An assessment of high touch object cleaning thoroughness using a fluorescent marker in two Australian hospitals
Cathryn L. Murphy A B C E , Deborough A. Macbeth A , Petra Derrington A , John Gerrard A , Jacinta Faloon A , Kellie Kenway A , Samantha Lavender A , Simon Leonard A , Amanda Orr A , Dayani Tobin A and Philip Carling D
+ Author Affiliations
- Author Affiliations
A Infection Control, Infectious Diseases and Microbiology Departments, Gold Coast Hospital, 108 Nerang Street, Southport, Qld 4215, Australia.
B School of Nursing and Midwifery, Griffith University, Southport, Qld 4215, Australia.
C Faculty of Health Sciences and Medicine, Bond University, Qld 4229, Australia.
D Hospital Epidemiology, Carney Hospital, 2100 Dorchester Avenue, Boston, MA 02124, USA.
E Corresponding author. Email: Cathryn_Murphy@health.qld.gov.au
Healthcare Infection 16(4) 156-163 https://doi.org/10.1071/HI11024
Submitted: 16 September 2011 Accepted: 19 December 2011 Published: 16 January 2012
Abstract
Objective: We needed to better understand the usefulness of different methods of monitoring and achieving sustained improvement in cleaning. Common elements of successful international approaches include a covert nature, the use of a method to visually identify and highlight deficiencies in the cleaning of high touch objects (HTOs) and the provision of feedback and education before re-evaluation. The specific purpose of this study was to evaluate fluorescent marking, education and feedback for assessing and improving HTO cleaning in a typical Australian inpatient hospital setting.
Methods: A three-phase, prospective study was conducted in two acute care hospitals over 17 weeks. For each phase, in a set of 37 specific single-inpatient rooms, seven predefined HTOs were marked with a liquid isopropyl alcohol and optical brightener formulation targeting material solution containing a fluorescent marker (FM), known as DAZO®, designed specifically for the purpose of evaluating surface cleaning. In each hospital we targeted rooms located in the four wards with the greatest de novo multidrug resistant organism burden. Forty-eight hours after applying the FM we used a black-light to visualise the mark’s presence or removal. In phase 1 only, HTOs were swabbed before marking. Also in the first phase only and immediately following the initial assessment, each HTO was cleaned, remarked and re-assessed at 48 h. Between phases 1 and 2, investigators provided results to environmental services (EVS) leadership and staff. Education was provided to EVS staff after phase 1 only.
Results: A total of 986 marks were evaluated. The cleaning scores for individual HTOs in phases 1–3 ranged from 9.4 to 77.8%, 10.8 to 93% and 13.5 to 67.7% respectively. In phase 3, three HTOs scored lower than in phase 1. The mean overall cleaning scores for phases 1–3 were 34%, 53% and 41% respectively.
Conclusions: The FM was useful to assess HTO cleaning thoroughness. It facilitated relevant feedback and education and motivated staff to strive for continual improvements in environmental cleaning. Without on-going education, preliminary improvements were unsustained. However, investigators better understood flaws in cleaning and policy/procedure conflicts.
References
[1] Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control 2010; 38 S25–33.| Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species.Crossref | GoogleScholarGoogle Scholar |
[2] Po JL, Carling PC. The need for additional investigation of room decontamination processes. Infect Control Hosp Epidemiol 2010; 31 776–7.
| The need for additional investigation of room decontamination processes.Crossref | GoogleScholarGoogle Scholar |
[3] 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 S41–50.
| Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.Crossref | GoogleScholarGoogle Scholar |
[4] Dumford DM, Nerandzic MM, Eckstein BC, Donskey CJ. What is on that keyboard? Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains. Am J Infect Control 2009; 37 15–9.
| What is on that keyboard? Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains.Crossref | GoogleScholarGoogle Scholar |
[5] Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect 2009; 73 378–85.
| The role of environmental cleaning in the control of hospital-acquired infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1MjmsFOqsQ%3D%3D&md5=b2e6566c58785f9606fc05d62f53fd5fCAS |
[6] Hayden MK, Blom DW, Lyle EA, Moore CG, Weinstein RA. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients’ environment. Infect Control Hosp Epidemiol 2008; 29 149–54.
| Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients’ environment.Crossref | GoogleScholarGoogle Scholar |
[7] Sattar S, Tetro JA. Environmental Survival and Microbicide Inactivation of Some Currently Significant Nosocomial Pathogens. In Rutala WA, ed. Disinfection, Sterilization and Antisepsis. Washington: APIC; 2007.
