Environmental Cleaning

Slide 1

Environmental Cleaning David Woodard, MSc, CIC, CPHQ, CLSObjectivesDiscuss the role of environmental cleaning and disinfection in the prevention of HAIs.Identify evidence-based methods and best practices for environmental cleaning in healthcare facilities.Discuss controversies and challenges for infection control managers and resources for effective management.Outline of todays presentationIssues with terminology

Why terminal room cleaning is important Addressing suboptimal cleaning practice

Does enhanced cleaning make a difference?Conventional vs. enhanced environmental cleaning monitoringWhere are we going with surface disinfectants and new technologies?Disinfection cleaning Implies the use of a low level disinfectant to decrease bio-burdenEnvironmental cleaning (in Healthcare) surface cleaning to reduce bio-burdenHygienic cleaning New, more specific term surface cleaning to reduce bio-burden (confusion with hand hygiene?)Terminology - new

Sax H, Pittet D et al. JHI September 2007

What is clean? Swab surface luciferace tagging of ATP Hand held luminometer

How Clean is the Clean Appearing Hospital Environment ?Visually clean surfaces may be contaminated.

82% of sites visually clean

24% clean by ATP bioluminescence

30% clean using microbiological techniques

Some clean surfaces had organism counts > 40 cfu/cm2Correlation between ATP bioluminescence (RLU/Swab) and aerobic colony count (cfu/swab)

Bioluminescence PPV = 63% NPV= 71%Satisfactory by RLUs but Unsatisfactory by # CFUIncreased acquisition risk from prior room occupant 6 studies as of January 2011

Carling PC, Bartley JM. Am J Infect Control 2010;38 S41-50.

Baseline Environmental Evaluation of Terminal Room Cleaning in 23, 36, 82 Acute Care Hospitals

Proportion of Objects Cleaned as Part of Terminal Room Cleaning in 20 Acute Care Hospitals

Thoroughness of Environmental Cleaning

Hospitals Environmental Hygiene Study Group36 Hospital ResultsPost InterventionGroup Benchmarking

Group Benchmarking

These results suggest that substantial improvements in environmental cleaning are achievable and sustainable

Leadership

Enid K. Eck, RN, MPH Regional Director, Infection Prevention and Control Kaiser Permanente, Dedicated, Energetic, Supportive and Optimistic!Programmatic ApproachSenior leadership supportES buy inTransparencyBlameless BenchmarkingProblems Solutions open cooperationRecognition of success at all levels

Improved thoroughness of hygienic cleaning is a worthy goal given the billions of dollars involvedbut will it impact transmission of HAPs ?

Approaches to Programmatic Environmental Cleaning Monitoring

Conventional Program

Subjective visual assessmentDeficiency orientedEpisodic evaluationProblem detection feedbackOpen definition of correctable interventions

Enhanced Program

Objective quantitative assessmentPerformance orientedOngoing cyclic monitoringObjective performance feed backGoal oriented structured Process Improvement model

Approaches to Programmatic Environmental Cleaning Monitoring

Conventional Program Advantages

An established model

Enhanced Program Advantages

Direct evaluation of practiceUses a standardized, consistent, objective and uniform system of monitoringProvides regular and ongoing performance results to ES staffFacilitates the monitoring of many data points to optimize performance analysisProvides positive practice based feedback to ES staffAllows for objective remedial interventionsEasily adaptable to existing PI modalitiesFacilitates compliance with JCAHO standardsFacilitates compliance with CMS CoPIntrinsic internal benchmarkingExternal benchmarking, reporting and recognition feasible

Approaches to Programmatic Environmental Cleaning Monitoring

Conventional Program Limitations

Inability to evaluate actual practiceBased only on negative outcome analysisLimited generalizability of findingsPoor specificity and low sensitivitySubjectivity with a high potential for observer biasPoor programmatic specificityPotential for observer biasOnly evaluates daily HPLimited ability to support JCAHO standard EC.04.01.03.EP2Limited ability to demonstrate compliance with CMS CoP 482.42Benchmarking not feasibleEnhanced Program Limitations

Requires a new program implementationOngoing administrative support critical to successPotential resistance to objective monitoring and reportingWhile useful, the covert baseline evaluation may be difficult to implement effectively

Monitoring tool considerations

Evaluating Patient Zone Environmental CleaningMethodEase of UseIdentifies PathogensUseful for Individual Teaching Directly Evaluates CleaningPublished Use in Programmatic ImprovementCovert PracticeLowNoYesYes1 Hospital Swab cultures HighYesNot StudiedPotentially1 Hospital Agar slide cultures GoodLimitedNot StudiedPotentially1 HospitalFluorescent gelHighNoYesYes49 HospitalsATP systemATP Bioluminescence Testing in Healthcare SettingsPotential usefulness:Has been used as a surrogate for environmental culturing

Evaluates cleanliness

Can rapidly define how clean an object is. but non-microbial ATP is also evaluated

Standards to optimize predictive values are still being evaluated

Can be used to do one-on-one education of ES staff

ATP Bioluminescence Testing in Healthcare SettingsPotential limitations:Secondary cleaning of the site is required to remove disinfectant induced signal decay or enhancement.

