Advertisement

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

      Highlights

      • Cleaning variations occur within the complexity of healthcare settings.
      • Using a mixed method design identified significant determinants of practice variation.
      • A significant barrier to cleaning was observed in semi-private patient rooms.
      • A significant facilitator to cleaning was detected with patient absence from the room.

      Objectives

      To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process.

      Methods

      A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities.

      Results

      Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis.

      Conclusion

      Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

      Key words

      Abbreviation:

      Environmental Cleaning (VA), CleanR (Study)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Klevens RM
        • Edwards JR
        • Richards Jr., CL
        • et al.
        Estimating health care-associated infections and deaths in U.S. hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Hota B.
        Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection?.
        Clin Infect Dis. 2004; 39: 1182-1189
        • Boyce JM.
        Environmental contamination makes an important contribution to hospital infection.
        J Hosp Infect. 2007; 65: 50-54
        • Dancer SJ.
        Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning.
        Lancet Infect Dis. 2008; 8: 101-113
        • Otter JA
        • Yezli S
        • French GL.
        The role played by contaminated surfaces in the transmission of nosocomial pathogens.
        Infect Control Hosp Epidemiol. 2011; 32: 687-699
        • Weber DJ
        • Anderson DJ
        • Sexton DJ
        • Rutala WA.
        Role of the environment in the transmission of Clostridium difficile in health care facilities.
        Am J Infect Control. 2013; 41: S105-S110
        • Anwar S.
        Multi-Drug Resistant Organisms within Biofilms on Dry Hospital Surfaces: Is this Worldwide?.
        The Society for Healthcare Epidemiology of America, San Diego, CA: presented at2017
        • Mitchell BG
        • Dancer SJ
        • Anderson M
        • Dehn E.
        Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis.
        J Hosp Infect. 2015; 91: 211-217
        • Donskey CJ.
        Does improving surface cleaning and disinfection reduce health care-associated infections?.
        Am J Infect Control. 2013; 41: S12-S19
        • Leas BF
        • Sullivan N
        • Han JH
        • Pegues DA
        • Kaczmarek JL
        • Umscheid CA.
        AHRQ comparative effectiveness technical briefs.
        Environmental Cleaning for the Prevention of Healthcare-Associated Infections. Agency for Healthcare Research and Quality (US), 2015
        • Mitchell BG
        • Farrington A
        • Allen M
        • et al.
        Variation in hospital cleaning practice and process in Australian hospitals: a structured mapping exercise.
        Infect Dis Health. 2017; 22 (2017/12/01/): 195-202
        • Dancer SJ.
        Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination.
        Clin Microbiol Rev. 2014; 27: 665-690
        • Sitzlar B
        • Deshpande A
        • Fertelli D
        • Kundrapu S
        • Sethi AK
        • Donskey CJ.
        An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms.
        Infect Control Hosp Epidemiol. 2013; 34: 459-465
        • Pronovost P
        • Needham D
        • Berenholtz S
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
        • Dubberke ER
        • Carling P
        • Carrico R
        • et al.
        Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. Sep 2014; 35: S48-S65
        • Doll M
        • Marra AR
        • Apisarnthanarak A
        • Al-Maani AS
        • Abbas S
        • Rosenthal VD.
        Prevention of Clostridioides difficile in hospitals: a position paper of the International Society for Infectious Diseases.
        Int J Infect Dis. 2021; 102: 188-195
        • Jain R
        • Kralovic SM
        • Evans ME
        • et al.
        Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
        N Engl J Med. 2011; 364: 1419-1430
        • Evans ME
        • Kralovic SM
        • Simbartl LA
        • et al.
        Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative associated with a sustained reduction in transmissions and health care-associated infections.
        Am J Infect Control. 2013; 41: 1093-1095
        • Evans ME
        • Simbartl LA
        • Kralovic SM
        • Jain R
        • Roselle GA
        Clostridium difficile infections in Veterans Health Administration acute care facilities.
        Infect Control Hosp Epidemiol. 2014; 35: 1037-1042
        • Evans ME
        • Kralovic SM
        • Simbartl LA
        • Jain R
        • Roselle GA.
        Effect of a Clostridium difficile infection prevention initiative in veterans affairs acute care facilities.
        Infect Control Hosp Epidemiol. 2016; 37: 720-722
        • The Environmental Management Services
        Sanitation Procedure Guide. 2016;
        • Vaughn VM
        • Saint S
        • Greene MT
        • et al.
        Trends in health care-associated infection prevention practices in us veterans affairs hospitals from 2005 to 2017.
        JAMA Netw Open. 2020; 3e1920464
        • Keating JA
        • Obasi C
        • McKinley L
        • et al.
        Building implementation science for veterans affairs healthcare associated infection prevention: VA Healthcare-Associated Infection Prevention Network (VHIN).
        Infection Control & Hospital Epidemiology. 2018; 39: 1-5
        • Yanke E
        • Moriarty H
        • Carayon P
        • Safdar N.
        A qualitative, interprofessional analysis of barriers to and facilitators of implementation of the Department of Veterans Affairs' Clostridium difficile prevention bundle using a human factors engineering approach.
        Am J Infect Control. 2018; 46: 276-284
      1. Guh A, Carling P. Options for Evaluating Environmental Cleaning. Centers for Disease Control and Prevention. 2010. Accessed June 22, 2022. https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html.