[8] Sattar S, Springthorpe VS. Disinfection of Environmental Surfaces to Interrupt the Spread of Nosocomial Pathogens: a Critical Look at Use Patterns and Expectations. In Rutala WA, ed. Disinfection, Sterilization and Antisepsis. Washington: APIC; 2007.
[9] Rutala WA, Weber DJ. Surface Disinfection: new Processes and Products. In Rutala WA, ed. Disinfection, Sterilization and Antisepsis. Washington: APIC; 2007.
[10] Dettenkofer M, Spencer RC. Importance of environmental decontamination – a critical view. J Hosp Infect. 2007; 65 55–57.
| Importance of environmental decontamination – a critical view.Crossref | GoogleScholarGoogle Scholar |
[11] Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007; 65 50–54.
| Environmental contamination makes an important contribution to hospital infection.Crossref | GoogleScholarGoogle Scholar |
[12] Sexton T, Clarke P, O’Neill E, Dillane T, Humphreys H. Environmental reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with patient isolates and implications for hospital hygiene. J Hosp Infect. 2006; 62 187–194.
| Environmental reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with patient isolates and implications for hospital hygiene.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28%2Fhs1enug%3D%3D&md5=64b5a84a80fc277121c5ef3785045eaaCAS |
[13] Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006; 166 1945–51.
| Risk of acquiring antibiotic-resistant bacteria from prior room occupants.Crossref | GoogleScholarGoogle Scholar |
[14] French GL, Otter JA, Shannon KP, Adams NMT, Watling D, Parks MJ. Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. J Hosp Infect. 2004; 57 31–37.
| Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2c3ksVGmsA%3D%3D&md5=a1b8c55b061d4b0bcd4593ec2a1ab4cbCAS |
[15] Denton M, Wilcox MH, Parnell P, et al Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit. Journal of Hospital Infection. 2004; 56 106–110.
| Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2c7ivVygtA%3D%3D&md5=b010d457970476cb76896daf7da1e4d5CAS |
[16] Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. J Hosp Infect. 2004; 58 42–49.
| Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2cvktlKisA%3D%3D&md5=ed0e59c5179f206637327a441ecdc8a0CAS |
[17] Weber DJ, Rutala WA. The role of the environment in transmission of Clostridium difficile infection in healthcare facilities. Infect Control Hosp Epidemiol 2011; 32 207–9.
| The role of the environment in transmission of Clostridium difficile infection in healthcare facilities.Crossref | GoogleScholarGoogle Scholar |
[18] Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM, Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol 2011; 32 185–7.
| Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients.Crossref | GoogleScholarGoogle Scholar |
[19] Chen LF, Falagas ME, Peleg AY. Facing the rising tide of multidrug resistant Gram-negative pathogens. Healthc Infect 2011; 16 1–5.
| 1:CAS:528:DC%2BC3MXhsFWis7%2FI&md5=09c48ca867178005e769daf6493a9860CAS |
[20] Conway R, Bunt S, Mathias E, Said H. The Norovirus experience: An exercise in outbreak management at a tertiary referral hospital. Healthc Infect 2005; 10 95–102.
| The Norovirus experience: An exercise in outbreak management at a tertiary referral hospital.Crossref | GoogleScholarGoogle Scholar |
[21] Stuart RL, Marshall C, McLaws M-L, Boardman C, Russon PL, Harrington G, et al ASID/AICA position statement – Infection control guidelines for patients with Clostridium difficile infection in healthcare settings. Healthc Infect 2011; 16 33–9.
