Welcome to Infection Control Week! Like us, many of you are probably launching a series of events to highlight this important time of the year. The theme for our company is Disinfection Delinquents: Crimes against Infection Prevention. The “CRIMEs” we will be focusing on are Compliance, Rushing, Insufficient Information, Mucky Hands and Exposure.
I’m pretty sure you’ve guessed based on the awesomely alliterated title where I’m going with the topic of this blog! I think we can all agree that reducing the incidence of HAIs requires proper environmental cleaning and disinfection of frequently touched objects in healthcare facilities. A quick PubMed search looking for “cleaning compliance” provided hundreds of studies that are looking into the impact that monitoring cleaning compliance can have on improved patient safety through reduction of HAIs. I think we could all say that we’ve likely read more than 1 study that has looked at testing patient rooms pre and post-cleaning showing poor compliance. Many studies look at the level and/or type of training provided to staff about proper cleaning. I would hazard a guess that the percentage of cleaned surfaces improved showing that repeat training favorably changes behavior in the staff.
But how is compliance measured? It depends on the outcome you are looking for and the time and budget that you have. Many facilities are utilizing the various UV reflective kits that are available on the market. These UV reflective kits can be an effective way of covertly monitoring what surfaces have been cleaned and have certainly been used by a number of journalists who have gone “undercover” to see how well hospitals clean. Many facilities who use UV reflective kits as their monitoring tools have found that when the staff achieves 80% or greater cleaning compliance of high touch surfaces, HAI rates are dramatically reduced. The downside of these kits is that some staff will go out and buy their own black light to find the spots…..
ATP Meters are another method that has been gaining interest as tool for monitoring cleaning compliance. ATP is present in many types of organic material including food, microbes, body fluids and other natural substances. An enzymatic reaction with the ATP in bioburden results in bioluminescence (biological production and emission of light) and the intensity generated is proportional to the amount of organic material present on the surface tested. The luminescence is expressed in "relative light units" (RLU), providing a quantitative measurement.
ATP has been used for many years in the food industry. While I agree that ATP has its use, there are several limitations to the use of ATP within healthcare facilities. First, the absence of standardization of the ATP technology from various manufacturers and RLU readings for use within healthcare makes cross-comparisons of readings and benchmarking problematic. Second, the lack of documented correlation between ATP readings and levels of microbial contamination on environmental surfaces makes meaningful interpretation of the data difficult and distinction between pathogenic and non-pathogenic microbes on the sampled surface virtually impossible. Also, ATP kits cannot detect or measure viral contamination because viruses do not possess ATP. Third, and perhaps most important, many surface disinfectant chemistries and cleaning tools interfere with ATP measurements. Therefore, the use of ATP as a tool to determine the effectiveness of different cleaning practices or to compare the effectiveness of different cleaning and disinfectant chemistries remains a challenge.
Regardless of the method you use to measure compliance, the key is to develop a program that can provide meaningful results for you. This should include a validation study to set a baseline by which to measure yourself against so you can show improvements or lapses in cleaning. It should also include a training program to ensure that everyone tasked with measuring compliance is doing it in the same way so that the results you are recording can provide direction for where improvements need to be made. Either way, it is important that these programs are introduced in a positive and not punitive manner. Our housekeeping staff are the backbone of our cleaning and disinfection programs. We need them to work with us, not against us and we need to let them know how important their jobs are to the safety of our patients.
PS – don’t forget to develop an equivalent program for our clinical staff. Shared patient care equipment is just as important as environmental surfaces!