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Best practices in disinfection of noncritical surfaces in the health care setting: Creating a bundle for success

      Because increasing evidence suggests that the environment plays a role in transmission of health care-associated infections, more attention is focusing on environmental cleaning and improving its efficacy. Creating and sustaining a successful cleaning and disinfection program should include several key components using a bundle approach and requires ongoing commitment within the institution.

      Key Words

      Because there is a growing body of evidence that the environment plays a role in the transmission of health care-associated infections (HAIs),
      • Boyce J.M.
      • Porter-Bynoe G.
      • Chenevert C.
      • King T.
      Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications.
      • Martinez J.A.
      • Rutjazer R.
      • Hansjosten K.
      • Barefoot L.
      • Snydman D.R.
      Role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococcus by inpatients treated in a medical intensive care unit.
      • Hayden M.K.
      • Bonten M.J.
      • Blom D.W.
      • Lyle E.A.
      • van de Vijver D.A.
      • Weinstein R.A.
      Reduction in acquisition of vancomycin-resistant Enterocccus after enforcement of routine environmental cleaning measures.
      • Drees M.
      • Snydman D.R.
      • Schmid C.H.
      • Barefoot L.
      • Hansjosten K.
      • Vue P.M.
      • et al.
      Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci.
      • Dancer S.J.
      • White L.F.
      • Lamb J.
      • Girvan E.K.
      • Robertson C.
      Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
      more attention is being focused on environmental cleaning and ways of improving the efficacy of the cleaning process to decrease the spread of HAIs in the health care setting.
      • Dancer S.J.
      Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning.
      • Datta R.
      • Platt R.
      • Yokoe D.S.
      • Huang S.S.
      Environmental cleaning intervention and risk of acquiring multidrug-resistant organisms from prior room occupants.
      Several studies have shown that there is increased risk of acquiring a HAI for patients placed in rooms where the previous occupant was colonized or infected with a pathogenic organism.
      • Datta R.
      • Platt R.
      • Yokoe D.S.
      • Huang S.S.
      Environmental cleaning intervention and risk of acquiring multidrug-resistant organisms from prior room occupants.
      • Huang S.S.
      • Datta R.
      • Platt R.
      Risk of acquiring antibiotic-resistant bacteria from prior room occupants.
      • Nseir S.
      • Blazejewski C.
      • Lubret R.
      • Wallet F.
      • Courcol R.
      • Durocher A.
      Risk of acquiring multidrug-resistant gram-negative bacilli from prior room occupants in the intensive care unit.
      • Shaughnessy M.K.
      • Micielli R.L.
      • DePestel D.D.
      • Arndt J.
      • Strachan C.L.
      • Welch K.B.
      • et al.
      Evaluation of hospital room assignment and acquisition of Clostridium difficile infection.
      Current guidelines recommend that health care facilities clean noncritical surfaces on a regular basis, when spills occur, and when these surfaces are visibly soiled.
      • Sehulster L.
      • Chinn R.Y.
      • CDC
      • HICPAC
      Guidelines for environmental infection control in health-care facilities: recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC).

      Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guidelines for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed May 1, 2012.

      However, because several studies have reported that cleaning practices are often suboptimal,
      • Carlin P.C.
      • Briggs J.L.
      • Perkins J.
      • Highlander D.
      Improved cleaning of patient rooms using a new targeting method.
      • Boyce J.M.
      • Havill N.L.
      • Dumigan D.G.
      • Golebiewski M.
      • Balogun O.
      • Rizvani R.
      Monitoring the effectiveness of hospital cleaning practices using ATP bioluminescence assay.
      it is now recognized by the Centers for Disease Control and Prevention and professional societies that there is a need for a system for monitoring adherence to recommended cleaning practices to ensure consistent cleaning and disinfection of surfaces in patient rooms.

      CDC. Management of multi-drug resistant organism in healthcare settings, 2006 HICPAC guideline. Available from: www.cdc.gov/ncidod/dhqp/pdf/ar/mreoGuideline2006.pdf. Accessed May 1, 2012.

