Proper Environmental Cleaning Relies on Education

ICT asked Philip Carling, MD, director of infectious diseases and epidemiology at Caritas Carney Hospital in Boston and a professor at Boston University School of Medicine, to share his insights on the topic of environmental cleaning.

Q: Your studies have indicated that hospitals have a lot of room for improvement in their surface cleaning protocols; to what degree is efficacious cleaning lacking in today’s hospitals and why?

A: Following completion of the Healthcare Environmental Hygiene Study Group (HEHSG)’s 36-hospital project, the results of which were published last fall, we have expanded the same programmatic analysis and process improvement intervention to almost 100 hospitals across the U.S., ranging in size from eight to 540 beds. One of the most interesting findings in our covert studies of the thoroughness of terminal room cleaning was the range as well as clustering of cleaning scores found (cleaning score equals the percentage of 14 high-risk objects in patient rooms and bathrooms cleaned following patient discharge). Most scores clustered around a mean of 63 percent with half of the hospitals having scores of 40 to 60. While some hospitals had much higher than average cleaning scores, several had scores which very much distressed them. In spite, or possibly because of, their low baseline cleaning scores, all of the low-scoring hospitals improved to 80 percent or greater following education and implementation of a structured monitoring and performance feedback intervention. On the basis of my discussion with dozens of infection preventionists participating in the HEHSG’s projects, it appears that the primary reasons for suboptimal performance in terminal room cleaning relate to shortcomings in the education of environmental services (ES) staff with regard to their understanding of specific, clinically relevant cleaning expectations, and their critical role in patient safety through the prevention of hospital-associated pathogen (HAP) transmission from near-patient environmental surfaces.

Q: In the context of your previous studies, which interventions do you believe are most effective in improving how surface cleaning is performed and why?

A: Once ES staff expectations are clearly and reasonably defined and understood by the staff, two interventions have accounted for most of the subsequent improvement in cleaning scores. First is the implementation of a process to inform and provide ongoing reinforcement to ES staff on the critical importance of their work. ES staff optimize patient safety by decreasing the risk of HAPs being transmitted from patient zone surfaces to susceptible hosts by healthcare workers. Optimizing hand hygiene is of great importance in any infection prevention program. However, it has been shown that patient care and glove use that continues beyond more than one environment – patient contact activity can lead to the transfer of HAPs from near-patient surfaces to patients and healthcare workers. Well-trained, conscientious ES workers who have a clear understanding of their role in decreasing such transmission are motivated to perform their surface cleaning activities more thoroughly. Second, having a system which provides ongoing objective and timely performance feedback to ES staff has also been shown to improve the thoroughness of disinfection cleaning. The evaluation and feedback process, based on ongoing analysis of cleaning performance, has also served to objectively pinpoint inefficient processes. Following process improvement and educational interventions, cleaning scores documenting high levels of performance have then been shared with a range of “consumers” including fellow healthcare workers, patients and organizations overseeing patient care activities such as local and state departments of health and the Joint Commission. Such recognition reinforces the importance of their work to the ES staff and helps them recognize their value to the hospital.

Q: Do you believe that current guidelines and recommendations provide sufficient instruction and evidence-based practices for proper cleaning? If not, what is missing and why?

A: Current guidelines and regulations related to healthcare environmental hygiene are in a state of rapid evolution. Guidelines developed by the CDC, APIC, AORN and ASHES now provide more specific and directly applicable guidance to assist IPs and ES managers in developing hospital- specific policies and procedures related to healthcare environmental hygiene. While more generally articulated, the mandate by the Centers for Medicare and Medicaid Services (CMS) now requires hospitals to have an infection prevention and control program that includes appropriate monitoring of housekeeping activities to ensure that the hospital maintains a sanitary environment. (§482.42 Condition of Participation: Infection Control - November 2007.) Templates which provide guidance for environmental hygiene policy and procedure development in a wide range of healthcare venues have been developed by ASHES. Together these resources provide clear direction and substantial guidance to healthcare facilities in developing best practices. Unfortunately, guidance based on clinical studies is only beginning to evolve. Several recent well-designed studies have demonstrated the impact of improved environmental hygiene on environmental contamination with C difficile, MRSA and VRE as well as decreased transmission of MRSA and VRE to patients as a result of improved cleaning. These findings will benefit from additional studies to further quantify the impact of improved environmental hygiene. Much critical work needs to be done to objectively define what Dr. Bill Rutala calls the “product vs. practice equation.” Furthermore, it will be critical to support multi-site clinical studies to delineate the relative benefits and limitations of products available today; green cleaning products, bleach based disinfectants, disposable wipes, microfiber cloths and traditional cleaning tools. The potential value of technological interventions such as hydrogen peroxide vapor decontamination and microbicide impregnated surfaces in decreasing environmental transmission of HAPs also require further study.

Q: Much of your research has focused on the use of a targeting method to determine cleaning efficacy; how are your findings evolving as you work more in this area, and what are the important benefits that can be achieved?

A: Further studies evaluating and improving the thoroughness of environmental hygiene in a wide range of hospitals, both in the U.S. and abroad, are currently underway. Our preliminary results suggest that various venues within acute care hospitals (i.e., operating rooms, intensive care units, emergency departments) and non-hospital healthcare settings (i.e., long-term care facilities, ambulatory care sites and dialysis units) show cleaning scores having a general distribution similar to that noted in Figure 1 (pre-intervention disinfection cleaning of vacated patient rooms). Improving the thoroughness of cleaning in all of these settings appears to be achievable but difficult challenges are being recognized in each of the different settings. As discussed above, the benefits to be achieved as a direct result of more thorough cleaning of patient surfaces have been documented by several dedicated research groups in this country and by Dr. Stephanie Dancer in Scotland. Multi-site studies will be needed to further quantify the magnitude and impact of these improvements.

