Evaluating and improving cleaning and disinfection in healthcare facilities
Traditional monitoring of environmental cleanliness through visual assessment can identify serious deficiencies in practice. However, in recent years, the limitations underlying the need to comply with cleaning and disinfection policies in the immediate vicinity of hospitalized patients have been widely recognized.
Representatives of Mafraq Hospital[1] in the United Arab Emirates have adopted a method that uses an invisible fluorescent marker system to target surfaces in the immediate vicinity of patients, in order to verify cleaning and disinfection standards. Evaluation of at least 30 surfaces and objects in patient rooms showed that only 11% of the targets had been cleaned. Simulation-based training, educational interventions, accountability, engagement in change, and recognition were implemented, which led to a sustained 77% improvement in both the second and third quarters regarding the cleaning and disinfection of all surfaces and objects.
The existing problem
Patients with pathogens (e.g., methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Acinetobacter) frequently contaminate environmental surfaces in their immediate vicinity. These organisms can remain viable in the environment for weeks, or even months. Objects near patients are frequently contaminated: this category includes bed rails, bed linen, tables, blood pressure cuffs, television remotes, nurse call buttons, etc.
Background of the problem
Contaminated environmental surfaces contribute to the transmission of pathogens and serve as a source from which healthcare personnel contaminate their hands and gloves. Contaminated medical equipment that has direct contact with the patient can also serve as a source of transmission. Patients admitted to a room previously occupied by a patient with a multidrug-resistant organism are at an increased risk of acquiring the organism, which suggests the necessity of inadequate cleaning.
The factors contributing to this situation are multiple. Sometimes, the personnel assigned to clean and disinfect surfaces do not understand which detergent or disinfectant to use, or there is a lack of a standardized mechanism for monitoring the effectiveness of sanitation practices. KLINTENSIV® – Concentrated disinfectant detergent
In the last decade, numerous studies have shown that approximately 30% to 60% of surfaces in the patient area of individuals colonized or infected with C. difficile, MDRO (e.g., VRE, MRSA) are contaminated with these microorganisms. Although less studied, several reports have identified similar rates of contamination with Acinetobacter baumannii in patient rooms occupied by colonized and infected cases. Studies have shown that better cleaning and disinfection of environmental surfaces can reduce the transmission of pathogens such as C. difficile.
Benchmark measurements
Infection prevention specialists conducted a review of the specialized literature to analyze evidence-based practices that led to the improvement of the cleaned environment. Four methods were identified: visual inspection, environmental culture, adenosine triphosphate (ATP) bioluminescence testing systems, and the fluorescent marker system.
Visual inspection is a simple method, but it does not provide a reliable assessment of the degree of cleanliness. Environmental culture is relatively simple for detecting the presence of pathogens, but it is more expensive, and results are not available until after 48 hours. Although ATP bioluminescence testing systems provide a quantitative measure of cleanliness and rapid results, this is also an expensive method and requires special equipment. Regarding the fluorescent marker system, it is inexpensive compared to environmental culture and ATP bioluminescence testing systems and requires only minimal equipment. However, it requires marking surfaces before cleaning and checking them after cleaning.
Biosimulators and visual training represent an important new approach for learning in the healthcare field; it allows healthcare workers to see the impact of disease transmission compared to traditional didactic education.
Assessment and planning
In the postnatal unit and operating rooms of the hospital, a total of 30 high-touch surfaces (e.g., door handle, alcohol-based hand dispenser, water faucet, overbed table, telephone keypad, etc.) were evaluated. Surfaces that were cleared of the fluorescent powder are considered "clean" and counted as compliant. When calculating the compliance rate, the numerator is the number of clean surfaces. The denominator is the total number of surfaces evaluated. Thus, the initial compliance rate was 11%.
When analyzing the root cause of this low compliance rate (11%), it became clear that the environment and equipment were not being properly disinfected. It was necessary to design an intervention to help improve this aspect. A number of ideas were considered to achieve this, including the development of policies, and educating environmental service staff on proper environmental disinfection. GLUTANOL® RTU – Disinfectant for surfaces and instruments
The process of evaluating cleaning and disinfection techniques provided extremely positive results in favor of objective monitoring and practice improvement at Mafraq Hospital, using the fluorescent marker system.
The strategy was as follows. At least 30 high-touch surfaces or objects were marked with fluorescent powder by the secret auditor before cleaning. The evaluation was carried out in patient rooms after patients were discharged but before they were occupied by the next patient. The targeted surfaces were evaluated using a portable ultraviolet light to see if the mark had been wiped away. The compliance rate was only 11% in the first quarter of research. The factors that led to non-compliance were analyzed, and these were: lack of supervision for the cleaning procedure, lack of standardization in allocating time for the cleaning procedure, lack of knowledge regarding the concentration and preparation of the surface disinfectant, rapid cleaning on demand during high patient turnover, the same disposable cleaning cloth for clean and contaminated surfaces or equipment, equipment that was not cleaned, and staffing shortages.
Based on the findings, the environmental services team improved the cleaning and disinfection training program. Healthcare unit managers and infection prevention and control liaison practitioners were trained on the use of the fluorescent marker system to evaluate cleaning and disinfection techniques in their respective areas.
Scheduled evaluation was performed by infection prevention specialists and prompt feedback was provided.
When practices were re-evaluated in the second quarter, compliance with cleaning and disinfection techniques increased to 76.9% after at least 30 surfaces were evaluated. The results were shared with key stakeholders. The test proved that the transmission of healthcare-associated pathogens can be mitigated by objectively monitoring and improving environmental cleaning and disinfection practices in healthcare settings. The fluorescent dye marking system was expanded to the entire Mafraq Hospital, in addition to periodic audits and continuous education. Units or departments that recorded the best compliance were recognized by senior management.
When the system was initiated, in February 2013, the compliance rate with cleaning and disinfection techniques was only 11% in the first quarter of 2013. When practices were re-evaluated in the second quarter, the degree of compliance with cleaning and disinfection techniques increased to 76.9% and was maintained at 77.3% in the third quarter.
However, the degree of compliance with cleaning and disinfection techniques fell to 50% in the fourth quarter, as liaison practitioners and the environmental services team were not empowered and were not given ownership to closely monitor practice in their respective areas. Once stakeholders were empowered, accountability was strengthened, and the top performers were recognized by the senior management team, compliance increased to 75% in the first quarter of the following year.
Conclusion
Widespread concerns regarding the capacity of current strategies, including hand hygiene and antimicrobial stewardship programs designed to diminish the prevalence of multidrug-resistant organisms in healthcare facilities, significantly reduce environmental contamination with a range of pathogenic organisms, which has led to a decrease in infections. KLINTENSIV DEZICON® – High-level concentrated disinfectant