      Several studies have shown that monitoring and providing feedback to the housekeeping staff can show significant improvement in their cleaning practices,
      • Carlin P.C.
      • Briggs J.L.
      • Perkins J.
      • Highlander D.
      Improved cleaning of patient rooms using a new targeting method.
      • Boyce J.M.
      • Havill N.L.
      • Dumigan D.G.
      • Golebiewski M.
      • Balogun O.
      • Rizvani R.
      Monitoring the effectiveness of hospital cleaning practices using ATP bioluminescence assay.
      but others have demonstrated that the improvement is not always sustainable.
      • Rutala W.A.
      • Weber D.J.
      Are room decontamination units needed to prevent transmission of environmental pathogens?.
      Administrative leadership and interdepartmental involvement are necessary to achieve success, and sustainability requires an ongoing commitment within the institution.

      Creating a bundle for success

      Similar to the Institutes for Healthcare Improvement bundle models for central lines and ventilators to prevent HAIs, an evidence-based care bundle is also needed for a successful environmental cleaning and disinfection program. Key components of this bundle should include the following: policies and procedures to delineate cleaning responsibilities among staff; selection of appropriate cleaning products; determining the method of application for the products; and to educate, monitor, and give feedback to the staff. All of these elements are required to create a bundle for a successful cleaning and disinfection program.

      Creating policies and procedures

      The first step in creating a successful environmental cleaning program is to form a multidisciplinary task force as described by Dumigan et al.
      • Dumigan D.G.
      • Boyce J.M.
      • Havill N.L.
      • Golebiewski M.
      • Balogun O.
      • Rizvani R.
      Who is really caring for your environment of care? Developing standardized cleaning procedures and effective monitoring techniques.
      The team should comprise members from administration, nursing, environmental services, infection prevention (hospital epidemiologist, infection preventionist), materials management, biomedical engineering, pharmacy, and epidemiology laboratory personnel. Every discipline that has any role in the cleaning process needs to be represented so that policies and procedures can be effectively defined. The policies need to clearly define the cleaning task, the responsible service to perform the task, the cleaning frequency, and the products to be used. Figure 1 is an example of a grid that defines these items in a cleaning policy.
      Figure thumbnail gr1
      Fig 1Example of an environmental cleaning grid.
      Following the Spaulding definitions, which categorize levels of disinfection based on the object’s intended use and risk for infection in the use of that item, noncritical surfaces in the health care setting are those that only touch intact skin, and these require low-level disinfection. Some examples of noncritical items includes noncritical surfaces that may have contact with patients or health care providers (bedside rails, toilet, sink, overbed tables, and others), noncritical surfaces that do not have contact with patients or health care staff (ceilings, walls, window sills, and others), and medical devices (blood pressure cuffs, monitors, and others). All require low-level disinfection, and the frequency may vary. For example, noncritical surfaces need cleaning only when visibly soiled and periodically; noncritical surfaces that contact patients or health care providers should be cleaned and disinfected daily (or more frequently) and at terminal cleaning; and equipment should be disinfected between patients if shared or at least daily and at terminal cleaning.
      By definition, a low-level disinfect is an agent that destroys all vegetative bacteria (except tubercule bacilli) lipid viruses, some nonlipid viruses, and some fungi but not bacterial spores on inanimate objects. There are many factors that affect the efficacy of the disinfectant including: prior cleaning of the item, whether there is any organic or inorganic substances present, the type and level of microbial contamination, the concentration and contact time of the disinfectant, the physical nature of the item, whether or not there is the presence of a biofilm, and also the temperature and pH of the environment.

      Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guidelines for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed May 1, 2012.

      One inconsistency in the Spaulding classification system and the definition of a low-level disinfectant is when it comes to Clostridium difficile (CD). One of our biggest challenges in cleaning and disinfecting the environment is to remove CD spores to prevent the transmission of this organism to other patients. In the case of CD, it is necessary for the CD spores to be physically removed from surfaces or inactivated by the use of a sporicidal germicide.

      Selection of cleaning products

      Selection of the cleaning products should include a review of the current cleaning agents and disinfectants used within your institution. Guidelines have outlined environmental disinfection protocols that include routine cleaning and disinfection of environmental surfaces with a US Environmental Protection Agency-registered, hospital-grade disinfectant.
      • Sehulster L.
      • Chinn R.Y.
      • CDC
      • HICPAC
      Guidelines for environmental infection control in health-care facilities: recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC).

      Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guidelines for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed May 1, 2012.

