Environment of Care

Question 1

The director of EVS has notified you that the organization will be changing cleaning products due to a change in contract requirements. When selecting a new product, you should consider which of the following?

1) What other organizations are using this product
2) Ease of use
3) Efficacy
4) The preference of the EVS director

a. 2, 3
b. 3, 4
c. 3, 4
d. 1, 2

Answer 1

A 2, 3
Rationale: When selecting disinfectants or cleaning products, factors to consider include ease of use, efficacy, acceptability, safety, and cost

Question 2

Your organization is planning a major construction project. You have been asked to complete the Infection Control Risk Assessment (IRCA) by the project manager. You explain that: a. It is his job to complete the ICRA b. The construction company will complete the ICRA c. An ICRA is not needed for the project d. The IRCA must be conducted by a committee with expertise in a variety of areas

Answer 2

D The IRCA must be conducted by a committee with expertise in a variety of areas
Rationale: The ICRA shall be conducted by a committee with expertise in infection control, direct patient care, risk management, facility design, construction, ventilation, safety, and epidemiology. The committee shall provide documentation of the risk assessment together with updated mitigation planning throughout construction.

Question 3

The appropriate hot water temperature for laundering linen is: a. 160°F b. 140°F c. 165°F d. 145°F

Answer 3

A 160°F
Rationale: Hot water also provides an effective means of destroying organisms. A temperature of at least 160°F (71°C) for a minimum of 25 minutes is recommended for hot water washing.

Question 4

Which of the following minimum efficiency reporting values (MERV) is sufficient to meet minimum OR standards for air filtration? a. MERV 10 b. MERV 12 c. MERV 14 d. MERV 16

Answer 4

C MERV 14
Rationale: Heating, ventilation, and air condition (HVAC) systems include filtration systems to remove particulate matter, including airborne microbes. The American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE) created a numerical system to rate filtration based on the particle size that the filter could remove. This system runs on a scale of 1 to 16, with 1 being a filtration system that removes only larger particulate matter and 16 being a filtration system that removes greater than 95 percent of particulate matter. The minimum standard for air filtration in an OR is 90 percent, which equates to a MERV of 14.

Question 5

The manager of linen services has contacted you for guidance regarding transporting clean and soiled linens in the same vehicle. Your response is: a. Clean and dirty linens should never be transported in the same vehicle b. Clean and dirty linens can be transported together in the same vehicle if they are clearly separated c. Clean and dirty linens can be transported together without the need to separate the items d. The health department must give permission to transport clean and dirty linen together

Answer 5

B Clean and dirty linens can be transported together in the same vehicle if they are clearly separated
Rationale: Clean and soiled textiles may be transported in the same vehicle if functional separation is maintained using physical barriers and/or space separation sufficient to protect clean textiles from soiled textiles.

Question 6

6. Which of the following would be an acceptable route for diffusion of air in an OR?
   a. Laminar airflow with a supply over the surgical table and an exhaust in the floor at the center of the room
   b. Laminar airflow with a supply over the surgical table and an exhaust near the floor at the periphery of the room
   c. Noninductional unidirectional infusion of air with a supply over the surgical table and an exhaust in the floor at the center of the room
   d. Noninductional unidirectional infusion of air with a supply over the surgical table and an exhaust near the floor at the periphery of the room

Answer 6

D Noninductional unidirectional infusion of air with a supply over the surgical table and an exhaust near the floor at the periphery of the room
Rationale: Airflow in a healthcare facility should move from a clean area to one that is considered to be less clean. In the OR, the air supply should be from the ceiling near the center of the room, and the air exhaust should be near the floor on the periphery of the room. Laminar airflow is not appropriate for an OR setting, as there is evidence that this high rate of airflow may induce hypothermia in the patient. A lower rate of air supply flow termed noninductional unidirectional infusion is used in the OR

Question 7

According to the OSHA Bloodborne Pathogen requirements, the appropriate concentration for household bleach used to clean up a blood spill on a nonporous surface is: a. 1:10 b. 1:100 c. 1:150 d. 1:50

Answer 7

B 1:100
Rationale: If a spill occurs on a nonporous surface, a 1:100 dilution of household bleach (one part plus 99 parts water or 0.25 cup of bleach in a gallon of water) is a highly effective disinfectant and is the least expensive. A 1:10 dilution of household bleach (one part household bleach plus nine parts bleach water or 1.5 cups of bleach in one gallon of water) is required for porous surfaces and large surfaces.

Question 8

You have been asked to advise the design team of a new healthcare facility on the planning for an airborne infection isolation room (AIIR). Which of the following are correct recommendations for this type of room in a new facility?

