Adenosine triphosphate (ATP) is an enzyme that is present in all living cells, and an ATP monitoring system can detect the amount of organic matter that remains after cleaning an environmental surface, a medical device or a surgical instrument. Hospitals are using ATP-based sanitation monitoring systems to detect and measure ATP on surfaces as a method of ensuring the effectiveness of their facilities’ sanitation efforts. The amount of ATP detected, and where this ATP was detected, indicates areas and items in the healthcare setting that may need to be recleaned, and the possible need for improvement in a healthcare facility’s cleaning protocols. We asked members of industry -- 3M, Charm Sciences, Ecolab Inc., Neogen and Ruhof -- to share best practices for ATP as used in a program to fight healthcare-acquired infections (HAIs).
What should healthcare professionals know about the importance of cleaning validation in the healthcare setting?
3M: In the CDC guidelines for multipledrug-resistant organisms, it is recommended that hospitals "monitor cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient..." To gauge the effectiveness of a cleaning program, most healthcare facilities rely on visual inspection as a cleaning monitoring method. Although easy to implement, visual inspection has been shown to be inadequate for ensuring proper cleaning has been performed.
Charm Sciences: Proper procedures and policies need to be in place to monitor daily cleaning effectiveness using methods beyond visual assessment. With increased risk of hospital acquired infections, healthcare professionals need real-time results in order to make good decisions regarding proper cleaning and disinfection of rooms before the next patient admission. Monitoring patient rooms, as well as other departments, is a proactive approach with measurable results, helping reduce HAIs and ultimately saving money due to better cleaning.
Ecolab: With the increasing evidence that the environment plays a key role in the transmission of pathogens to patients, there is now an emphasis on objectively measuring cleaning outcomes as a means to reduce the bioburden in patient care areas. We’ve seen the most success in organizations whose environmental services and infection prevention departments work together to monitor, evaluate and improve the cleanliness of the environment. To properly address environmental hygiene, there are several key components that must be in place to deliver improved cleaning outcomes. These include such critical process inputs as consistent delivery of the correct disinfectant concentration including compensation for the absorption of disinfectant by cleaning textiles; training and implementation of infection control best practices to prevent cross-contamination between rooms; standardized processes to ensure that high-touch surfaces are consistently disinfected; and an objective process to measure program effectiveness. To improve cleaning outcomes, healthcare facilities must consider a comprehensive, programmatic approach that incorporates dispensing accuracy, standardized processes, outcomes measurement and ongoing training.
Neogen: Healthcare professionals should recognize the critical role that unerringly thorough cleaning has on the overall patient experience. This relates to everything from HCAHPS scores, to community reputation, to the transmission of infectious agents or environmental HAIs. Because of its critical nature, cleaning should be regularly validated, verified and monitored. The role of cleaning in a healthcare setting has moved beyond simple aesthetics to being an integral part of a robust infection control program.
Ruhof: Reducing the number of healthcare-acquired infections (HAIs) is a major concern for all medical facilities. One way of doing this is being able to validate cleaning. Currently there are only two ways to do that. The first is to visually inspect the item after cleaning, which is very inaccurate; the human eye is unable to see micro-contamination which can cause HAIs. The second is to take a culture and send it to a lab for testing. This could take anywhere from two days to a week, during which time if there is any contamination it will remain present until the results come back. A new method to validate cleaning is measuring the amount of ATP on a surface. If ATP is present ,then there is micro-contamination on that surface. Ruhof’s ATP Complete® monitoring device allows you to accurately measure the amount of micro-contamination on any surface in just 15 seconds. If there is micro-contamination present, the surface can be re-cleaned immediately and retested to make sure it has been removed. This will significantly help in lowering the risk of HAIs.
How does an ATP-based product/system best fit into a program of healthcare environmental hygiene/instrument reprocessing?
3M: Using the 3M™ Clean-Trace™ Hygiene Management System as an environmental hygiene monitoring tool, one can improve the consistency and quality of their facility cleaning practices and protocols. By using the data collected one is able to gauge the effectiveness of their current or modified cleaning practices as well as monitor them. The data results can be used to demonstrate and train personnel on the importance and effectiveness of proper cleaning practices and adherence to protocols.
Charm Sciences: Charm Pocketswab Plus ATP swabs provide a true measure of 'hygiene' and 'cleanliness' by detecting both microorganisms and bio-burden residues present on surfaces in 5 seconds. Conventional microbiological methods detect only microorganisms and can take up to 48 hours for results. If ATP residue is left on a surface, it can provide a nutritious medium for microbial growth and act as a barrier to the direct action of both cleaners and disinfectants. Cleaning agents, when used properly with appropriate contact time, remove ATP. The Pocktswab Plus ATP test demonstrates due diligence and adherence to quality standards in cleaning and sanitizing, thereby providing documentable evidence of corrective actions taken. Improved hygiene and cleaning standards along with daily monitoring will help reduce micro-organisms in the hospitals and provide a safer, cleaner environment. When using the Pocketswab Plus for monitoring cleaning effectiveness in the central sterile processing areas, the swabs can be used as a tool to optimize the cleaning procedures to verify washers/sonicators are properly removing bioburden from instruments.
Ecolab: The measurement of ATP by a bioluminescence reaction has been successfully used in the food industry as an alternative method of monitoring environmental contamination for many years. Within the healthcare industry, the use of ATP as an educational and training tool may have some merit because there is some relationship between RLU readings and environmental cleanliness. However, the use of ATP as a hygiene audit tool is not recommended because the relationship between RLU and environmental cleanliness it is not directly equivalent to microbial monitoring, as both living and recently killed organisms "spill" ATP on surfaces at various rates. Consequently, there is no known correlation between ATP level and numbers of microorganisms, and therefore potential pathogens, present on a surface. Additionally, ATP is not produced in certain microbes, most notably viruses, and ATP-based systems will not detect the presence of these organisms on a surface. A study conducted by Ecolab, presented at APIC 2009, demonstrated that used, but laundered, microfiber cloths may give a false positive reading for ATP as evidenced high RLU readings with no viable bacteria present. Finally, because there are significant differences in the sensitivity and reproducibility of results of ATP systems offered by different manufacturers, its application within the healthcare environment should be approached with caution and awareness of the limitations of the system.
Neogen: An ATP cleaning verification and tracking system provides environmental services managers a tool to gauge their teams’ cleaning effectiveness on an ongoing basis. It provides immediate and trend data for making important decisions on the status of cleaning activities on any particular day, while providing an objective metric for future improvement and best practice objectives. This tool allows the managers to move beyond the janitorial aspects of their jobs to being a part of the HAI solution. Working in conjunction with infection preventionists, they can help develop programs that serve a bigger purpose — and become true partners in a comprehensive patient-care effort.
Ruhof: The ATP Complete® System is an invaluable tool for all departments in the hospital that are responsible for cleaning. It can be used by environmental services to test high-risk areas in the hospital to make sure they are being cleaned properly and often enough. Sterile processing can use it to test surgical instruments after cleaning to validate that the automatic washer is performing up to standard. It can be used to test the inside walls of the washers, counter tops, trays, etc. Endoscopy can use it to test the cleanliness of scopes surfaces and inside channels, scope cabinets, carts, etc. Surgery can use it to test operating tables, operating room carts, equipment, and any item that is used during surgical procedures. Infection control managers work hard at preventing cross contamination – what better way to provide them with information than using the ATP Complete® to test the levels of contamination on areas that they feel are the greatest risk to patients and staff. A test program can be created to spot-check the cleanliness of surfaces or integrate regular testing as a way of monitoring the cleaning of items on an on-going basis.
