Asking the Right Questions Guides Solutions to Improving Cleanliness

January 30, 2012

By Karen Martin MPH, RN, CIC

If we look at the current state of environmental hygiene, what we need to ask ourselves is, Why is cleanliness still such a problem?
In the past, hospitals have measured cleanliness using patient satisfaction survey responses. There are several pros and cons of this approach, though satisfaction surveys measure a patients impression of cleanliness, it does not objectively tell whether a surface is clean.

 This can be dangerous as a surface could look fine but be contaminated with infection-causing pathogens. The result, unfortunately, is that cleanliness scores nation-wide are reported as mediocre or poor at best. At the same time, public reporting of infection rates for central line infections, methicillin-resistant Staphylococcus aureus (MRSA), targeted surgical site infections (SSIs) and Clostridium difficile and other information are making patients more aware of cleanliness. If you were a patient which metric would you rely on for choosing a hospital?

While we all know that hand hygiene is the No. 1 way to prevent infections, its not a complete solution. As long as hospitals are inadequately cleaned, doctors and nurses hands will become contaminated seconds after they are washed. For example, a study conducted by Johns Hopkins Hospital found 26 percent of supply cabinets were contaminated with MRSA and 21 percent with vancomycin-resistant Enterococcus (VRE).

Why is hand hygiene such a persistent issue? Simply put, many personnel dont realize when they have germs on their hands because they underestimate transmission from various surfaces. Some surfaces may be perceived as being less likely to harbor bacteria even though healthcare workers can get hundreds to thousands of bacteria on their hands by doing simple tasks like:

- Pulling up patients in bed
- Taking a blood pressure or pulse
- Touching a patients hand
- Rolling patients over in bed
- Touching the patients gown or bed sheets
- Touching equipment like bedside rails, over-bed tables, IV pumps.

Adding to the problem, infection-causing pathogens can remain on surfaces for extended periods of time much longer than healthcare workers, patients or visitors may realize. For example, Clostridium difficile is a particularly persistent bacteria that can remain viable on a surface for months.

Research clearly links the hospital environment to healthcare-acquired infections so theres no excuse for not adequately addressing environmental hygiene. Here are some points to consider:

- Hospital rooms are not cleaned well (AJIC 2006; ICHE 2008)
- Previously contaminated rooms increase transmission risks (Sturdis 2008)
- Cleaning can be improved in hospitals (ICHE 2008; Hayden 2006)
- Decreased environmental contamination with improved cleaning ( Hayden 2006; Huang 2008)
- Decreasing pathogens with improved cleaning outcomes (Hayden 2006; Datta 2009)

As a reflection of the impact that evidence-based practices can have on improving cleanliness, requirements and recommendations by standards bodies and health agencies are recommending that data be used to measure progress:

- CDC Guidelines for Environmental Infection Control in Health Care
- CMS IC program must include appropriate monitoring of housekeeping
- IHI Hospitals should use immediate feedback mechanisms to assess cleaning
- Joint Commission Use data analysis to identify and resolve environmental issues
- State of California Constant evaluation and monitoring of a sanitary environment

What do we need to do differently? Although any environmental services (ES) department faces many challenges from ineffective cleaning measurement systems; room cross-contamination; staffing issues such as turnover, language, education; inefficient training and inconsistent processes each of these issues can be solved. What worked at for Advocate Christ Medical Center was a combination of implementing standard processes based on best practices, training and staff engagement, monitoring, and using the right tools and chemistries to minimize cross contamination and make thorough, effective cleaning easy and second nature for staff.

But even before improved outcomes are achieved, ES staff must be invested so that they understand the reasons behind the process and the impact of infections. At Advocate Christ, we showed our staff photos of patients with infections to bring to life why it was so important to clean thoroughly. Staff must be trained to clean 17 high-touch areas all the time and but also be armed with the right tools to clean.

How do you train staff? You cant just say heres a mop and cart, start cleaning. What we developed at Advocate Christ were Learning Modules that included multimedia materials for Adult learning that also accounted for language and education levels. What was important about our approach was it followed the "Learn, Practice, Do" process:

- Learn: Content is personally delivered
- Practice: Learner works on new content with guidance and direction of competent trainer
- Do: Learner applies new content and demonstrates competency
Once the training was completed we were ready to monitor our environment cleaning. What we considered before starting was what to set as a standard and how we were going to monitor. Some considerations included the ease of use of the monitoring device, its cost, validation, whether there was any possibility for cross contamination, the time commitment and the data reporting and analysis. The four methods of validation that we considered before selecting a fluorescing gel marker, were:

1. EOC rounds using subjective viewing of environment (also known as The White Glove Test)
2. Fluorescent products to mark surfaces or equipment -- Clear marker applied to high-touch objects after patient discharge, before cleaning. The room is reviewed by auditor with black light after cleaning and if the mark is removed the room has been cleaned thoroughly. 
3. Adenosine triphosphate (ATP) -- Present in all living cells not necessarily disease producing. How it works is an enzyme luciferase converts ATP into light emission. Monitoring for ATP can be indicator of viable cell numbers.
4. Cultures -- Measure colony-forming units (CFUs) of disease organisms on environmental surfaces. It is costly but more reliable and truly evidence based practice.

Combined with the training and room auditing, our program included cleaning carts designed to prevent cross-contamination from room to room, effective cleaning solutions  and microfiber clothes and mops.
Its important to remember that environmental disinfection is not just about chemicals. In an ideal setting, products are designed in combination with tools to deliver consistent, proven outcomes. For example, some considerations include whether microfiber technology ensures the appropriate amount of disinfectant is delivered. Also, something as simple as the ergonomics of the cart set up can impact cross contamination and efficiency.

For hospitals using quaternary ammonium disinfectants, quat absorption by cleaning clothes is also a concern because to achieve disinfection, the appropriate level of disinfectant must be applied to surfaces. Some factors impacting quat absorption include the volume of disinfectant per cleaning cloth, the fabric type and the time spent in disinfectant solution. Simple solutions to the issue include using automated dispensing systems and pre-mixed solutions ensure that the chemistry is mixed correctly and at the right concentration and to use microfiber clothes and mops.

Microfiber technology is significantly improving cleaning and decontamination capacity because fibers are split and form a woven fabric which allows 40 times more surface area coverage than cotton fiber. In fact, new technology features synthetic fibers that measure less than 1 denier, less than one-hundredth the size of a human hair. Microfiber clothes are also more sustainable. Assuming you are currently using string mops and changing solution every three rooms, using microfiber mops you can:
- Reduce water usage by 94 percent
- Reduce chemical usage on floors by 85 percent
- Reduce Chemical usage on surfaces 74 percent

 Altough simple answers are not always easy to come by, continuing to question our performance and ask how we can do better is our best path toward finding solutions. Some lessons we learned at Advocate Christ Medical Center were that monitoring does improve cleaning and reduce overall room bioburden but that training and housekeeper buy-in is critical as is a standardized, programmatic approach. Healthcare organizations cant just adopt one piece and assume things will change infection prevention is a complex puzzle but one that we can solve.

Karen Martin MPH, RN, CIC, is director of infection prevention at Advocate Christ Medical Center.