One of the common questions during many of the presentations that I give is asking if you know who cleans what. As you’d likely suspect, the answers vary significantly. The reason I call this out as an important consideration for your infection prevention program is to remind everyone that our jobs are not done once we have chosen what we think the optimal disinfectant is, and this I know for fact.
The story I usually share is one about a commode. It’s a true story. It’s one that occurred during a clinical study I was working on, which was focusing on the cleaning of patient rooms comparing the cleaning compliance in a patient room with diarrhea, versus a patient room with confirmed C. difficile. We were focusing on toilets (and commodes) so we put a UV marker on the underside of the toilet or commode seat. After several days in a C. diff positive patient room the study researcher called the nursing and environmental services (EVS) staff together to discuss the fact that for several consecutive days she was finding that the commode in a particular room had not be cleaned (it had the same piece of feces on it), and none of the UV markers had been removed. As you may guess the question was asked in terms of who is cleaning the commode. The nursing staff said “not us”. It’s a toilet, that’s the responsibility of EVS. The EVS staff said “not us”. It’s on wheels, that’s considered portable patient care equipment. I think you get the picture. Without communicating and setting clear roles and responsibilities things get overlooked.
Knowing this, the findings of a study recently published in AJIC titled “A pilot study into locating the bad bugs in a busy intensive care unit” did not surprise me. The researchers wanted to find out where multi-drug resistant (MDRO) organisms were lurking in spite of the environmental cleaning practices. To do so, the researchers traced the steps of healthcare workers between their workstations and patient bedsides then sampled high touched surfaces they found in the path of the healthcare worker. What they found was that many of the high touch surfaces identified in the path of the healthcare worker, such as the chairs, clipboards, keyboards, telephones and computer mouse found at the clinical workstation, were contaminated with MDROs. Perhaps more surprising was that when they dug a little deeper, these surfaces were not included in the EVS cleaning protocols.
The long and the short is developing a cleaning and disinfectant program is not simply about what a product kills, what the contact time is or if EVS staff are achieving 80% or higher cleaning compliance. Developing an effective cleaning and disinfectant program also needs to ensure that everyone who works in a space and is responsible for keeping that space clean needs to get together, look at every surface in the unit – patient room and otherwise - and come to an agreement on who cleans what and with what frequency. If we do not have clear roles and responsibilities, studies like this one will continue to be published and HAIs will continue to flourish. We need to think beyond the obvious. By focusing on the unobvious, we’ll really move the needle in stopping HAIs and saving lives.
PS – What happens if an EVS is cleaning a room, but the patient has used the toilet and has a note on file that a doctor / nurse needs to see it before its flushed? Do you really think the EVS person is going to have time to come back and clean? Do you think the clinical staff will notify EVS that the toilet can be cleaned? Who should clean the toilet in this situation? I ask because I’ve seen it.....and the toilet did not get cleaned and this was a semi-private room. Gross right?