1) The AIIR must have an audible alarm to indicate when negative airflow is not being maintained
2) If the AIIR is a permanent, dedicated negative airflow room, then the air should exhaust to the outside
3) The AIIR must have at least 12 air changes per hour
4) The AIIR is required to have an anteroom
a. 1, 2
b. 2, 3
c. 1, 2, 3
d. 1, 2, 3, 4

Answer 8

B 2, 3
Rationale: Airborne infection isolation rooms (AIIR) should be maintained under negative air pressure to ensure that airborne infectious organisms are not ventilated into the facility’s corridor. These rooms must have at least 12 air changes per hour and newly constructed AIIR’s must have a visible means of monitoring air flow. Anterooms are not required but there must be an area outside the room that allows for hand washing and for storage and disposal of personal protective equipment. If an AIIR is a dedicated negative airflow room then it should be designed to allow for air to exhaust directly outside the facility.

Question 9

During infection prevention rounds, you discover a small bucket filled with liquid inside the cart used by an EVS staff member. The staff person tells you that she pours her cleaning solution into the bucket because it is easier than pouring it from the product’s container. Your response is:

a. Tell her that this practice is acceptable
b. Talk to the EVS manager and ask that she be placed in corrective action
c. Explain that as long as she writes the name of the product on the bucket, the practice is acceptable
d. Explain that the cleaning solution container must be labeled with the chemical content, name, and expiration date

Answer 9

D Explain that the cleaning solution container must be labeled with the chemical content, name, and expiration date
Rationale: Containers for cleaning agents must be labeled in accordance with regulatory requirements (e.g. chemical content, name, expiration date).

Question 10

The water temperature range recommended by the CDC for prevention of growth of Legionella bacteria is:

a. Hot water at 124°F and above and cold water at 68°F
b. Hot water at 108°F and above and cold water at 77°F
c. Hot water at 110°F and above and cold water at 80°F
d. Hot water at 77°F and above and cold water at 50°

Answer 10

A Hot water at 124°F and above and cold water at 68°F Rationale: Legionella species are bacteria that are naturally found in water sources, including municipal drinking water. Infection with Legionella can occur through inhalation of aerosols containing the bacteria, and can result in pneumonia. The optimum temperature range for growth of Legionella is between 25°C and 42.2°C (77°F to 108°F) so the CDC recommendations have been made to maintain water temperatures that fall outside that range and are therefore not optimal for growth of Legionella.

Question 11

The director of facilities at your organization does not feel it is necessary to include infection prevention in the design phase of a construction project planned for your facility. Your response to him is: a. Request that all blueprints and committee minutes be shared with you b. Agree with him, but request that he call if questions arise c. Ignore his comment and attend anyway d. Explain why it is important for you to participate at all levels of a construction project

Answer 11

D Explain why it is important for you to participate at all levels of a construction project
Rationale: Issues frequently addressed in the design phase include budget, space constraints, appropriate finishes, specific products with infectious implications, and applicable regulations. IPs should be prepared and support their position and recommendations with published citations whenever feasible, but particularly if a recommendation is not budget neutral.

Question 12

Which of the following is the most reliable method of monitoring the effectiveness of environmental cleaning in a healthcare facility? a. Visual inspection of the room after cleaning b. An adenosine triphosphate bioluminescence test after cleaning c. Fluorescent marking of a surface prior to cleaning with follow up after cleaning to determine if the mark was removed d. Environmental cultures using Rodac plates

Answer 12

D Environmental cultures using Rodac plates
Rationale: Cleaning of the patient care environment with special attention to high touch surface is important for the prevention of healthcare-associated infections. The effectiveness of cleaning may be assessed in several ways, and this should be carried out in conjunction with timely feedback to environmental services personnel. The most reliable method to monitor cleaning is to use environmental cultures with Replicate Organism Detection and Counting (RODAC) plates. This method allows direct detection and counting of organisms from environmental surfaces, rather than relying on a proxy that may detect cleanliness but not whether there has been an acceptable reduction in bio burden after cleaning

Question 13

The Food and Drug Administration (FDA) approves which of the following: a. Liquid disinfectants used for cleaning and disinfectants b. Medications only c. Antiseptics d. Disinfectant and cleaning wipes

Answer 13

C Antiseptics
Rationale: Antiseptics are approved by the FDA as antimicrobial agents safe for use on skin. They are not to be used for cleaning inanimate objects or environmental surfaces because of their unproven efficacy on nonhuman surfaces.

Question 14

An infection preventionist should be involved in which of the following phases of construction and renovation?

1) The design phase
2) The construction phase
3) The clean-up phase
4) The return to use phase

a. 1
b. 1, 2
c. 1, 2, 3
d. 1, 2, 3, 4

Answer 14

D 1, 2, 3, 4
Rationale: It is critical that an Infection Preventionist is involved in all phases of construction. Involvement during the design phase will ensure proper selection of materials, placement of products, and oversight of air and water quality. Involvement during the construction phase will ensure that design plans are being implemented properly and that the patient care environment is being protected from construction materials and dust. Involvement during the clean up phase will ensure that any existing dust and debris are properly removed and involvement during the return to use phase will ensure that the area is functional and is being utilized in the manner in which it was intended.

