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These are not necessarily the most highly contaminated points, but rather the ones most frequently omitted from cleaning and disinfection protocols.
In a multicenter study conducted in 23 acute care hospitals, researchers evaluated the thoroughness of terminal cleaning in the immediate patient environment.
Surfaces were marked with an invisible fluorescent solution before the patient left, and it was subsequently checked how many of the markers had been removed through the mechanical action of wiping. The average level of cleaning thoroughness was 49%, with major variations from one hospital to another:
In the same analysis, items such as doorknobs, light switches, grab bars in restrooms, and bedpan washers had average cleaning rates of under 30%, while sinks, toilet seats, and bedside tables exceeded 75%.
Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. The study evaluates the rigor of terminal cleaning (mechanical wiping of surfaces), not the antimicrobial efficacy of the disinfectant product used, and does not, in itself, demonstrate the transmission of an infection via the respective surfaces.
In the same analysis, some of the tracked surfaces had much higher cleaning rates than others. The differences were particularly large between surfaces that clearly appear to be part of the cleaning routine and some small but frequently touched surfaces.
Over 75%
Under 30%
Bed rails, call devices, and patient telephones showed significant variations in cleaning levels across hospitals and do not fall into the two categories above.
Therefore, the CDC recommends identifying high-touch surfaces for each care area and including them in cleaning lists and audit tools.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recomm Rep. 2003;52(RR-10):1–42. Centers for Disease Control and Prevention (CDC). Environmental Cleaning Procedures.
Door handles are repeatedly touched by staff, patients, visitors, and other people entering or leaving the room.
In the study conducted across 23 hospitals, door handles were among the surfaces with the lowest average cleaning rates: less than 30% of the tracked markers were removed during terminal cleaning. However, the study also showed a very large variation between institutions, ranging from 0% to 90%, which indicates that the results were not identical in all hospitals.
The door handle is a good example of a simple problem: if a frequently touched surface is not explicitly identified, it may be omitted from the routine.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. WHO. WHO Guidelines on Hand Hygiene in Health Care (My 5 Moments for Hand Hygiene). Geneva: World Health Organization; 2009.
Light switches are high-touch surfaces, but their small size can make them easy to overlook in a routine primarily focused on large surfaces.
In the Carling study, light switches had an average cleaning rate of under 30%, with significant variation between institutions.
The CDC includes light switches among the examples of high-touch surfaces that must be considered in cleaning procedures.
Attention
Do not spray the product directly onto electrical components. The product and application method must be compatible with the surface and the manufacturer's instructions.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. Sehulster L, Chinn RYW; HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recommendations and Reports. 2003;52(RR-10):1–42.
In the Carling study, grab bars in restrooms had average cleaning rates of under 30%, while toilet seats and sinks exceeded 75%. The difference shows why it is not sufficient to consider the "bathroom" as a single work surface. A room contains several items, with different frequencies of touch and different levels of attention given during cleaning. The CDC recommends cleaning and disinfecting high-touch surfaces in restrooms, including handles, faucets, and doorknobs.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. Sehulster L, Chinn RYW; HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recommendations and Reports. 2003;52(RR-10):1–42.
Bed rails are touched by both patients and staff during care. In the Carling study, they did not fall into the category of surfaces with consistently high or consistently low rates. Their cleaning varied considerably between hospitals.
The CDC includes bed rails among the examples of high-touch surfaces and recommends identifying them in cleaning checklists.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. Sehulster L, Chinn RYW; HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recommendations and Reports. 2003;52(RR-10):1–42.
In the Carling study, patient call devices showed inconsistent cleaning and significant variations between hospitals.
This is an example of an object that cannot be evaluated solely by size or appearance. It can be small, mobile, and positioned differently from one patient to another.
Sources: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329. Sehulster L, Chinn RYW; HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recommendations and Reports. 2003;52(RR-10):1–42.
The patient bedside phone was included in the Carling study among the items whose cleaning varied significantly between hospitals.
It is important to specify what was evaluated: the patient's room phone, not the medical staff's personal mobile phone.
Therefore, the data from this study cannot be automatically applied to personal phones.
Source: Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infection Control & Hospital Epidemiology. 2008;29(1):1–7. doi:10.1086/524329.
The curtain pull edge should be considered a high-touch surface.
A longitudinal study conducted in two intensive care units and one medical ward tracked 43 curtains through 180 samples collected over three weeks.
Of the 13 new curtains tracked from installation, 12 (i.e., 92%) showed contamination in the first week. In total, 41 out of the 43 curtains were contaminated at least once; MRSA was identified on 21% of the curtains, and VRE on 42%.
These data show how quickly privacy curtains can become contaminated. However, the study does not demonstrate that the curtains were the source of infection transmission; the authors recommend further research to clarify their role in transmission.
Sources: Ohl M, Schweizer M, Graham M, Heilmann K, Boyken L, Diekema D. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control. 2012;40(10):904–906. doi:10.1016/j.ajic.2011.12.017. WHO. WHO Guidelines on Hand Hygiene in Health Care (My 5 Moments for Hand Hygiene). Geneva: World Health Organization; 2009.