      Common products include quaternary ammonium compounds, sodium hypochlorite, phenolics, and hydrogen peroxide. All products have pros and cons for use, but it is of utmost importance to use the product following manufacturer’s recommendations for use on certain surfaces and for the correct use dilution. Some characteristics to consider when choosing the appropriate disinfectant are listed in Table 1.
      Table 1Desired disinfectant characteristics
      FunctionSafety
      Broad-spectrum antimicrobial efficacyLow toxicity to humans
      Short contact timeNonallergenic and nonsensitizing
      Good cleanerNonhormone disrupting
      Compatible with materialsEnvironmentally sound
      NoncorrosiveLow volatile organic compounds
      Long shelf lifeSafe to transport
      Safe and easy to store

      Determining method of application

      After determining the products to be used and developing guidelines for when to use various agents, the method of application needs to be defined. These products can be applied with cotton cloths, microfiber cloths, or disposable wipes. The disinfectant may be sprayed, wiped, or applied with a saturated cloth. The application process may be determined by a facility’s capability of laundering within the facility or contracting with an outside vendor or by budget constraints. Regardless of the method of application to be used, the most important factor is that the disinfectant be applied liberally enough to achieve sufficient wetness to ensure that the correct disinfectant contact time is being achieved.

      Education

      The next step in the process is to educate the environmental services personnel. There is an enormous amount of information that they must be given to perform their tasks effectively. They must be educated on the items that they are required to clean, the frequency of which they are to be cleaned, the order in which to clean the items, the products to be used, the concentration of the products, and the correct contact time to achieve cleaning. Boyce et al
      • Boyce J.M.
      • Havill N.L.
      • Lipka A.
      • Havill H.
      • Rizvani R.
      Variations in hospital daily cleaning practices.
      describe the variations in cleaning practices, such as the time spent cleaning surfaces, the order in which items were cleaned, and how many disposable wipes were used per room when a standardized policy is not defined. Housekeepers also need to be aware of the personal protection equipment required to protect themselves from the chemicals they are using and the role of the environment in disease transmission. It is also important to emphasize that they are part of a team and that their role is crucial in a successful cleaning and disinfection program.
      A study by Guerrero et al

      Guerrero D, Carling PC, Jury L, Ponnada S, Nerandzic M, Eckstein EC, Donskey C. Beyond the “Hawthorne Effect”: Reduction of Clostridium difficile Environmental Contamination through Active Intervention to Improve Cleaning Practices. Abstract Presented at: the Fifth Decennial International Conference of Healthcare Associated Infections 2010, Atlanta, GA. (Abstract 60).

      demonstrated the effect that managers have in achieving adequate cleaning with various levels of interaction with their staff. They cultured 3 items for CD that included the tables, bedrails, and drawer handles after housekeeping cleaning was performed with bleach, while the housekeeper was either unobserved, observed, or supervised. They demonstrated that the percentage of cultures that were positive for CD significantly decreased when the housekeepers were being observed versus unobserved and even more so when they were being supervised, thus confirming that sustainability requires an ongoing commitment within the institution.

      Monitoring

      It is now recommended by the Centers for Disease Control and Prevention, Society for Healthcare Epidemiology of America, Infectious Disease Society of America, Association for Professionals in Infection Control and Epidemiology, Inc, and other professional associations that facilities monitor their cleaning practices to ensure the adequacy of their cleaning practices.

      Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guidelines for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed May 1, 2012.

      Four current methods available to monitor cleaning practices include visual inspection, aerobic colony counts, fluorescent marker systems, and adenosine triphosphate (ATP) bioluminescence assays. Although visual inspection is still the most widely used, it has been shown to be an inaccurate assessment of cleaning efficacy when compared with other methods.
      • Sherlock O.
      • O’Connell N.
      • Creamer E.
      • Humphreys H.
      Is it really clean? An evaluation of the efficacy of four methods for determining hospital cleanliness.
      • Mulvey D.
      • Redding P.
      • Robertson C.
      • Woodall C.
      • Kingsmore P.
      • Bedwell D.
      Finding a benchmark for monitoring hospital cleanliness.
      Aerobic colony counts can provide the level of bacterial contamination and can identify pathogens if necessary, although results are not available for 48 to 72 hours and require the use of a microbiology laboratory. Fluorescent markers systems provide an inexpensive means of monitoring whether certain surfaces have been wiped by the housekeepers. This method provides a qualitative result and requires the surface to be marked before cleaning and observed with ultraviolet light (UVL) after cleaning has been performed. ATP provides a quantitative measurement of organic substances present on the surfaces sampled, and results are expressed as relative light units (RLUs). This system requires the purchase of a luminometer and swabs, but results are available within seconds to allow immediate feedback to environmental services personnel (Table 2).
      Table 2Advantages and disadvantages for methods for accessing cleaning practices
      MethodAdvantagesDisadvantages
      Visual inspectionSimple