Involvement of the ES staff is implicit since evaluation must be done within minutes of cleaning. Pre-intervention evaluation of disinfection cleaning is difficult without inducing a Hawthorne effect

Results are individual ES staff / time specific.

Many manufacturers of luminometers and ATP swabs makes interinstitutional standardization difficultThe challenge of using a cleanliness tool to evaluate cleaning

Sherlock O, OConnell N, Creamer E, Humphries H. J Hosp Infect (2009)72;140-146.

http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

Dont forget the Rutala EquationEffective Disinfection Cleaning

Product + PracticeWhat did Sir Thomas Sydenham have to say about evolving new technologies to replace or enhance healthcare environmental hygiene?

What did Sir Thomas Sydenham have to say about evolving new technologies to replace or enhance healthcare environmental hygiene?

When in darkness so deep I move with an especially slow foot.When in darkness so deep I move with an especially slow foot. Remember:While surface cleaning in the patient zone is important, we really dont know:How important which disinfectant is;

How much better microfibre is than traditional cloth for surface cleaning;

When to use bleach and when not to;

When technological interventions should be consideredDecontamination with UVC Disadvantages:Do not know if use decreases the incidence of HAIsOnly done at terminal disinfection (i.e., not daily cleaning)All patients and staff must be removed from the room/areaCapitol equipment costs are substantialDoes not remove dust and stains which are important to patients/visitorsSensitive use parameters (e.g., UV dose delivered)

When in darkness so deep I move with an especially slow foot.

Finally remember:There may be unintended consequences of such new technologies

Advertising and marketing are much less expensive than researchConclusions It is very likely that surfaces in the Patient Zone are highly relevant in the transmission of Healthcare Associated Pathogens.While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.Key ReferencesDancer SJ. The role of the environmental cleaning in the control of hospital acquired infections. J Hosp Infect. 2009; 1-10.Carling PC, Bartley JM. evaluating hygienic cleaning in healthcare settings: What you dont know can hurt your patients. Am J Infect Control 2010;38 S41-50.CDC/HICPAC. Guidelines for environmental infection control in health care facilities. MMWR 2003;52:No. RR-10.http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html. October 2010.AttributionThis is the Readers Digest version of the presentation prepared by the Society of Healthcare Epidemiology of America (SHEA) for use by the CMS to train state HAI coordinators. Chart1300102401101705440

Increased Risk of Aquisition (%)

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Proportion of Objects Cleaned (%)Hospitals

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Sheet1ALTRUBMC ENBMC MCHFLOKSACMERCYMIRMWMC FMWMC NQMCS COUST VSTAMTOLWHCMEM RINEWPSINK83819298929675789795578985777684787896TOILET SEAT77528581948173449092799490678976445593TRAY TABLE78939086657363671007191985977536383100TOILET HANDLE619284858145446966412388276079447636HAND HOLD2980024161717413373342526173718BEDPAN CLEANER250221115328161884834020283911SIDE RAILS594357454282782796532576527736785393CHAIR430405648111375761754214880100TOILET DOOR23273102333284171141614639282720ROOM DOOR23031216153161331017211431316012CALL BOX48503942655254319265724574971547343TELEPHONE484365185736544047235560573847544586BR LIGHT176313130311371502303714

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Chart148HEHSG HOSP62IOWA HOSP42OTHER HOSP32OPERATING ROOMS36NICU12EMS VEHICLESICU DAILY31AMB CHEMO26MD CLINIC24LONG TERM34DIALYSIS28

CleanedTERMINAL CLEANINGDAILY CLEANING%

Sheet1HEHSG HOSP48IOWA HOSP62OTHER HOSP42OPERATING ROOMS32NICU36EMS VEHICLES12ICU DAILY31AMB CHEMO26MD CLINIC24LONG TERM34DIALYSIS28

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Chart120.428571428624.42857142867040.857142857146.91558441568936.2857142857C2381.985871271678488940.857142857171.3821892393692.642857142950.57682449135323.857142857172.922077922166.5714285714I45.0549450549777531.8226561885066.803465765L

CLEANGOALBASELINEPOST EDUCATIONPOST F/U%Patient Area Infection Prevention CleaningKaiser Permanante S. California Hospitals

Sheet1A202470B414789C36D238278E4889F417169G35153H2473I67J457775K3250L67

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Chart1322042716337273485026445024479883867351868977778570899680939553859085749084839488899472979387899489939793879683979595979695998790979791969395959892999089989894969496969896999290989999989488

90% GOALCLEAN%

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Chart13968844093

%

Sheet1Programmatic decrease in aquisition39Programmatic decrease in environmental contamination68Thoroughness of cleaning following structured interventions84Baseline thoroughness of Cleaning40Increased risk of prior room occupant transmission93

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Chart11751701200500450375600900350200700900325375

BEFORE CLEANINGAFTER CLEANINGAverage ATP RLU

Sheet1BED FRAME175170LOCKER1200500CURTAIN450375TOILET HANDLE600900TOILET FLOOR350200TREATMENT ROOM700900NURSES DESK325375

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