The stethoscope is different from the other examples on this list: it is not an environmental surface, but a noncritical medical device that comes into contact with intact skin and can be used successively on multiple patients. The CDC explicitly includes it in the category of frequently touched noncritical equipment.
In a prospective study conducted on 83 patients, researchers collected samples from 489 surfaces of physicians' hands and stethoscopes after examination. The stethoscope diaphragm showed a median contamination of 89 CFU, compared to 467 CFU on the fingertips.
The study shows that the stethoscope can become contaminated during examination. This does not mean that every contamination leads to the transmission of an infection.
Sources: Longtin Y, Schneider A, Tschopp C, Renzi G, Gayet-Ageron A, Schrenzel J, Pittet D. Contamination of stethoscopes and physicians' hands after a physical examination. Mayo Clin Proc. 2014;89(3):291–299. doi:10.1016/j.mayocp.2013.11.016. Sehulster L, Chinn RYW; HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR Recommendations and Reports. 2003;52(RR-10):1–42.
The eight points presented above belong to the category of frequently touched surfaces around the patient. Microbiological studies show that such surfaces and equipment can be contaminated with a variety of microorganisms, including bacteria associated with healthcare-associated infections.
In studies conducted in intensive care units, among others, Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Staphylococcus aureus have been identified on surfaces and equipment used in patient care.
It has been identified on frequently touched surfaces in intensive care units, including near the patient's bed. In a prospective study, A. baumannii was identified on bed rails and other surfaces in the patient's environment.
It has been identified on frequently touched surfaces and equipment in hospital environments. Studies conducted in intensive care units have included K. pneumoniae among the microorganisms identified in samples collected from such surfaces.
It was also identified on surfaces in the patient's environment and on high-touch points. In microbiological studies in intensive care, P. aeruginosa was tracked alongside other microorganisms associated with healthcare-associated infections.
Identifying a microorganism on a surface demonstrates contamination of that surface, but it does not, in itself, demonstrate the transmission of an infection.
However, the fact that microorganisms associated with healthcare-associated infections can be identified on frequently touched surfaces shows why these points must be explicitly included in the cleaning and disinfection routine. For reusable equipment, cleaning and disinfection are carried out according to the manufacturer's instructions and the unit's procedure.
Hand hygiene remains a separate and essential measure: contact with the patient's environment should not be confused with direct contact with the patient.
Sources: Thom KA, Johnson JK, Lee MS, et al. Environmental contamination due to multidrug-resistant Acinetobacter baumannii surrounding colonized or infected patients. American Journal of Infection Control. 2011;39(9):711–715. doi:10.1016/j.ajic.2010.09.005.
Costa DM, Johani K, Melo DS, et al. Biofilm contamination of high-touched surfaces in intensive care units: epidemiology and potential impacts. Letters in Applied Microbiology. 2019;68(5):350–356. doi:10.1111/lam.13127.
Surfaces and objects around the patient are only one part of the chain of transmission. Staff hands bridge the gap between the patient, the patient's environment, and other surfaces touched during care.
WHO defines five moments when hand hygiene is indicated:
In the context discussed here, the fifth moment is particularly important. Bed rails, call buttons, curtains, tables, and other objects in the patient's immediate vicinity are part of the patient environment.
WHO. WHO Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization; 2009.
When hands are visibly soiled, washing with soap and water is recommended.
When hands are not visibly soiled, rubbing hands with an alcohol-based product is the preferred method for routine hand hygiene in healthcare.
Source: WHO. WHO Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization; 2009.
Knowing the technique does not automatically mean that all surfaces of the hands are covered. A study conducted on 190 nursing students evaluated 52 areas of both hands following a basic hand hygiene course. Among the frequently missed areas were the thumbs, the fingertips, and certain regions of the palms and the backs of the hands. Only 13% of participants achieved complete coverage of all 52 evaluated areas.
Diagram of highlighted areas
Highlighted regions
NOTE: The technique must be learned, but also verified.
Source: Gniadek A, Ogórek-Tęcza B, Inglot A, Nowacka A, Micek A. Hand Areas Which Are Commonly Missed during Hand Disinfection by Nursing Students Who Completed a Basic Educational Course in Hand Hygiene. International Journal of Environmental Research and Public Health. 2021;18(5):2590. doi:10.3390/ijerph18052590.
Gloves can become contaminated during care and do not replace hand hygiene. Wearing gloves does not change the moments when hand hygiene is indicated. Gloves must be changed when necessary, and hand hygiene must be performed at the right time, including after removing gloves.
WHO. WHO Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization; 2009.
An efficient procedure means more than just applying a product to a surface. The order of work, the cleaning method, avoiding recontamination, and observing the contact time all matter. Follow the six principles below to reduce the risk of omission and ensure epidemiological safety.
Start by identifying high-touch surfaces and objects allocated for the cleaning procedure in the respective area.
Attention to detail:
Door handles, light switches, bed rails, call buttons, and curtain edges are examples of highly contaminated surfaces that can easily be overlooked if you do not explicitly include them in your work plan.