Q: What is the single most important piece of advice you can share with practitioners looking to address pathogen resistance, eradicate surface contamination and prevent infections?

A: The ongoing contamination of patient zone surfaces with all of the major pathogens currently associated with healthcare associated infections and the substantial environmental resilience of every one of the pathogens noted in Figure 2, is a major concern. The path to optimizing the safety of high risk surfaces and patient care equipment will be through the optimization of cleaning practice along with the development of the best tools and solutions to provide thorough cleaning. While it is possible to “eradicate” all of these pathogens at a single point in time with aggressive interventions such as bleach based disinfectants or technological tools such as hydrogen peroxide vapor, the practical limitations of using such high intensity tools for day to day cleaning of occupied rooms, public areas, nurseries and ambulatory settings is prohibitive. Although newer, better, safer hygienic cleaning solutions and systems are being developed, without optimizing hygienic practice these tools will never realize their potential for reducing hospital-associated infections.

Studies Demonstrate Importance of Environmental Cleaning

A number of recent studies indicate the importance of thorough environmental cleaning in the healthcare setting.

Carling et al. (2008) sought to evaluate the thoroughness of disinfection and cleaning in the patient’s immediate environment and to identify opportunities for improvement in a diverse group of 23 acute-care hospitals. The researchers conducted a prospective multi-center study to evaluate the thoroughness of terminal room cleaning in hospitals using a novel targeting method to mimic the surface contamination of objects in the patient’s immediate environment.

The researchers found that the overall thoroughness of terminal cleaning, expressed as a percentage of surfaces evaluated, was 49 percent (range for all 23 hospitals, 35 percent-81 percent). Despite the tight clustering of overall cleaning rates in 21 of the hospitals, there was marked variation within object categories, which was particularly notable with respect to the cleaning of toilet handholds, bedpan cleaners, light switches and door knobs (mean cleaning rates, less than 30 percent; institutional ranges, 0 percent-90 percent). Sinks, toilet seats, and tray tables, in contrast, were consistently relatively well cleaned (mean cleaning rates, over 75 percent). Patient telephones, nurse call devices, and bedside rails were inconsistently cleaned.

The researchers identified significant opportunities in all participating hospitals to improve the cleaning of frequently touched objects in the patient’s immediate environment. They say that the information obtained from such assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feedback to the environmental services staff, to improve cleaning and disinfection practices in healthcare institutions.

Reference: Carling P, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008 Jan ;29 (1):1-7 18171180.

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Goodman et al. (2008) sought to evaluate the adequacy of discharge room cleaning and the impact of a cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) on environmental surfaces in intensive care unit (ICU) rooms at an academic hospital. Researchers employed an intervention consisting of a change from the use of pour bottles to bucket immersion for applying disinfectant to cleaning cloths, an educational campaign, and feedback regarding adequacy of discharge cleaning.

Cleaning of 15 surfaces was evaluated by inspecting for removal of a preapplied mark, visible only with an ultraviolet lamp. Six surfaces were cultured for MRSA or VRE contamination. Outcomes of mark removal and culture positivity were evaluated. The researchers found that the mark was removed from 44 percent of surfaces at baseline, compared with 71 percent during the intervention (P_.001). The intervention increased the likelihood of removal of marks after discharge cleaning (odds ratio, 4.4; P _ .001), controlling for ICU type (medical vs. surgical) and type of surface. The intervention reduced the likelihood of an environmental culture positive for MRSA or VRE (proportion of cultures positive, 45 percent at baseline vs. 27 percent during the intervention; adjusted odds ratio, 0.4; P _ .02). Broad, flat surfaces were more likely to be cleaned than were doorknobs and sink or toilet handles. The researchers concluded that increasing the volume of disinfectant applied to environmental surfaces, providing education for environmental services staff, and instituting feedback with an ultraviolet light marker improved cleaning and reduced the frequency of MRSA and VRE contamination.

Reference: Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-eesistant Enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol 2008; 29:593-599.

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Boyce et al. (2009) sought to evaluate the usefulness of an adenosine triphosphate (ATP) bioluminescence assay for assessing the efficacy of daily hospital cleaning practices in their two-phase prospective intervention study at a university-affiliated community teaching hospital. In phase one, the researchers sampled five high-touch surfaces in 20 patient rooms before and after daily cleaning. Moistened swabs were used to sample these surfaces and were then plated onto routine and selective media, and aerobic colony counts were determined after 48 hours of incubation. Specialized ATP swabs were used to sample the same high-touch surfaces in the 20 patient rooms and were then placed in luminometers, and the amount of ATP present was expressed as relative light units. During phase two of the study, after in-service housekeeper educational sessions were given, the housekeepers were told in advance when ATP readings would be taken before and after cleaning. The researchers found that during phase one, the colony counts revealed that the five high-touch surfaces were often not cleaned adequately. After cleaning, 24 percent of the 100 surface samples were still contaminated with methicillin-resistant Staphylococcus aureus, and 16 percent of the 100 surface samples still yielded vancomycin-resistant enterococci. ATP readings (expressed as relative light units) revealed that only bathroom grab bars and toilet seats were significantly cleaner after daily cleaning than before. During phase two, a total of 1,013 ATP readings were obtained before and after daily cleaning in 105 rooms. The researchers found that the median relative light unit was significantly lower (i.e., surfaces were cleaner) after cleaning than before cleaning for all five high-touch surfaces. The researchers concluded that ATP readings provided quantitative evidence of improved cleanliness of high-touch surfaces after the implementation of an intervention program.

Reference: Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O and Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 2009;30:678-684.