Question 15

In a cost saving effort, staff has requested that they be allowed to “top off” cleaning products from a larger bottle. Your response is: a. This a really good idea and offer to take the idea to the infection control committee for approval b. The “topping off” of nearly empty containers of cleaning products is prohibited c. “Topping off” is acceptable for cleaning products only d. There is no evidence that this practice will results in harm

Answer 15

B The “topping off” of nearly empty containers of cleaning products is prohibited
Rationale: It is important to prevent the extrinsic contamination of disinfectants and detergents. The practice of “topping off” nearly empty containers of disinfectants and detergents creates a risk for introducing unwanted microorganisms.

Question 16

You are experiencing an outbreak of Clostridium difficile infection (CDI) in your facility. Which of the following practices related to environmental cleaning should you recommend that the environmental services director evaluate first to determine the cause of the outbreak? a. Whether quaternary ammonium compounds are being mixed properly before being used to clean patient rooms b. Whether EVS personnel are changing gloves in between cleaning patient care rooms c. Whether rooms where a patient had CDI infection or known colonization are being terminally cleaned with bleach d. Whether high touch surfaces in a room where a patient has CDI infection or known colonization are being cleaned at least once daily with detergent

Answer 16

C Whether rooms where a patient had CDI infection or known colonization are being terminally cleaned with bleach
Rationale: CDI can be acquired from the environment and is a serious cause of healthcare- associated infections. Patient rooms that were occupied by a person with known CDI or colonization with Clostridium difficile should be terminally cleaned with bleach or with an appropriate sporicidal disinfectant. This practice is critical to remove Clostridium difficile vegetative cells and spores and prevent transmission to the next room occupant. Also important in preventing the spread of Clostridium difficile is that EVS personnel change gloves and perform hand hygiene in between cleaning patient room and that high touch surfaces are cleaned at least daily.

Question 17

Construction and renovation policies should include which elements:

1) Phasing and commissioning of projects
2) List of construction companies allowed to work in the facility
3) Authority for determining unit closure issues
4) Start and stop dates of projects

a. 1, 2
b. 2, 3
c. 3, 4
d. 1, 3

Answer 17

D 1, 3
Rationale: Elements of the construction and renovation policy should include key issues, beginning with ensuring at least annual review and approval by the infection control committee and governing board of trustees. Broadly applicable elements should include the following as appropriate: Authority for closing units and phasing and commission in addition to several other elements.

Question 18

Environmental Services is interested in using the most environmentally friendly product for cleaning a patient care room whenever possible. Which of the following are your recommendations to help accommodate this request?

a. All room surfaces should be cleaned with a disinfectant only
b. All room surfaces should be cleaned with a detergent only
c. Horizontal and high touch surfaces may be cleaned with a detergent provided that the contact time is at least 10 minutes
d. Floors may be cleaned with a detergent if the room was not last being used as an isolation room

Answer 18

D Floors may be cleaned with a detergent if the room was not last being used as an isolation room
Rationale: Detergents tends to be more environmentally friendly, less toxic, and less likely to cause respiratory reactions than disinfectants. Disinfectants must be used on horizontal surfaces and high touch surfaces in the patient room, but detergents are acceptable for cleaning the floor provided that the most recent occupant of the room was not on isolation precautions during their stay

Question 19

Healthcare workers in your facility have requested that environmental services purchase a hydrogen peroxide vapor unit to decontaminate patient care rooms. The administrators would like you to work with the director of environmental services to determine the pros and cons of this technology. Which of the following is an accurate argument in favor of using the technology?

a. It is effective at disinfecting all surfaces and supplies in the room
b. It cuts down on room turnaround time because personnel don’t need to clean the room before disinfection
c. The room can be occupied during the process so it is useful for daily cleaning
d. The heating, ventilation, and air condition (HVAC) system does not need to be turned off while the unit is being used

Answer 19

A It is effective at disinfecting all surfaces and supplies in the room
Rationale: Vaporized hydrogen peroxide units are useful for room disinfection after terminal cleaning, especially if there is concern for environmental contamination with Clostridium difficile. The hydrogen peroxide vapor easily reaches all surfaces in the room, including fabrics and wall behind furniture. It is also useful for disinfecting patient care items in the room and is safe for use in the presence of patient care equipment. However, the patient room must be cleaned prior to disinfection in order to remove organic material and the hydrogen peroxide vapor must be contained in the patient room during the disinfection process.