[22] Van Gessel H, Riley T, McGregor A. Clostridium difficile infection: an update for infection control practitioners. Healthc Infect 2009; 14 115–8.
| Clostridium difficile infection: an update for infection control practitioners.Crossref | GoogleScholarGoogle Scholar |
[23] Pearman JW, Peterson AM, Lee RC, Orrell CT, Perry P, Kosaras FP, et al The epidemiology of a large single-strain outbreak of vancomycin-resistant Enterococcus faecium vanB in an Australian teaching hospital. Healthc Infect 2003; 8 77–87.
| The epidemiology of a large single-strain outbreak of vancomycin-resistant Enterococcus faecium vanB in an Australian teaching hospital.Crossref | GoogleScholarGoogle Scholar |
[24] Mitchell DH, Dempsey KM, Jelfs PJ. Multi-resistant Acinetobacter baumannii: description of an outbreak centred on an intensive care unit in an Australian hospital. Healthc Infect 1999; 4 12–5.
| Multi-resistant Acinetobacter baumannii: description of an outbreak centred on an intensive care unit in an Australian hospital.Crossref | GoogleScholarGoogle Scholar |
[25] Farmer T, Mitchell C. Australian Infection Control Guidelines: preventing and managing infection in health care. Healthc Infect 2010; 15 101–3.
| Australian Infection Control Guidelines: preventing and managing infection in health care.Crossref | GoogleScholarGoogle Scholar |
[26] Dendle C, Martin RD, Cameron DR, Grabsch EA, Mayall BC, Grayson ML, et al Staphylococcus aureus bacteraemia as a quality indicator for hospital infection control. Med J Aust 2009; 191 389–92.
[27] Grayson ML, Russo PL. The national hand hygiene initiative. Med J Aust 2009; 191 420–1.
[28] Gillespie EE, Scott C, Wilson J, Stuart R. Pilot study to measure cleaning effectiveness in health care. Am J Infect Control 2011; (in press)
[29] Stuart RL, Marshall C. Clostridium difficile infection: a new threat on our doorstep. Med J Aust 2011; 194 331–2.
[30] Collignon PJ, Grayson ML, Johnson PD. Methicillin-resistant Staphylococcus aureus in hospitals: time for a culture change. Med J Aust 2007; 187 4–5.
[31] Griffith CJ, Obee P, Cooper RA, Burton NF, Lewis M. The effectiveness of existing and modified cleaning regimens in a Welsh hospital. J Hosp Infect 2007; 66 352–9.
| The effectiveness of existing and modified cleaning regimens in a Welsh hospital.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2svnvFGgtg%3D%3D&md5=030eb793764acbabfff025aa98fecba4CAS |
[32] Carling PC, Von Beheren S, Kim P, Woods C. Intensive care unit environmental cleaning: an evaluation in sixteen hospitals using a novel assessment tool. J Hosp Infect 2008; 68 39–44.
| Intensive care unit environmental cleaning: an evaluation in sixteen hospitals using a novel assessment tool.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1c%2Fjs1WrtA%3D%3D&md5=92c77ef66dc79c5c8e764249d816749aCAS |
[33] Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren S. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 1035–41.
| Improving cleaning of the environment surrounding patients in 36 acute care hospitals.Crossref | GoogleScholarGoogle Scholar |
[34] Carling PC, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 1–7.
| Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1c%2FmvFOkug%3D%3D&md5=8e25e2c3fadfd6a557e0e5371f1b2516CAS |
[35] Carling PC. Evaluating the thoroughness of environmental cleaning in hospitals. J Hosp Infect 2008; 68 273–4.
| Evaluating the thoroughness of environmental cleaning in hospitals.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1c7otlalsg%3D%3D&md5=035014e59960c2d7edcae1acfb35d1beCAS |
[36] Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved. Standard—Tenth Edition. 2009;29(1).
[37] Ragan K, Khan A, Zeynalova N, McKernan P, Baser K, Muller MP. Use of audit and feedback with fluorescent targeting to achieve rapid improvments in room cleaning in the intensive care unit and ward settings. [Corrected Proof.] Am J Infect Control. 2011; (in press)
| Use of audit and feedback with fluorescent targeting to achieve rapid improvments in room cleaning in the intensive care unit and ward settings. [Corrected Proof.]Crossref | GoogleScholarGoogle Scholar |
[38] Dumigan DG, Boyce JM, Havill NL, Golebiewski M, Balogun O, Rizvani R. Who is really caring for your environment of care? Developing standardized cleaning procedures and effective monitoring techniques. Am J Infect Control 2010; 38 387–92.
| Who is really caring for your environment of care? Developing standardized cleaning procedures and effective monitoring techniques.Crossref | GoogleScholarGoogle Scholar |
[39] Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010; 31 850–3.
| A quantitative approach to defining “high-touch” surfaces in hospitals.Crossref | GoogleScholarGoogle Scholar |