      Inexpensive
      Not reliable measure of cleanliness
      Aerobic colony countsRelatively simple

      Can detect presence of pathogens
      More expensive

      Results not available for 48 hrs later

      Requires the use of a microbiology lab
      Fluorescent marker systemInexpensive

      Minimal equipment needed

      Can improve practices
      Must covertly mark surfaces before cleaning and check them after cleaning with a UV light
      ATP bioluminescence assay systemsProvides quantitative measure of cleanliness

      Quick results

      Can improve practices
      More expensive

      Requires purchase of a luminometer

      Requires purchase of swabs

      Providing feedback

      After monitoring of cleaning practices, providing feedback to the staff is an essential element in a successful cleaning program and has been shown to significantly improve cleaning practices. Boyce et al
      • Boyce J.M.
      • Havill N.L.
      • Dumigan D.G.
      • Golebiewski M.
      • Balogun O.
      • Rizvani R.
      Monitoring the effectiveness of hospital cleaning practices using ATP bioluminescence assay.
      showed significant improvement in daily cleaning practices with the use of ATP, in a 2 phase, prospective interventional study. In phase I, 5 high-touch surfaces were sampled before and after daily cleaning in 20 patient rooms without the housekeeper being notified. Feedback and reeducation was provided on their cleaning practices at the completion of phase I. In phase II, the same 5 high-touch surface in 105 patient rooms were sampled, before and after cleaning, and this time the housekeepers were notified that sampling the rooms would occur immediately after they were finished cleaning. Surfaces sampled were significantly cleaner after daily cleaning in phase II than in phase I, except for the toilets, which were adequately cleaned in phase I (Fig 2). This clearly demonstrates the positive effect of the feedback given to the staff after phase I, which led to significant improvement of the cleaning practices of the staff.
      Figure thumbnail gr2
      Fig 2Median relative light units (RLUs) for 5 sites for phase I and phase II.
      Similarly, Carling et al
      • Carling P.C.
      • Parry M.M.
      • Rupp M.E.
      • Po J.L.
      • Dick B.
      • Von Beheren S.
      Improving cleaning of the environment surrounding patients in 36 acute care hospitals.
      demonstrated significant improvement in cleaning practices after providing feedback of results using a fluorescent marker system in a prospective quasiexperimental, before-after study, in 36 acute care hospitals. Of 20,646 standardized environmental surfaces that included 14 types of objects, only 9,910 (48%) were cleaned at baseline. After interventions and performance feedback to the environmental services staff, 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P<.001).
      Not only should you be monitoring the cleaning practices of your environmental services personnel, but you also need to be monitoring items that have been designated to be cleaned by nursing services. Such examples include rolling mobile vital signs carts and glucometers. Havill et al
      • Havill N.L.
      • Havill H.L.
      • Mangione E.
      • Dumigan D.G.
      • Boyce J.M.
      Cleanliness of portable medical equipment disinfected by nursing staff.
      used ATP to access the cleanliness of all rolling vital signs carts, which are used to take patients’ vital signs and are rolled from one patient bed to the next. The policy states that these should be cleaned by the nursing staff in between each use. In this study, 5 distinct surfaces were sampled on all devices from all of the medical and surgical wards in the institution. Surfaces sampled included the control buttons on the front of the device, the electronic thermometer, the blood pressure cuff, the top of the machine handle, and the pulse oximeter. The median ATP RLU values for each of the 5 sites was calculated, and only the control buttons had a median result that was less than a proposed “clean” cut-off value of 250 RLUs
      • Lewis T.
      • Griffith C.
      • Gallo M.
      • Weinbren M.
      A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces.
      (Table 3). The thermometer, the blood pressure cuff, and the machine handle all had medians that fell between 250 and 500 RLUs, but the pulse oximeter had a median result of close to 1,200 RLUs, which is more than 4 times greater than the “clean” standard of 250 RLUs. As pulse oximeters are placed on the patient’s finger, any contamination on that finger is then being transferred directly onto pulse oximeter and again directly transferred to the finger of the next patient. It becomes clear how important it is to ensure that this equipment is being cleaned between each patient use. It must be emphasized that the cut-off of <250 RLUs has not been validated because there has not been a study that demonstrated <250 RLUs is associated with a reduction in HAIs; thus, it is unclear whether we should use a lower or higher cut-off value. Regardless of the actual cut-off value used, it is clear that, in this case of these mobile vital signs carts, feedback and education to the nursing staff are warranted.
      Table 3Adenosine triphosphate readings from 5 sites sampled from 101 portable medical units and the percentage of readings <250 RLU
      Site sampledMedian RLU value (range)Percent < 250 RLU value
      Control buttons (n=58)86 (14-1,532)76
      Thermometer (n=44)346 (23-5,340)39
      Blood pressure cuff (n=79)477 (42-31,877)24
      Machine handle (n=54)480 (42-31,877)24
      Pulse oximeter (n=65)1,208 (59-27,297)22
      RLU, Relative light unit.