        • Sehulster L
        • Chinn RY.
        Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
        MMWR Recomm Rep. 2003; 52: 1-42
        • Siegel JD
        • Rhinehart E
        • Jackson M
        • Chiarello L.
        2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings.
        Am J Infect Control. 2007; 35: S65-164
        • Doll M
        • Stevens M
        • Bearman G.
        Environmental cleaning and disinfection of patient areas.
        Int J Infect Dis. 2018; 67: 52-57
        • Rutala WA
        • Weber DJ.
        Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: a bundle approach.
        Am J Infect Control. 2019; 47s: A96-a105
        • Atsma F
        • Elwyn G
        • Westert G.
        Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems.
        Int J Qual Health Care. 2020; 32: 271-274
        • JW C
        • AC K
        • VL C
        • KC S
        Best practices for mixed methods research in health sciences.
        Office of Behavioral and Social Sciences: National Institute of Health, 2011
      2. CDC Environmental Checklist for Monitoring Terminal Cleaning. Centers for Disase Control. 2010. Accessed June 22, 2022. https://www.cdc.gov/hai/pdfs/toolkits/environmental-cleaning-checklist-10-6-2010.

        • Marshall B
        • Cardon P
        • Poddar A
        • Fontenot R
        Does sample size matter in qualitative research?: A review of qualitative interviews in is research. Article.
        J Comput Informat Systems. 2013; 54: 11-22
        • Bengtsson M.
        How to plan and perform a qualitative study using content analysis.
        NursingPlus Open. 2016; 2 (2016/01/01/): 8-14
        • Ryan GW
        • Bernard HR.
        Techniques to identify themes.
        Field Methods. 2003; 15 (2003/02/01): 85-109
        • Pope C
        • Ziebland S
        • Mays N.
        Qualitative research in health care. Analysing qualitative data.
        BMJ. 2000; 320: 114-116
        • Elo S
        • Kääriäinen M
        • Kanste O
        • Pölkki T
        • Utriainen K
        • Kyngäs H.
        Qualitative content analysis: a focus on trustworthiness.
        SAGE Open. 2014; 4 (2014/01/01)2158244014522633
        • Fetters MD
        • Curry LA
        • Creswell JW.
        Achieving integration in mixed methods designs-principles and practices.
        Health Serv Res. 2013; 48: 2134-2156
        • Guetterman TC
        • Fetters MD
        • Creswell JW.
        Integrating quantitative and qualitative results in health science mixed methods research through joint displays.
        Ann Fam Med. 2015; 13: 554-561
        • Carling PC
        • Bartley JM.
        Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.
        Am J Infect Control. 2010; 38: S41-S50
        • Huslage K
        • Rutala WA
        • Sickbert-Bennett E
        • Weber DJ.
        A quantitative approach to defining "high-touch" surfaces in hospitals.
        Infect Control Hosp Epidemiol. 2010; 31: 850-853
        • Han JH
        • Sullivan N
        • Leas BF
        • Pegues DA
        • Kaczmarek JL
        • Umscheid CA.
        Cleaning hospital room surfaces to prevent health care-associated infections: a technical brief.
        Ann Intern Med. 2015; 163: 598-607
        • Schoyer E
        • Hall K.
        Environmental cleaning and decontamination to prevent Clostridioides difficile infection in health care settings: a systematic review.
        J Patient safety. 2020; 16: S12-S15
        • Yanke E
        • Moriarty H
        • Carayon P
        • Safdar N.
        The invisible staff": a qualitative analysis of environmental service workers' perceptions of the VA Clostridium difficile prevention bundle using a human factors engineering approach.
