cross contamination than a specific pathogen.

“If someone with an infectious disease is not washing their hands, they will definitely pass it on,” Cromartie said. “One of our biggest fears is that a patient or their family member will leave the hospital with a healthcare-acquired infection (HAI).”

To protect visitors to the bathrooms, cleaning crews at Cone Health Alamance Regional address all high-touch surfaces, including toilets, sinks, and doorknobs. (Cromartie said doorknobs can be the most germ-ridden surfaces.) They also focus on cleaning and disinfecting soap and towel dispensers.

Bathroom challenges

With numerous high-touch surfaces, such as grab bars, light switches and toilet flush buttons, even the smallest of public bathrooms can pose a challenge to EVS crews.

“Our concern is getting all those areas cleaned and disinfected so somebody else doesn’t come in and pick up a germ,” Heatley said.

“With the presence of bodily fluid in restrooms—from urine to faeces to blood—there is all that opportunity for something to be easily spread, especially if someone happens to get sick and throw up.”

Cromartie added he is most bothered by product shortages.

“What I notice is missing paper products, whether it be toilet paper or paper towels,” Cromartie said. “Seeing no paper products is a no-no. Germs are definitely going to be passed around.”

To help resolve product shortages, Cromartie said the hospital tries to buy the largest dispensers and paper product rolls available and the cleaning crews make frequent rounds.

“First thing in the morning we make sure the first impression areas of the hospital are ready, then check them throughout the day,” he explained. “First impression areas of a hospital include the restrooms, for sure, especially the public restrooms near the registration area.”

According to Gardner, guest impressions are a particular challenge —especially in older bathrooms. Even if older toilets are cleaned to the same standard as newer ones, visitor feedback does not reflect that reality.

Tried and true cleaning methods

Most EVS teams follow the strategy of cleaning restrooms from the top down to prevent soiling areas they already cleaned, as well as helping to eliminate the risk of cross contamination. This strategy means the floor is always cleaned last.

“The infection prevention team we work with considers bathroom floors as being always dirty, all it takes is for one shoe to hit the floor,” Heatley said.

Cromartie said dusting is always done first, followed by disposing of any rubbish from the bins.

“We go from the cleanest surfaces, the mirrors and sinks, then proceed to the toilets and pipes, washing the floors on the way out.”

Gardney said that, while the door comes last, there is a need to clean both sides of the door and the door handles when exiting.

“Unfortunately, not everyone washes their hands before opening the door on the way out.”

Scheduling paired with technology

Hospital EVS workers must clean both private patient toilets and larger public bathrooms. They have found that creating schedules based on bathroom traffic works best, Heatley said.

“We found that a bathroom near the main entrance had very high usage early in the morning. Anyone coming in for an outpatient procedure was using it, so we adjusted our cleaning times to make sure it was stocked and ready to go.”

Typically, EVS staff will clean private patient toilets once or twice a day and after patients are discharged. Public bathrooms are cleaned from two to six times in an eight-hour shift, depending on the frequency of their use. Bathrooms with the heaviest traffic—such as those in the lobby, near surgical waiting areas, and near the cafeteria—are cleaned the most often.

“We have a motion detector that counts people that enter the bathrooms,” Heatley said. “It comes in handy for scheduling our cleanings.”

Heatley added that feedback from restroom users is key. “We have a system with a feedback panel that allows people to press a button that says paper products needed, or soap needed, or there’s a leak or a clog,” he said. “These messages get sent to an email into a smart phone, alerting our staff.”

Cromartie also works in facilities with smart technology that allows hospital visitors to communicate with EVS crews when restrooms need cleaning or supplies.

“This technology lets patients and their families know we are concerned about the cleanliness of our restrooms. It also allows them to press a button to give a thumbs up if the restroom is in good condition; that’s nice for us to know.”

EVS workers on all three shifts (days, evenings, overnight) clean public restrooms, usually saving the deep cleaning for overnight.

“Doing the dusting and deep cleaning overnight speeds things up for workers during the high-traffic day shifts,” Cromartie said.

Little chance exists of cleaning a heavy-use restroom too much, Gardner said.

“We try to mirror what they do in airports, which is clean busy bathrooms once an hour. In between cleanings, we check them to make sure they are not torn apart, with paper towels or toilet paper all over the floor. Nine times out of 10 there is water on floor that dripped from people’s hands when they turned from the sink to dry them, then they will track that water outside the restroom. And there have been times just five minutes after we finished cleaning, someone had an accident.”

Tools of the trade

Just as important as how often EVS crews clean restrooms are the cleaning products and tools they use.

EVS staff at Atrium Health System use a hydrogen peroxide cleaning and disinfection formulation.

“The product we use is a one-step cleaner and disinfectant, so we can get both done at the same time,” Heatley said.

EVS managers train their staff to follow a five-minute contact time, making sure the surface stays wet with the product for the full five minutes so the disinfection is complete. Microfibre mops and cloths are typical cleaning tools for EVS staff, who use the cloths and mops in a way to prevent cross contamination.

“We always start with a fresh cloth and fold it so we have eight fresh sides we can use,” Heatley said. “We use multiple microfibre cloths, so we never clean a toilet with one and go to the next toilet with the same one,” Cromartie said.

EVS workers also depend on product organisation to prevent cross contamination.

“We colour code using a red or orange cloth for the toilets and a green cloth for other restroom surfaces,” Gardner said. “We also use a separate mop for the restroom. Once we mop out the restroom, that mop immediately goes into the dirty mop bag.”

Pressure washers and floor scrubbers are popular equipment for healthcare facility bathrooms and toilets.

“For public restrooms we use a machine that scrubs the floors and then vacuums them dry immediately so there is no risk of slipping,” Heatley said.

And the final touch? Sometimes it’s a light one.

“Most of our bathrooms are tiled so we spray them down and vacuum them dry,” Cromartie said.

“Then we use a UV device [ultraviolet disinfecting light] to kill the spores. It gives the bathroom the last cleaning touch and is the icing on the cake.”

A version of this article was published in CMM Online.

Photo by Nice M Nshuti on Unsplash.