Question 20

Which of the following is most critical in selecting a cleaning agent for use on patient care equipment?

a. The product should be one that is already in use in the facility
b. The product should be selected based on the manufacturer’s guidelines for cleaning the equipment
c. The product should be the best disinfectant available regardless of other factors
d. The product should be environmentally friendly

Answer 20

B The product should be selected based on the manufacturer’s guidelines for cleaning the equipment
Rationale: Patient care equipment can have many different components and material and not all cleaning and disinfecting agents will be appropriate for use on the equipment. It is important to follow manufacturer’s guidelines when selecting a cleaning and disinfecting agent

Question 21

The director of environmental services (EVS) has asked for your assistance in collecting data related to process measures involving cleaning of high touch surfaces in patient care rooms. Which of the following monitoring methods would be most accurate for collecting this data?

a. Administer a survey to EVS personnel to ask about consistency of cleaning high touch surfaces
b. Survey patients to determine how clean the high touch surfaces were in their rooms
c. Ask EVS personnel to observe and report on each other’s practices related to cleaning high touch surfaces
d. Use a secret shopper to observe cleaning practices related to high touch surfaces

Answer 21

D Use a secret shopper to observe cleaning practices related to high touch surfaces
Rationale: Frequent cleaning of high touch surfaces with the correct cleaning and disinfecting agents is critical to reduce the occurrence of healthcareassociated infections. The most reliable way to collect data on the process of cleaning high touch surfaces is to enlist a secret shopper, a person who is unknown to EVS personnel, to discreetly observe the practice and gather data related to it. EVS personnel should receive timely feedback on the process being observed and should receive further education and training as needed.

Question 22

Which of the following recommendations should be made to reduce the risk of infection from sinks in patient care areas?

a. Sink basins should be deep enough to prevent splashing of water onto nearby patient care items
b. Sinks faucets should be located such that the flow of water hits the drain directly
c. Sinks should be placed within two feet of the point of care to encourage frequent hand hygiene
d. Aerators should be installed on faucets to minimize the amount of splash in the sink

Answer 22

A Sink basins should be deep enough to prevent splashing of water onto nearby patient care items
Rationale: Sink placement and design have been implicated in several outbreaks of healthcare- associated infections. Sinks should be far enough away from patients and patient care areas to prevent splashing of water onto these areas. The sink basin should be deep enough to help prevent this splashing and the stream of water should not be directed immediately over the drain because of the potential for aerosolization of microbes that can contaminate the drain. Use of aerators should be discouraged because of the potential for biofilm development.

Question 23

The planning committee for your new healthcare facility would like to include a water feature just inside the entrance of the new building. Which of the following recommendations should you make to ensure that this does not put patients, staff, and visitors at risk of infection:

1) The water feature must include underwater lighting to allow personnel to visualize whether it is being properly maintained
2) The water feature should be designed so that water does not remain stagnant in any part of the feature, and should include built-in methods of filtering or disinfecting the water
3) The water feature should be designed to prevent aerosolizing of water
4) The water feature must have routine maintenance
a. 2
b. 2, 4
c. 2, 3, 4
d. 1, 2, 3, 4

Answer 23

C 2, 3, 4
Rationale: Although water features can create a relaxing ambiance inside or outside a facility, they are associated with a risk of infection from pathogens that grow in water and can be aerosolized in the environment, such as Legionella. Water features are not prohibited in healthcare facilities but they must be carefully planned and maintained. These features should include filtration and/or ozone systems to remove pathogens from the water. Water should not be allowed to stagnate in any area of the feature because of the risk of biofilm development, and routine maintenance of the water feature must be followed. Underwater lighting may increase the water temperature to within a range that is optimal for growth of some pathogens, and has been implicated in at least one outbreak of Legionellosis

Question 24

In a construction zone in a healthcare facility that is occupied, airflow should be: a. Negative in the construction zone b. Positive in the construction zone c. Neutral in the construction zone d. Negative outside the construction zone

Answer 24

A Negative in the construction zone
Rationale: Because of the potential in a construction area to generate dust that may contain harmful pathogens such as Aspergillus, it is critical that airflow in a construction zone that is in an occupied facility is negative. This will pull air into the construction zone whenever someone enters it rather than allowing air to escape from the construction zone into areas where patients and healthcare workers might be exposed

Question 25

Which of the following is an Infection Control Risk Assessment (ICRA) element related to building design features?

a. An assessment of the specific construction hazards and the determination of protection levels for those hazards
b. The impact of a water outage during construction activity
c. The number of airborne infectious isolation (AII) rooms and where they will be located in the facility
d. A plan on where to relocate patients during construction

Answer 25

C The number of airborne infectious isolation (AII) rooms and where they will be located in the facility
Rationale: An ICRA should be utilized for the design phase of a healthcare facility and for the active construction phase. ICRA elements to be included in the design phase are how many AII rooms and protective environments rooms will be in the facility and where they will be located, the needs and locations for air ventilation, the types of water systems to include, and which finishes and surfaces are appropriate.