      No-touch room decontamination

      Additionally, no-touch room decontamination devices such as hydrogen peroxide vapor (HPV) or ultraviolet light (UVL) are available to supplement cleaning practices. The fact that several investigators have shown that cleaning practices are often suboptimal
      • Carlin P.C.
      • Briggs J.L.
      • Perkins J.
      • Highlander D.
      Improved cleaning of patient rooms using a new targeting method.
      • Boyce J.M.
      • Havill N.L.
      • Dumigan D.G.
      • Golebiewski M.
      • Balogun O.
      • Rizvani R.
      Monitoring the effectiveness of hospital cleaning practices using ATP bioluminescence assay.
      and that improvements made through education and feedback are often not sustainable
      • Rutala W.A.
      • Weber D.J.
      Are room decontamination units needed to prevent transmission of environmental pathogens?.
      has led us to these new technologies. Their advantage is they eliminate human factors such as relying on an operator to ensure that all surfaces are disinfected adequately. It has been demonstrated that surfaces cleaned multiple times with bleach still may not sufficiently remove all of the contamination.
      • Manian F.A.
      • Griesenauer S.
      • Senkel D.
      • Setzer J.M.
      • Doll S.A.
      • Perry A.M.
      Isolation of Acinetobacter baumannii complex and methicillin-resistant Staphylococcus aureus from hospital rooms following terminal cleaning and disinfection: can we do better?.
      • Morter S.
      • Bennet G.
      • Fish J.
      • Richards J.
      • Allen D.J.
      • Nawaz S.
      • et al.
      Norovirus in the hospital setting: virus introduction and spread within the hospital environment.
      Several studies have demonstrated the effectiveness of UVL on surface microbial contamination.
      • Boyce J.M.
      • Havill N.L.
      • Moore B.A.
      Terminal decontamination of patient rooms using an automated mobile UV light unit.
      • Nerandzic M.M.
      • Cadnum J.L.
      • Pultz M.J.
      • Donskey C.J.
      Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms.
      Boyce et al
      • Boyce J.M.
      • Havill N.L.
      • Otter J.A.
      • McDonald L.C.
      • Adams N.M.
      • Cooper T.
      • et al.
      Impact of hydrogen peroxide vapor room decontamination on Clostridium difficile environmental contamination and transmission in a healthcare setting.
      demonstrated the effectiveness of HPV on surface microbial contamination but also showed a reduction in the transmission of CD after the introduction of HPV room decontamination. Multiple studies have proven the efficacy of these no-touch room decontamination systems and that they may be more reliable in reducing transmission and acquisition of pathogens, and therefore these technologies should be considered for use in the health care setting.

      Conclusion

      There is compelling evidence that the environment plays a role in transmission of HAIs, and therefore more attention is being focused on environmental cleaning and improving the efficacy of cleaning practices. Key components using a bundle approach to create and sustain a successful cleaning and disinfection program should include written policies and procedures, selecting the appropriate cleaners and disinfectants, selecting the method of application of the products, education of the staff, monitoring cleaning practices, and providing feedback to the environmental service personnel. Sustaining a successful cleaning and disinfection program requires ongoing commitment within the institution to effectively decrease the spread of HAIs from environmental contamination.

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        Monitoring the effectiveness of hospital cleaning practices using ATP bioluminescence assay.
        Infect Control Hosp Epidemiol. 2009; 30: 678-684
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        Variations in hospital daily cleaning practices.
        Infect Control Hosp Epidemiol. 2010; 31: 99-101
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        • Sherlock O.
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        Is it really clean? An evaluation of the efficacy of four methods for determining hospital cleanliness.
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        Finding a benchmark for monitoring hospital cleanliness.
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        • Rupp M.E.
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