Handrails, Equipment Controls Among Most Contaminated High-Touch Surfaces in Long-Term Care Facilities

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Nearly all high-touch surfaces in a recent study of 11 long-term care (LTC) facilities in South Carolina tested positive for crAssphage, a DNA bacteriophage useful in indicating human fecal contamination, and adenosine triphosphate (ATP), the organic compound that can help evaluate the efficacy of cleaning. Handrails, equipment controls, and patient beds were the most contaminated sources.

These results, published this week in the American Journal of Infection Control, support the use of multiple hygienic monitoring tools to quantify levels of contamination before and after cleaning as health workers in LTC facilities work to cut down on the high rates of diarrheal illness, such as norovirus and/or Clostridioides difficile infection.

“We designed a study to help LTC facility directors and environmental service staff better direct their existing cleaning efforts by identifying the surfaces most often contaminated with high levels of fecal material,” Jennifer Cannon, PhD, lead author of the study, told Infection Control Today®. “This is important because noroviruses and C difficile, which cause the most diarrheal diseases among LTC facility residents, are transmitted through feces.”

The investigators contacted 113 LTC facilities to participate in site visits to conduct the environmental hygiene evaluation, and 11 agreed; 9 were skilled nursing facilities (1 of which was also a nursing home), 1 was a nursing home, and 1 was a continuing care retirement home. The number of beds in each facility ranged from 36 to 220 (median 132 beds). The median capacity of beds filled in each facility was 90% at the time of the site visits and ranged from 68% to 100%.

The team tested at least 30 high-touch surfaces and locations for the presence of ATP, norovirus, and crAssphage, including handrails on patient beds, common area hallways, door handles, equipment and TV controls, physical therapy equipment, and tables and chairs. The team found that more than 90% of the surfaces tested positive for crAssphage or returned failing ATP scores compared with manufacturer suggested threshold values.

Although norovirus contamination was not detected on any surface, investigators found that handrails, equipment controls, and patient beds were 4 times more likely than other surfaces or locations to have high levels of crAssphage (odds ratio [OR] 4.1, CI 2.0-8.5, P < .001 for handrails and OR 3.6, CI 1.1-12.8, P < .05 for equipment controls). Further, investigators found high levels of both ATP and crAssphage on patient bed handrails and tables and chairs in patient lounges.

“This information is primarily important for LTC facility directors and environmental service staff or those responsible for designing and implementing infection control practices,” Cannon told ICT®. “These tools give them a quantitative way to monitor surface cleanliness over time and make improvements to their existing cleaning practices as needed.”

Cannon told ICT® that she was surprised that so many high-touch surfaces were contaminated with organic and fecal material, but she qualified that detecting fecal material is not the same as detecting infectious microorganisms. She noted that the study was not designed to evaluate the risk of diarrheal illness associated with fecal contamination of environmental surfaces, and she thinks that that issue might be something interesting to explore in future studies.

“Most importantly, we think our findings will really help LTC facility directors and environmental services staff identify where they can enhance their cleaning efforts,” Cannon said. “Monitoring surface hygiene routinely over time and using that data to make improvements to their existing cleaning practices would benefit LTC facilities, particularly if included as part of their infection prevention programs. Further studies might explore the impact of implementing a hygiene monitoring program in reducing the number of diarrheal illnesses and deaths among residents in LTC facilities.”