        J Patient Saf. 2018; https://doi.org/10.1097/pts.0000000000000500
        • Van Tiem JM
        • Friberg JE
        • Cunningham Goedken C
        • et al.
        Environmental service workers as potential designers of infection control policy in long-term care settings.
        Am J Infect Control. 2020; 48: 398-402
        • Cullen D
        • Thomas Y.
        EOC-113 - The Impact of Clutter on Healthcare Acquired Infections in a Long-Term Acute Care Hospital.
        Am J Infect Control. 2018; 46 (2018/06/01/): S71
        • Xie A
        • Rock C
        • Hsu YJ
        • et al.
        Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach.
        IISE Trans Occup Ergon Hum Factors. 2018; 6: 178-191
        • Bernstein DA
        • Salsgiver E
        • Simon MS
        • et al.
        Understanding barriers to optimal cleaning and disinfection in hospitals: a knowledge, attitudes, and practices survey of environmental services workers.
        Infect Control Hosp Epidemiol. Dec 2016; 37: 1492-1495
        • Stiller A
        • Salm F
        • Bischoff P
        • Gastmeier P.
        Relationship between hospital ward design and healthcare-associated infection rates: a systematic review and meta-analysis.
        Antimicrob Resist Infect Control. 2016; 5: 51
      3. CDC A, APIC, ASHE. Using the health care physical environment to prevent and control infection: A Best Practice Guide to Help Healthcare Organizations Create Safe, Healing Environment. 2015.

        • Havill NL.
        Best practices in disinfection of noncritical surfaces in the health care setting: creating a bundle for success.
        Am J Infect Control. 2013; 41: S26-S30
        • Allen M
        • Hall L
        • Halton K
        • Graves N.
        Improving hospital environmental hygiene with the use of a targeted multi-modal bundle strategy.
        Infection Dis Health. 2018; 23 (2018/06/01/): 107-113
        • Mitchell BG
        • Hall L
        • White N
        • et al.
        An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial.
        Lancet Infect Dis. 2019; 19: 410-418
        • Ivers N
        • Jamtvedt G
        • Flottorp S
        • et al.
        Audit and feedback: effects on professional practice and healthcare outcomes.
        Cochrane Database Syst Rev. 2012; CD000259
      4. Centers for Medicare & Medicaid Service. 42 CFR 482.42 Condition of participation: Infection Prevention and Antibiotic Stewardship Programs. 2016.

        • Carling PC
        • Bartley JM.
        Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.
        Am J Infect Control. 2010; 38: S41-S50
        • Kenters N
        • Gottlieb T
        • Hopman J
        • et al.
        An international survey of cleaning and disinfection practices in the healthcare environment.
        J Hosp Infect. 2018; 100: 236-241
        • Carling P.
        Methods for assessing the adequacy of practice and improving room disinfection.
        Am J Infect Control. 2013; 41: S20-S25
        • Snyder GM
        • Holyoak AD
        • Leary KE
        • Sullivan BF
        • Davis RB
        • Wright SB.
        Effectiveness of visual inspection compared with non-microbiologic methods to determine the thoroughness of post-discharge cleaning.
        Antimicrob Resist Infect Control. 2013; 2: 26
        • Rock C
        • Xie A
        • Andonian J
        • et al.
        Evaluation of environmental cleaning of patient rooms: impact of different fluorescent gel markers.
        Infect Control Hosp Epidemiol. 2019; 40: 100-102
        • Rock C
        • Small BA
        • Hsu YJ
        • et al.
        Evaluating accuracy of sampling strategies for fluorescent gel monitoring of patient room cleaning.
        Infect Control Hosp Epidemiol. 2019; 40: 794-797