Cleaning removes visible dirt and organic matter, substantially reducing the initial microbial load on the surface.
Mandatory order:
When the procedure involves both actions, perform them strictly in the order prescribed by the protocols (first cleaning, then disinfection). The presence of blood, secretions, or dust can inactivate the active substances in disinfectants, rendering them ineffective.
A strictly established work order helps you eliminate the risk of transferring contamination to areas that have already been sanitized.
Flow direction:
Always work from the cleanest areas to the dirtiest, and from top to bottom (from tall furniture to the floor), adapting the steps to the layout of the space and the unit's internal procedures.
Manage cleaning materials so that you do not move dirt and microorganisms from one surface to another.
Codes and techniques:
Change or reposition the cloths, strictly adhering to the hospital's color-coding system. Once a cloth has been used, do not place it back into the clean solution container to prevent contaminating the entire batch of solution.
The effectiveness of any disinfectant is dependent on a minimum contact time. Keep the surface visibly wet for the entire duration indicated by the manufacturer.
Avoid premature drying:
If the product evaporates or you wipe it off before the contact time has elapsed, the conditions of use are no longer those under which the biocidal efficacy was demonstrated.
Each surface, object, or medical device included in the procedure must be assigned to a clearly designated person.
Non-critical devices:
For medical equipment (stethoscopes, monitors, infusion pumps), ensure it is clearly established who performs the cleaning and disinfection (cleaning staff or medical staff), how often it is carried out, and what specific product is approved for that equipment.
A correct procedure involves choosing a suitable product for each type of use. A product intended for hand hygiene is not intended for surface disinfection, and a product for surfaces should not be applied to the skin.
In the case of biocidal products, the use must correspond to the product type and the purpose for which it is authorized. For hand hygiene, we are referring to PT1, and for surface disinfection, PT2 is used.
Below, you can consult the products intended for hand hygiene and those intended for surface cleaning and disinfection.
In addition to the individually presented products, certain items are also available in bundles. These bring together various combinations of products for hand hygiene and for cleaning and disinfecting surfaces.
Our disinfectants are approved by the Ministry of Health through the National Commission for Biocidal Products, and technical documentation is available upon request. ⚠️ Use biocides responsibly. Always read the label and product information before application. Follow the instructions provided by the manufacturer to ensure effective disinfection and safe use.
The surfaces most frequently missed in hospital cleaning include doorknobs, light switches, grab bars in restrooms, bed side rails, call buttons, bedside telephones, and curtain pull edges. The studies presented in the article show that these surfaces can have very different levels of cleanliness between hospitals and must be explicitly identified in work procedures.
Cleaning removes dirt, organic matter, and a portion of the microorganisms through mechanical action, while disinfection aims to inactivate microorganisms on the surface by using a product intended for this purpose. When the procedure involves both stages, cleaning must be performed before disinfection.
High-touch surfaces must be identified separately because small or easily overlooked objects can be missed from the cleaning routine. Door handles, light switches, bed rails, call buttons, and curtain edges are examples of surfaces that must be explicitly included in the cleaning lists and procedures for each area.
Surface cleaning and disinfection must be carried out methodically, starting from the cleanest surfaces and proceeding toward the dirtiest, from top to bottom, and without transferring microorganisms between surfaces. Cleaning must be performed before disinfection when both steps are required, and the disinfectant must be used according to the manufacturer's instructions, including regarding contact time.
The disinfectant must be kept on the surface for the contact time indicated by the manufacturer for the respective use. If the surface dries or the product is removed before the contact time has elapsed, the conditions of use no longer correspond to those under which the product's efficacy was demonstrated.
Hand hygiene is indicated at the five moments defined by the WHO: before patient contact, before a clean or aseptic procedure, after the risk of exposure to biological fluids, after patient contact, and after contact with the patient's environment. The latter moment is relevant for objects such as bed rails, call buttons, curtains, and tables in the immediate vicinity of the patient.
Hand washing with soap and water is recommended when hands are visibly soiled, while rubbing hands with an alcohol-based product is the preferred method for routine hygiene when hands are not visibly soiled. The washing procedure takes 40-60 seconds, and rubbing with an alcohol-based product takes 20-30 seconds.
Gloves do not replace hand hygiene and do not alter the moments when hand hygiene is indicated. Gloves can become contaminated during care, and hand hygiene must be performed at the recommended times, including after glove removal.
The choice of product for hand hygiene or surface disinfection must be made according to the type of use for which the product is approved and the manufacturer's instructions. In the classification of biocidal products, PT1 refers to products for human hygiene, while PT2 includes products for the disinfection of surfaces, materials, equipment, and furniture that are not intended for direct contact with food or animal feed.
Romanian manufacturer of professional cleaning and disinfection products used in hospitals, clinics, dental and medical offices, laboratories, and other professional environments. The quote in this guide comes from an educational conversation with an independent epidemiologist, who does not endorse or recommend any product. The usage method in this guide is for guidance purposes only—the instructions on the label of the product in use take precedence.
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